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Medicare and Medicaid
Medicare is a federal governed program that pays for hospital and medical care for elderly and certain disabled Americans while Medicaid is a means tested health and medical services program for certain individuals and families with less resources. The populations that are served with the Medicaid are the American citizens and those people who may not necessarily be of American origin but have a legal and permanent residence in America. It also covers adults with extremely low income and their children, and people with certain disabilities.
Medicare is a predominantly federal government program and sponsored while on the other hand, Medicaid is a state governed program in collaboration with the federal government.
Medicare deals with people of age 65 and over, people of any age who may be having kidney failure and long-term kidney diseases, permanently disabled people who cannot work and it is applied for at…… [Read More]
Unlike Medicare, Medicaid is not a purely federally-funded program. Every state has a Medicaid budget, which the federal government 'matches' based upon a formula, despite the fact that Medicaid is considered an entitlement, implying that enrollees are entitled to benefits regardless of where they live. Because federal funding is 'matched' that means that states that spend more on Medicaid -- usually wealthier states -- tend to receive more federal funds (Villarreal 2006). The reason for the 'matched' funding is partially due to the highly variable costs of living from state to state -- it is far more expensive to reside in New York City than Wyoming, for example -- and also to honor the principles of federalism, allowing the states to determine additional categories eligible for care. Although states must provide Medicaid for persons with income below a certain level, they do have a great deal of discretion in covering…… [Read More]
Medicare and Medicaid
These two terms are government programs meant to assist specific groups of in the United States regarding health matters and are both managed by the Centers for Medicare and Medicaid Services, a division of the U.S. Department of Health and Human Services.
Medicare is a social insurance program that pays for hospital and medical care for elderly and certain disabled Americans. The program consists of hospital insurance which pays the bill of the patient including meals, supplies, testing, and a semi-private room. The hospital insurance also has home extension healthcare provision such as physical, occupational, and speech therapy as medic may deem it necessary. Medicare also covers supplementary medical insurance that makes and settles medical bills relating to physician visits, outpatient hospital visits, home health care costs and other service costs for the aged and disabled. (MediLexicon International, 2011).
On the other hand Medicaid refers to health…… [Read More]
Medicare and Medicaid
An important part of health care delivery within the state of Pennsylvania involves access to services such as Medicaid and children's insurance programs. These programs help families in need to obtain health services in order to maintain a high level of health and well-being. There are certain strengths and weaknesses exhibited by the population of Pennsylvania that may influence the consumption of insurance services.
According to the United Health Foundation (2012), Pennsylvania demonstrates strengths such as a low rate of uninsured population, high availability of physicians involved in primary care, as well as a high rate of high school graduation. In regard to weaknesses, the state of Pennsylvania has exhibited high air pollution levels, low funding for public health per capita, as well as a high prevalence of diabetes (United Health Foundation, 2012). Also, obesity as increased dramatically in the past decade, from 21.2% to 29.2% of…… [Read More]
The fears of the elderly were rooted in the fact that the reforms would eliminate "the tax deductibility of the 28% federal subsidy, known as the retiree drug subsidy (DS), for employers who provide creditable prescription drug coverage to Medicare beneficiaries, effective in 2013" (KFF, 2010). Thus, the 'gutting' feared by elderly Americans is the end of subsidies to private programs of elderly individuals with health coverage in addition to Medicare. The 2010 Healthcare Law also increases the Medicare payroll tax for individuals earning above $200,000 a year and establishes a new office within the Centers for Medicare & Medicaid Services (CMS) and the Federal Coordinated Health Care Office to "reduce annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice and other Medicare providers" (KFF, 2010).
Supporters of the 2010 Healthcare eform Law point out the number of Americans with no health coverage at all. The…… [Read More]
Medicare and Medicaid are government-sponsored programs whose objective is to provide patients with health assistance upon meeting specific criteria. Medicare is the federal program that provides insurance for elderly patients aged 65 and over, and approximately 40 million people are enrolled in this program. Medicaid is an insurance program that is available for disadvantaged persons, including the elderly, who cannot afford health benefits because of low incomes or other factors. Both programs are subsidized by government funds and in many instances, will cover the costs of basic medical care as well as specialized testing and supplies. However, as time progresses and the elderly population increases and requires additional medical care, it is evident that Medicare and Medicaid are assuming less responsibility for healthcare costs, leaving the majority of the costs to be assumed by the patient. Furthermore, the necessity for prescription drugs is on the rise, yet pharmaceuticals are only…… [Read More]
S.A. It is worth noting that some of these parts that are left out can be very expensive at times particularly when the beneficiary has to pay the out-of-pocket premiums and deductibles as well, and these services could be inevitable like seeking medical services outside the U.S.A. Some of the services left out by the cover at times can be more expensive and life threatening that those covered hence this serves to negate the whole purpose of the CMS health care services.
In order to cover the above mentioned areas that the CMS leaves out, there is the Medicare part C which is also referred to as Medicare + Choice program which allows the beneficiary to select a private health plan provider such as the Health Maintenance Organization (HMO) who will then contract with the Medicare in order to provide all the covered health services. This is the other undoing…… [Read More]
However, it presented the major problems of covering only half of the workers of the labor force and the undercutting of political support for public health insurance (erkowitz).
As social security became popular and Congress passed bills raising social security benefits in that decade, reformers were inclined to extend health insurance to social security beneficiaries, mostly elderly persons (erkowitz 2001). Most of them had stopped paying for their employer-based health insurance and had high morbidity rates. The federal government could then come in as a health provider through what came to be Medicare. The concept of limiting federally financed national health insurance for the elderly received congressional attention in 1957 (erkowitz).
In 1961, President John F. Kennedy endorsed a Medicare bill, followed by a long campaign for its passage (erkowitz 2001). The concept of national health insurance underwent another transformation or major change of sharing common grounds with…… [Read More]
Medicaid and Medicare Value-Based Purchasing
A value chain is defined as "a linked set of value creating activities that begin with basic raw materials coming from suppliers, moving on to a series of value-added activities involved in producing and marking a product or service, and ending with distributors getting the final goods into the hands of the ultimate consumer" (Wheelen & Hunger, 2009). The process of improving raw goods along a value chain until a product is ready to bring to market includes chain segments such as uphill and downhill, and the effective supervision and analysis of its value chains is paramount to a corporation's ability to grow and thrive. The center of gravity along any value chain is defined as "the part of the chain that is most important to the company and the point where its greatest expertise and core competencies lie" (Wheelen & Hunger, 2009). Speaking of…… [Read More]
Preventing 30 Day eadmission on Medicare and Medicaid Patients
One of the most costly and common phenomenon in the modern healthcare system is the increased rates of readmission to hospital of Medicare and Medicaid patients within a short period after discharge i.e. usually within the first 30 days. These readmissions are usually caused by progression of chronic diseases among these patients as well as insufficient post-discharge care. Actually, insufficient post-discharge care is the major factor contributing to these preventable re-hospitalizations. Therefore, reducing the rates of readmissions to hospital of Medicare and Medicaid patients requires developing and implementing a new or enhanced plan for patients' follow-up after discharge. According to the findings of a recent survey, 22% of patients admitted to hospitals are either re-hospitalized or visit an emergency department within the first month after discharge (Harrison et al., 2011, p.27). This plan focuses on preventing readmission of these patients through…… [Read More]
With four out of every ten hospital stays covered by Medicare, and almost half of hospitals’ overall revenue, Medicare cost strategies are critical for healthcare financial management (Herman, 2012). In “7 Strategies to Help Hospitals Break Even on Medicare,” Herman (2012) discusses ways hospital administrators can better manage their Medicare strategy. Hospitals do not break even on Medicare unless they implement proactive strategies for addressing potential shortfalls. Short of advocating for political reform of Medicare policies and programs, Herman (2012) claims that hospital CFOs can actually develop methods of financial management that minimize losses and ensure solvency. Herman (2012) offers seven suggestions to hospital administrators and CFOs, the most important of which is forming strategic alliances and partnerships.
Strategic partnerships are important to hospitals not just for Medicare cost structuring but for overall cost-effectiveness. Pooling resources allows all partners to benefit from their relationships, while also improving the quality of…… [Read More]
Star atings for Centers for Medicare and Medicaid Services (CMS)
Discuss your findings; identify the implications for healthcare and for pharmaceutical companies, and offer conclusions or suggestions.
In the last several years, the CMS has been focused on reducing the costs associated with Medicare and Medicaid related services. At the same time, there is an emphasis on improving quality. A rating system is designed to provide better insights about how pharmaceutical and healthcare providers are achieving these objectives. There is a focus on five different areas during this process. The most notable include: healthcare effectiveness data / information, consumer assessments, CMS, health outcomes survey and the independent review. These variables are designed to provide better information about quality, safety, costs and the delivery of services. ("Choosing Higher Quality," 2013)
The findings are showing how the five star system, is providing more clarity about the kinds of healthcare solutions and pharmaceutical…… [Read More]
The CDC has provided almost $7 million in funding to establish DPPs for research purposes, which means the number of pre-diabetes individuals helped by these programs will be very limited (CDC, 2012). While these programs will probably provide free or nearly-free diabetes preventive services to a large number of individuals, most underserved patients will not benefit from these programs.
S. 452 is worded in such a way that establishing DPPs under Medicaid will be optional for states (Sebelius, 2010). As of 2010, 43 states covered the expense of screening Medicaid patients for diabetes, but only 13 states provided reimbursement for obesity preventive services. This suggests that states are willing to pay for screening, but not preventive services like lifestyle interventions; however, if only a few states implement DPPs for Medicaid recipients, this will provide a proof-of-principle experiment in a real-world setting and establish the overall healthcare savings such programs can…… [Read More]
A brief history of Medicaid and Medicare
The idea of a national health insurance plan gained political momentum in the first part of the 20th C. President T. Roosevelt was among the pioneers in making the health insurance issue a campaign matter. The Second New Deal crafted by President Roosevelt involved including the Social Security program in the laws (Piatak, 2015). The act tried to reduce the extent to which such factors as poverty, old age, widowhood and children without known fathers were seen as dangers. The New Deal had a chunk of its content expunged by the Supreme Court because they were either seen as unconstitutional or simply not within the jurisdiction of the federal government. Some of the acts such as the National Industrial Recovery Act and the Agricultural Adjustment Act were ordered removed, by the Supreme Court.
The medical insurance scheme that had been drawn by…… [Read More]
On April 16, 2015 an Act called the Medicare Access and CHIP Reauthorization Act (MACRA) was passed, which is a piece of history of bipartisan legislation. Eventually, on October 14, 2016 the Centers for Medicare & Medicaid Services, the department of Health and Human Services, and the regulatory agency which takes care implementing and putting into practice MACRA, gave out an ultimate rule with a comment duration putting into practice the provisions of MACRA. MACRA revokes the highly denounced Sustainable Growth Rate Formula together with its schedule for Medicare Physician Fee (MPF) cuts, substituting it with the Quality Payment Program, which is a new model that focuses on cost measurement and quality, as well as payment and reporting adjustments. Physicians and their assistants, clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetics are all part of the eligible clinicians indicated in Medicare Part B and their QPP includes the…… [Read More]
Medicaid Budget Analysis
The author of this report has been charged with doing a budgetary analysis of the federal program that is known is Medicaid. While its counterpart Medicare focuses on helping those that have reached retirement age, Medicaid is geared more towards those people of any age that are encountering poverty and/or that have encountered a recent disaster like a hurricane or an earthquake. This report will answer several questions about Medicaid including the general budgetary policies that Medicaid follows, the legislative committee(s) that are assigned to the task, how the budgetary changes affect the community, whether a deficit/cut situation is better or whether surplus/additional funding should be done instead, the political climate in the home state of the author of this report, how the people in that home state drive the agenda and how this all differs from developing legislation overall. At least five references will be cited…… [Read More]
Medicaid has long been an issue of debate throughout the country. Healthcare is a critical need and many Americans do not have any healthcare. Therefore, Medicaid is vitally important because it provides healthcare to the poor. For many years, both federal and state governments have attempted to reduce the cost associated with Medicare. Some states have resorted to allowing HMO's to take responsibility for some of the recipients of Medicaid. This is particularly true is Georgia with the passage of House Bill 392. According to Goggin (2002) "the shift to managed care has been evident in both the private and public sectors ... Today, over 85% receive health care through some type of "managed delivery." Similarly, growth in managed care coverage of Medicaid clients has grown from 14% in 1993 to 56% in 2000 (Goggin 2002)."
For the purposes of this discussion we will focus on the implications of this…… [Read More]
Medicaid Health Care Assistance
How does the organization fund its programs?
Medicaid was developed for the sole purpose of providing health care services to low income individuals and families. For those people that cannot afford to pay for these services, the program makes it possible for you to get the treatment you need when obtaining them is challenging (based upon financial considerations). To qualify for this entitlement program there are a number of different factors that will be taken into account to include: the age of a person, nationality, disability (if any), income and property owned. ("Overview," 2011)
The program is funded by the states / federal governments and it is managed by each state individually. The federal government pays an average of 57% of Medicaid's expenses. While the state, designs their own program within specific federal requirements. In general, state participation in the program is voluntary. The way that…… [Read More]
There will no longer be automatic re-enrollment for recipients. The plan seeks to cut the cost of Medicaid by moving at least half of the recipients out of the program (Medicaid changes on the horizon in Illinois, 2011, Quad City Times).
Even President Obama recently proposed cost cuts to the federal Medicaid program, in light of the pressure to reduce government expenditures. Obama has proposed replacing the federal Medicaid matching formula with a single rate and also to reward states for efficiency and enrollment reduction (Luhby 2011). (The set limits will increase if the unemployment rate increases and the U.S. another recession). The bill would also bolster the controls of the Independent Payment Advisory Board (Luhby 2011).
Still, if the Affordable Care Act's full provisions are put into action, it could prove highly beneficial for a particular problem that afflicts Illinois -- that of reimbursement for physicians who serve Medicaid…… [Read More]
Further, in order to be covered by Medicare, the stay at the nursing home must include care that requires skilled nursing. In other words, Medicare will not cover custodial, non-skilled or long-term care that includes activities of daily living, such as cooking, cleaning and hygiene. A stay at a skilled nursing facility under Medicare is limited to one-hundred days per ailment. Medicare will pay for the first twenty days in full. The remaining eighty days requires the patient to pay a co-payment of approximately $124.00 per day.
Under Medicare Part , Medicare will provide medical insurance to a qualified individual. This coverage includes physician and nursing services, x-rays, laboratory and diagnostic testing, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital treatment, some ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments and other outpatient medical care treatments as administered in a physician's office. However, medication administration…… [Read More]
educe Medicaid Program Costs and Enhance Utilization and the Quality of Care Through Medicaid Managed Care
Medicaid is a type of health insurance provided and funded by the federal government and states to provide coverage to all Americans who are eligible low-income adults, children, elderly adults, pregnant women, and individuals with disabilities. Managed Care is a health care delivery system that was organized to manage cost and quality. The use of managed care in Medicaid is to deliver Medicaid health benefits and additional services through contracted arrangements that are between state Medicaid agencies and managed care organizations. By contracting with different types of managed care organizations, states can reduce Medicaid program costs and better manage the use of health services as well as enhance health care quality (Medicaid.gov).
Medicaid Managed Care is a federal government sponsored medical care system designed to deliver quality care and to reduce cost of health…… [Read More]
The Act creates a positive balance between government interests to save money and the interests of Medicare recipients to receive a wide range of drugs for their specific needs. The current ban on government negotiations with pharmaceutical companies serves to protect Medicate recipients by using the positives of the free market, such as the experience and purchasing power of PBMs. hile there are serious potential problems with this approach, such as the potential for fraud between pharmaceutical companies and private interests, overall the ban on government negotiations with pharmaceutical companies provides a good balance between recipient and government interests.
American Legislative Exchange Council. Prescription Drugs. 19 October 2005. http://www.alec.org/2/4/talking-points/7.html
Barry, Patricia. New Salvos in the Prescription Drug ars: Class action suits are exposing schemes that gouge consumers. AARP Bulletin, January 2005.
19 October 2005. http://www.aarp.org/bulletin/prescription/a2005-01-06-salvos.html
Dealey, Sam. Drug Dealings: Democrats had it right before. National Review Online, May…… [Read More]
Healthcare Law -- Ethics & Policy
Memo to ABC Hospital Board of Directors: How to develop strategies to help mitigate abuse and fraud within our organization by understanding fraud and abuse issues.
The Department of Health and Human Services has provided a great deal of good information for healthcare professionals and the public in terms of ways to avoid and/or deal with fraud and abuse. This document reflects the ways in which this hospital can be on the lookout for fraud and abuse when it comes to Medicare. This document will also explain the difference between fraud and abuse in the Medicare system.
Typically Medicare fraud means a person in this hospital -- or a doctor affiliated with this hospital contractually -- would knowingly submit false statements or somehow misrepresent what his or her services actually were, in an attempt to cheat the federal government. Also a healthcare…… [Read More]
Professional health care providers in direct contact with patients have been required to be licensed and credentialed demonstrating current competencies of quality and safe healthcare practice. Should similar licensing and credentialing requirements be imposed on collaborative workers in the health care industry who may not be directly serving patients (e.g., business office personnel, CEOs, CFOs, or other administrators)? Why or why not?
Collaborative health care workers should not be generally required to obtain similar licensing and credentials as their direct-patient care provider counterparts for two main reasons: redundancy and excessive costs First, requiring collaborative health care workers to obtain licensing and credentialing similar to direct patient care providers would be redundant because some collaborative health care industry executives who perform administrative tasks that do not involve direct patient care already possess professional licensing and credentials by virtue of their current occupational status and previous work experience (e.g., physicians or advanced…… [Read More]
Eligibility ules and Agency/Program Policy
The Medicaid Program
Medicaid is a federal assistance program that is administrated at the federal level by the Centers for Medicare and Medicaid Services (CMS) and at the state level by the corresponding state agencies of the individual states. It is a program designed to assist needy individuals with medical expenses. Medicaid eligibility is quite strict and is an example of eligibility by rule and regulation as well as by means testing (Chambers & Wedel, 2005).
The program provides coverage for all of the following healthcare services for program beneficiaries: Inpatient hospital services, Outpatient hospital services, Laboratory and X-ray services including radiation therapy, Physician's services, Podiatric services, Naturopathic services, Vision care, Family planning services, Home health services, Certain chiropractic services, Health clinic services, Early Periodic Screening, Diagnosis and Treatment (EPSDT), Dental services, including orthodontia services, Maternity clinic services, Ambulatory surgical center facility services, Emergency hospital…… [Read More]
Process for Budgetary Policies and Assigned Legislative Committees
A government budget can be defined as an official contract or arrangement that specifies the amount of revenue to be raised, where such revenues will be sourced, and the manner in which the revenues will be utilized. In most societies, the budget is in actual fact an assortment of policy contracts that specify the tax laws and also the level of spending for particular programs; thus they are more than just a complete and inclusive document. The process for budgetary policies therefore refers to the guidelines and procedures that are employed by policy makers to frame, ratify, and implement these agreements for revenues and spending (Crain, 2004).
For state governments as well as the federal government in America, the process for creating budgetary policies is comparatively simple to define in a conventional manner. Generally, the first phase of the process…… [Read More]
Although the Medicare prescription drug program has provided access to medications for seniors at a lower cost to the government than was originally expected and has lowered the out of pocket costs for the consumers, there is talk about needing to overhaul the program. Critics contend that the government should be able to negotiate lower costs for prescription drugs than private insurances can. It is also felt that the entire program is too confusing for the elderly beneficiaries and needs to be made more understandable (Wechsler, 2008). All of these proposed changes come with Medicare still trying to uphold there objectives of providing affordable prescription drugs to seniors.
It is believed that even with these proposed changes taking place there is still a need for greater education about the program as a whole. It is hoped that with increased education that consumers will be more informed about the choices that…… [Read More]
Medicaid and the ACA
Discuss the issues central to the expansion of Medicaid created by the Affordable Care Act. From state policy perspective is this a good way to increase access to healthcare at a reasonable cost? Be sure to discuss the success stories you uncover as you complete your research for this question. eview the following and consider the questions below as part of your initial post.
From the State's perspective, expanding Medicaid under the ACA is a sound financial investment. However, the Supreme Court ruled that each state could decide to enter the program individually and as a consequence many states have not. These states claim that they cannot afford the program. However, a report by the Congressional Budget Office clearly shows that the Federal Government will actually be responsible for the bulk of the costs in the first decade of the program -- about 93% of the…… [Read More]
Medicare and Medicaid Services (CMS) announced in January that ICD- 10-CM will be implemented into the HIPAA mandated code set on Oct. 1, 2013.
Introduction to the new structure of ICD manual o Statistics
The International Classification of Diseases (ICD) is a program that is designed in order to record statistics of morbidity and mortality and for the indexing of hospital records of disease.
ICD is published by the World Health Organization (WHO).
It has always been statistically difficult to categorize diseases according to any one specific category since different professions that work with diseases have traditionally classified them according to different categories. The pathologist, for instance, is primarily interested in the natural course of the disease process, whilst the anatomist may prefer to have a classification that groups the disease according to the effected part of the body. The statistical classification of disease and injuries depends upon how the…… [Read More]
Healt Care Policy
Te government of te United States can influence ealt policy in many ways. Specifically, Congress as te autority to pass laws affecting te ealt care system in te country. Most recently tey debated te new ealt care law tat was passed in 2009. Tis debate was primarily between te Republicans in Congress, wo felt tat easier access to existing private insurance plans was te key to overauling te system, and te Democrats, wo preferred a government run plan to compete wit te private plans (Keefe, 2009).
Te President as te role of ceerleader and adviser, witout a direct role in passing laws. President Obama went on te campaign trail to try to rally people to is side and convince tem tat is plan to cover te uninsured, lower costs, and improve care (Stolberg, 2009). Te President can elp steer te discussion towards te direction e would like…… [Read More]
Health Policies Medicare
hen everyone in our country finally starts to reach the age of 65 years of age or older, then every person will become eligible for Medicare. It is clear that there are some elderly that are having minimum health concerns while others recurrently are dealing with medical issues for which they will have to seek out treatment by the doctor. However, research is starting to display that there are at least five top conditions that are enhancing on medical and drug spending. It is obvious that Heart disease circumstances are the number one medical issue that the those that are considered elderly are facing and that is becoming very costly to them. Most are unaware that the second one is the disease cancer and it could be internal or external for various elderly patients. Other issues such as joint ailments a lot of the times can cost…… [Read More]
Medicare and Medicaid Services (CMS), previously the Health Care Financing Administration (HCFA), that by the time 2011, health care expenditure will arrive at $2.8 trillion, as well as it will bill for 17% of the Gross Domestic Product. As a result, it is no revelation that white-collar offenders observe health care deception as a rewarding effort. Certainly, the General Accounting Office ("GAO") quotes that such deception accounts for up to 10% of entire health care expense (3).
As health care deception outlays taxpayers almost $100 billion a year, federal, as well as state agencies have given health care fraud tribunal a key center of attention. All through her term, Attorney General Janet Reno made impeaching health care fraud a top precedence at the Department of Justice ("DOJ"), subsequent only to brutal offenses (3).
The government focuses its pains to perceive, as well as take legal action against health care fraud…… [Read More]
Sociology Discussion Responses
Response to Post #
Your post raises some very important issues that face the entire nation as well as the individual states such as New Mexico. The largest social services programs such as Medicare and Medicaid are unsustainable for the long-term, largely because of the dramatic demographic changes in American society since their development. Today, the average longevity is almost double what it was in the early 20th century when the average life span was only 47 years of age. Likewise, the fact that the post-Word War II Baby-Boom generation is now entering retirement age means that larger than ever numbers of program beneficiaries will have to be supported by fewer working program contributors. Meanwhile, the economy is undergoing a very difficult period and unemployment and underemployment rates, even for college graduates, are at all time lows. Some of the most sensible approaches to solutions might include…… [Read More]
Then, when you combine this with the fact that Medicaid serves 53 million people with an annual budget of $329 billion, means that rising costs is severely affecting this program. ("Medicaid Reform," 2005) the inflexibility of this program has contributed to problem as a one size fits all approach is taken. Then, when you combine the different state programs offered through Medicaid, means that an uneven standard of inflexibility is used. An illustration of this can be seen by looking no further than the overall focus of Medicaid, where an emphasis is placed on addressing major health issues. This is problematic because like with Medicare, an approach must be taken of dealing with the patient once they are facing major health issues. Then Medicare has to engage in multiple functions to include: comprehensive acute / primary care, long-term care services (for those who qualify), a source of funding for uncompensated…… [Read More]
Management of Continuum of Care Services
As the new director appointed for the Medicare and Medicaid Services (CMS), I realize the climbing costs of payments of these two programs and have met with the other members to come up with a plan of that will help enforce the strategies and guidelines in the state of North Carolina that can help us follow a budget that will assist the overall national requirements for persistent care. In doing so fellow board members have met with me to look at the Medicare Modernization Act (MMA), Administration on Aging (AoA), and other parts of the medical services to help come up with an arrangement that will help us reduce costs in our particular area that will assist the national healthcare problems that we currently face.
After looking at the problems within our own area we have decided to enforce the guidelines of the current…… [Read More]
eimbursement Ethics and Compliance: Impact of Health Care eform on Medical Coding and Billing
"Medical billing and coding lays the foundation for any successful healthcare provider," yet its common practices are undergoing significant changes under the recent proposal for health care reform (Griffey, 2013). The nature of medical coding and billing is increasingly becoming more and more complicated. The recent healthcare reform legislation, passed in 2010, promises to complicate the situation even further. Such reforms will undoubtedly have a huge impact on medical billing and coding processes.
The reform bill was a monumental piece of legislation passed by Pres. Obama and his Democratic supporters in 2010. There are a number of stipulations which aim to help increase access to appropriate health care for millions of Americans who are currently without any coverage, helping lower the cost of premiums too much more affordable rate for most Americans but also increasing the…… [Read More]
H's claim with an HMO plan is the need for individuals to remain within the network to receive care. Initially, Mr. H was denied coverage because he did not get a referral from his primary physician to see a specialist. The original treatment to which Mr. H's primary care physician was subjecting Mr. H was 1. not effective and 2. The physician suggested a radical amputation for his condition while the second opinion Mr. H sought suggested a much less radical procedure which would allow Mr. H to retain his mobility. It could be logically argued that had Mr. H not gone 'out of network' he would have suffered substantial medical harm. Furthermore, while the HMO cited as a reason for denial of claim a provision in the plan documents that prevents referrals outside the plan's network when the network's physicians have the capability to perform the required procedure, Mr.…… [Read More]
RATIONALE for the ELEMENTS
The rationale for the elements stated within the mission, vision and values statement is that through educating and assisting patients in signing up for and choosing their provider under the Medicare Advantage plan that the patients will be enabled to receive the best possible benefits for their individual health maintenance needs.
E. PROPOSED STRATEGIC GOALS
Strategic goals of this program includes those as follows:
1) Enrollment of all patients in the Medicare Advantage program who are eligible for this coverage.
2) Assisting all Medicare Advantage enrolled patients in utilizing this coverage to the best possible level enabling them to receive the best care possible.
F. IDENTIFICATION of CRITICAL SUCCESS FACTORS
Critical success factors are identified as being those as follows:
Adoption of the necessary technology applications to assist patients;
Efficiency and effectiveness in getting information out of patients concerning the assistance offered by the HMO; and…… [Read More]
Integrity is a major issue for healthcare organizations because there are many avenues for fraud, and for people to demonstrate a lack of ethics. The problem is that the temptation is sometimes too great and despite the fact that there are laws in place to guard against these practices unethical behavior takes place anyway. The government, which supplies a lot of the money which goes for treatments through Medicare and Medicaid, has structured certain laws to make sure that the practices of healthcare organizations are ethical, but billions of dollars in fines are still doled out every year. The big drug companies complain of arcane and hard to decipher legalese, but the fact is that although they realize the issue and the penalty they continue to subvert the law. This paper looks at qui tam statutes and cases, Medicare and Medicaid admissions criteria, installing a corporate integrity program, and…… [Read More]
Policy Changes in Healthcare Finance
The American Medical Association (2013) developed the Current Procedure Terminology (CPT) codes decades ago in the 1960s. The first edition was published in 1966 and over the subsequent years several updated versions were created. The reasons for developing the CPT code system was to make communications about medical procedures easier between health care providers, help patients and their doctors submit claims for services to insurance providers, create a structure that would facilitate the development of an electronics records system, and create categories that would help researchers collect data on the health care field.
The CPT code system expanded with each subsequent edition and with publication of the second edition the codes were transitioned from a 4 to a 5 digit system (American Medical Association, 2013). This transition was necessary as the services covered by the code expanded beyond medicine, radiology, and…… [Read More]
Health care in the United States has evolved through governmental and private answers to historical trends, starting with the first days of the United States. Often arising as responses to serious gaps in health care, these remedies traditionally build on each other and have resulted in a uniquely American health care system. The trickle of Baby Boomers into "the elderly" is now posing new challenges for both governmental and private providers, which must be met by new responses and a newly adapted health care system.
Discuss the government's role in responding to historical trends that impact the delivery of hospital care and how this has added to the expansion of hospitals in the United States.
Commencing with the very existence of our Republic, the United States government has taken a leading role in dealing with historical trends, significantly impacting delivery of hospital care and expansion of hospitals in this…… [Read More]
Balanced Budget Act of 1997
Introduction with Background
In the last several years, health care costs have been increasingly exponentially. To control the expenses associated with Medicare and Medicaid, the Balance Budget Act of 1997 was enacted. At the heart of its focus, was on reducing the total amounts of fees that are provided to health care providers, doctors and nurses. This is troubling, as these transformations will have an impact on facilities and health care professionals (who may not want to work with these kinds of patients). When this happens, there will be a decrease in choices and the overall quality of services that are provided to these individuals. This is the point that these challenges could adversely impact treatment options that are provided. (Kilgore, 2009)
Evidence of this can be seen in a study that was conducted by Kilgore (2009). She found that the act has changed consumer…… [Read More]
Health insurance has gone up over the past two years as a result of a nationwide increase .insurance companies have the tendency of settling only a percentage of a patient's bill. The truth of the matter is patients are not the only people who suffer due to this crisis the doctors too fall victims as mots of them opt to close down since they are underpaid by the insurance companies as well as being forced to pay the yearly premiums for malpractice .physicians are taken as the ones who are at fault for the ongoing healthcare crisis. This is true to some extent but they are not the bones to blame entirely as there are many parties involved in this issue. First of all when we look at the money involved we can say that this crisis is the fault of insurance companies since they are out there…… [Read More]
However, this might turn competent healthcare professionals away, who were angry that they no longer could exercise discretion over their treatment, in conference with their patients. Patients might refuse to come to the hospital. And those that did would cause costs to escalate, as they stayed longer, received more extensive care, and thus exhausted their insurance benefits.
A summary presentation of a comprehensive solution that would cover all of the issues
Firstly, the board of directors should be convened to establish a policy about what the religiously founded hospital considers to be a quality life and an ethical system of evaluating critical patients, when dispensing care. Doctors, nurses, and other involved personnel must be convened to discuss various issues that continually arise and a uniform policy must be established, so that such ethical decisions are not solely the burden of patients and healthcare providers in the field.
A press release…… [Read More]
On March 23, 2010 the Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama. Along with the Health Care Reconciliation Act of 2010, the PPACA became part of the overall Health Care Reform concept of 2010. The health care reform process was promoted as a way to completely transform the health care industry and ensure that all Americans received affordable health care. hile supporters praise the legislation as a revolutionary law which will benefit ordinary Americans, critics claim that the Obama Administration used the health care reform process as a means of gaining control over the entire health care system. In an attempt to compare and contrast the provisions of this new law, this essay will discuss several provisions of the new health care legislation and compare the benefits as well as the criticisms of them.
Section 5501 of the PPACA provides for…… [Read More]
The facts that you have provided indicate extremely troubling circumstances that could seriously jeopardize the welfare of your organization. It is well-settled law that entities contracting for the services of subsidiaries are legally responsible for legal and ethical improprieties committed by those subsidiaries irrespective of whether or not the contracting organization had any specific involvement in or knowledge of those actions. Accordingly, we would strongly advise that you take immediate action to rectify the situations described in the manner outlined in our recommendations below.
To avoid the potentially serious criminal, civil, and financial consequences arising under MWHC's respondeat superior responsibility to prevent fraud and abuse in connection with its association with subsidiaries, it is hereby recommended that MWHC immediately:
1. Instruct the subsidiary to cease and desist from offering its contracted home health agency employees compensation of any kind in connection with client durable medical equipment (DME) orders from…… [Read More]
This information was obtained from the facilities giving dialysis and it was for the first two months only. The study excluded darbepoetin doses as it had only been administered to a few patients. Inpatient EPO doses were not easily determinable as they are not billed differently to Medicare. The use of outpatient EPO only may be underestimating the total use of the medication. The cohort dealt with the biasness by determining the amount of time a patient stayed in hospital. The calculations on the average dose of EPO for every patient per day was by adding the total dose for a whole month then separating it by the number of days of outpatient then multiplying by 30 to get the total of a calendar month. According to the medical reports the study used the right amount of doses. The study was not randomized as it was aimed towards the African-American…… [Read More]
egulations and Guidelines in nursing
The CMS-implemented Pay-for-Performance initiatives are designed to incentivize greater quality of care by all medical practitioners for all recipients of Medicare/Medicaid services (Fenter & Lewis, 2008). The fee-for-service model that the CMS still employs on a wide basis incentivizes a lower quality of care that leads to or includes more services, which has direct detrimental effects for patients and increases the cost burden on the Medicare and Medicaid programs and thus on the federal budget and on taxpayers (Fenter & Lewis, 2008). The Joint Commission on Accreditation of Health Organizations' Core Measures are a set of guidelines meant to modernize and standardize the processes and criteria of accreditation and ongoing measurement and quality assurance at health organizations (JCAHO, 2011). These standards are also related to care, but involve licensing and accreditation rather than payment and thus work as different incentives (JCAHO, 2011).
As…… [Read More]
Health Care Plans
Types of Health Insurance
This type of insurance is also known as a traditional or fee-for-service plan. The benefit of an indemnity plan is the flexibility; this plan allows members to choose any doctor or hospital. However, members must pay an annual deductible and then a percentage of each medical bill. Although these plans offer the greatest freedom to select any doctor, they are usually the most expensive option.
Typically, the member or the provider sends the bill to the insurance company. These plans usually have an annual deductible before the insurer starts paying. Once the deductible has been met most indemnity plans pay a percentage of what they consider the "Usual and Customary" charge for covered services. The insurer generally pays 80% of the Usual and Customary costs and the member is responsible the other 20%, known as coinsurance. If…… [Read More]
Risk Management Issue
Over the last several years, the issue of patient safety has been increasingly brought to the forefront. Part of the reason for this, is because a number of high profile accidents have taken place. This has increase the chances that patient will develop complications. Evidence of this can be seen by looking no further than the most commonly reported cases involving malpractices lawsuits to include: incidents involving misdiagnosis, prescription medication errors, Obstetrics and surgery. As, these different events account for a total of: 62% of all medical malpractice cases. ("CRICO Coverage," 2011) This is significant, because it shows how the underlying risks facing many health care organizations have risen exponentially. In the case of the health organization we are studying, they have taken different steps to address these kinds of issues that they are facing. To fully understand the overall scope of their strategy requires: looking at…… [Read More]
Social Work Statement of Purpose
While some people may be able to point to a distinct time or place in their lives when they knew how they wanted to make their livelihood, for others, the path to a profession cannot be mapped so precisely. My motivation to seek a Master's Social Work (MSW) degree is rooted in diverse experiences in both my personal and occupational lives.
I grew up in a family with a strong sense of community. In my extended family, some members had limited resources but they still found ways to be of help to their neighbors. When I think back to the years of my upbringing, I remember that many people in my family and community communicated their values to me, and expected me to assume a helpful stance in my life. As I grew, those expectations did too, and I learned that an aspect of my…… [Read More]
The problems facing Medicare recipients and the federal government almost seem to be overwhelming. There are proponents of a plan to privatize Social Security and health insurance, placing the onus on the individual to pay for his own health care through savings specifically for this. Some others would have the program go through the private HMOs who have, in the past, contained the costs of care by having primary care physicians manage a patient's care and purposely keeps the costs of care down.
As with Medicaid, the recipients of Medicare would have difficulty obtaining health care without this program. The recipients would most likely have no other health insurance. The trend being what it is, a lot of individuals retiring today are fortunate to have pensions from their companies, much less health benefits. ithout a national health insurance plan, like Medicare, those individuals would have to pay for health care…… [Read More]
"What is the role of Congress in policy making process"?
Policy is a plan to identify goal or possible course of actions with administrative or management tools to accomplish these goals. n the other hand, policy is the authoritative decision made by the U.S. executive, legislative, judicial branch of government to influence the decision of others. Government is a key player in decision-making process and congress plays important roles in decision-making . In the United States, both House of Representatives and House of Senate fulfill the congressional policy responsibilities, and congress plays important role in health policy, which includes obesity prevention measures or health insurance program. Congress is an important arm of government that makes law. Important strategy that congress uses to make policy preference is by passing a bill into law. Typically, the congress could make a decision to pass or not to the policy of the…… [Read More]
Strategic Management of a Healthcare Facility in St. Louis
In the late 1800's and early 1900's St. Louis was a major center for automotive and other heavy manufacturing but the industrial restructuring of the Midwest during the latter half of the century has resulted in consistent economic decline of the St. Louis region. Today however as the rest of the country faces a slowing economy this region is showing new signs of growth. [Kotkin, 2002] Due to changing socio-demographics, the demand for health care and advanced medical technologies is growing consistently with a concomitant rise in health expenditure. [Zhou 2001] Health expenditure in the U.S. has risen from 7.4% of the GNP in 1970 to 15% of the GNP in 1995.[Zhou, 2001] The Health care sector deals with not only the clinical medical services, but also include methods which finance them, for e.g. insurance, benefit schemes, Medicare and Medicaid. eforms…… [Read More]
Health Care Reimbursement and Billing
Both Mrs. Zwick and Mr. Davis face significant issues in the presented scenarios. Mrs. Zwick has multiple considerations under Medicare Parts A, B and D, in addition to her hospital-acquired urinary tract infection. Meanwhile, Mr. Davis must address the severe time constraints and costs of COBRA in light of his job termination. These two scenarios underscore current difficulties and complexities of current health care in the United States.
Discussion of Mrs. Zwick's coverage under Medicare Parts A, B and C
Medicare Part A (often called "hospital insurance") (U.S. Department of Health and Human Services, 2011, p. 15) assists in covering inpatient hospitalization and skilled nursing facilities, hospice and home health care (U.S. Department of Health and Human Services, 2011, p. 14). There is usually no monthly premium if you and/or your spouse paid Medicare taxes while employed (U.S. Department of Health and Human Services, 2011,…… [Read More]
Health Care Cost and Quality
The objective of this study is to examine the relationship between health care cost and quality. This study will select one public agency and one private agency and differentiate their roles and major activities in addressing cost and quality in health care and analyze current and projected initiatives to improve quality while simultaneously controlling costs. This study will additionally conduct a synthesis of indications for staff nurses and advanced practice nurses, including evidence-based practice, relative to cost and quality.
There are many initiatives presently underway to meet the growing need of health care for a population that is greatly under-insured and many that are uninsured.
U.S. Department of Health and Human Services eport
According to the U.S. Department of Health and Human Services (2014) "Medicare is improving the way it pays for physician services. The Center for Medicare and Medicaid Innovation (Innovation Center) is exploring…… [Read More]
It appears the dangers of a commercialized healthcare system have demonstrated that this beastly practice of profiting off the sick is not good for the society at many different level it contains.
Healthcare discussions of this matter do not belong in a committee that is dedicated to commercial purposes. Medicare and Medicaid were successful in the past in spite of the many governmental forces that played a role in their existence, but like all things these are old and obsolete ways of dealing with this current crisis of confusion.
A philosophical mindset, absent from this meeting, that included individual responsibility and preventative efforts to maintain health should be emphasized from leaders. Safety can never be guaranteed, neither can good health, so to offer such promises of universal coverage is over-idealistic if not criminally negligent. Like the answer to most problems, the solutions are local and come from within communities and…… [Read More]
Johnson administration's "Great Society" initiatives? Defend your response.
As for intentions, the Johnson administration's "Great Society" initiatives should be given an A. hen he took office, Johnson saw that the country's success following orld ar II was declining and there was a potential for the country to enter a period of serious decline, a situation which ultimately did come to pass in the 1970s and again in the present period. Programs such as Medicare and Medicaid which were created during this period have continued to benefit Americans fifty years after their initial creation. However, given that much of Johnson's attention was being given to the escalation of the Vietnam ar and Johnson's encouragement of American involvement on that front, the actual effectiveness of the "Great Society" initiatives deserves a final grade of B- or C+. He was successful in getting the Civil Rights Act passed and tried to help Americans…… [Read More]
Maryland Health Service Cost Review Commission
Maryland is the only state that has a Board overseeing its inpatient commission. he Board is called the Maryland Health Service Cost Review Commission. It is a panel that regulates the rates for all hospital services in its state and requires all payers -- commercial, Medicaid, Medicare, self-pay -- to pay each hospital (regardless of status, history, and quality) the same fixed rate.
he he Health Services Cost Review Commission's (HSCRC's) statute was first enacted in 1971 and began setting hospital rates in 1974. At first, it pertained only to non-governmental care institutions, but, in time, the federal government granted it a waiver and the State was exempted from national Medicare and Medicaid reimbursement principles. Increasingly more and more, the HSCRC was granted power over setting rates for inpatient reimbursement, until it became the sole body that set the rates that payers pay for…… [Read More]
If the area wage index is greater than 1, the labor share equals 69.7%. The law requires the labor share to equal 62% if the area wage index is less than 1.0.
2) the wage adjusted labor share is added to the non-labor share of the standardized amount.
3) the wage adjusted standardized amount is multiplied by a relative weight for the DG. The relative weight is specific to each of 746 DG's (for fiscal year [FY] 2009) and represents the relative average cost of a beneficiary in one DG compared to another.
4) if applicable, additional amounts will be added to the IPPS payment for hospitals engaged in teaching medical residents, hospitals that treat a disproportionate share of low income patients, and for high cost outlier cases" (Acute Inpatient Prospective Payment System, 2009).
Physician services include office visits, surgical procedures, and other diagnostic services. These services are usually performed…… [Read More]