Health Issues for Mrs Zwick and Mr Davis - Essay Example

?Running head: Health Issues for Mrs. Zwick and Mr. Davis Health Issues for Mrs. Zwick and Mr. Davis Introduction This paper examines two case studies involving Mrs. Zwick and Mr. Davis. Mrs. Zwick was hospitalized for a mild stroke. She was then referred to a skilled nursing healthcare where she contracted a urinary infection. The medical profession considered this as a no event. Mr. Davis on the other hand suffered sickle cell anemia which made him absent from work. His employment was terminated and he went to seek extension of his insurance cover. This paper also examines the COBRA policy, ethical issues in hospitals and the challenges faced by both the State and the local governments in providing insurance. A Medicare Part A Medicare Part A is hospitalization insurance. It was to cover Mrs. Zwick’s stay in hospital and the skilled nursing facility. This was only if the annual deductable had been paid. Mrs. Zwick was eligible for Part A coverage since she was above 65 years. Her enrollment in the insurance also depended on whether she was already receiving Social Security, dependents or survivors’ benefits and Railroad Retirement payments. If she was not receiving Social Security, then she would apply for Medicare Part A. If Mrs. Zwick has been receiving the Social Security benefits but had not in the month of her 65th birthday, she would have to contact the local Social Security office. If Zwick has not been receiving Social Security or Railroad benefits, she has to apply it at the Social Security administration website (Matthews & Berman, 2012). Part A does not cover monthly premium; hence Mrs. Zwick has to pay a monthly fee. She would not pay monthly premium if she was eligible for Social Security. If she has 30-39 quarters of Social Security credits, she has to buy part A and pay a monthly premium of $248. If she has 0-29 quarters, she has to pay a monthly premium of $ 451. Once Mrs. Zwick has paid the fee, Medicare would cover all the costs during her first sixty days in hospital. Therefore, the coverage would have automatically paid for her 5-day inpatient care in hospital. The Medicare website gives the specifics about the costs beyond the first 60 days of hospitalization (Delehanty, Ginzler, & Pipher, 2008). Mr. Zwick was hospitalized with mild stroke for five days and then received skilled nursing care. Part A coverage required at least three days of hospitalization prior to skilled nursing care in order to cover all costs without copayment for the first 20 days of Mrs. Zwick’s skilled nursing care. Mrs. Zwick had to pay a fee of $ 248 in 2012 per day copayment for the skilled nursing care from 21st- 40th day of her stay. Part A does not cover care from doctors in inpatient hospitals. The doctors’ bills are covered by Medicare Part B. It does not cover emergency room care either. Part A covers the necessary medical care delivered on an inpatient basis only. Therefore, part A did not pay for Zwick’s urinary tract infection. Moreover, Part A did not cover for Zwick’s stay after the hospital was ready to discharge her (Matthews J. , 2012). Medicare Part B Medicare Part B covers outpatient care including doctor’s services, home health care and durable medical equipment. Mrs. Zwick was assigned a walker for her outpatient care; hence, it was necessary to find a medical equipment provider. Mrs. Zwick’s enrollment in Part B was to be automatic if she had already received Social Security benefits or Railroad Retirement benefits. Part B is optional and requires a monthly payment fee. If Zwick did not enroll for Part B insurance for seven months she was to be penalized for delay in enrollment. This period included three months prior to Zwick turning 65, the month she turned sixty-five, and the three months after she turned sixty-five years. The penalty is an extra premium charge of 10 % per annum after the year she was formerly eligible for Medicare. Part B included a monthly premium of $ 96.40 in 2008, and annual deductable amount of $ 135 in 2008. After the deductable was paid, Mrs. Zwick had to pay 20 percent of the cost of walker, while Part B would cover 80 percent. Medicare Part D Medicare Part D included the prescription plan of medication provided by Medicare. It was therefore imperative for Mrs. Zwick to be aware of the prescription plan for her medication because the insurance covered specific drugs which varied according to the plan and region of the country. This insurance cover was voluntary just like Part B. However, the privately administered drug plan was to set and collect the premium. Mrs. Zwick could have been eligible for Medicaid if she was a low-income earner with limited financial resources. Medicaid programs provide health care insurance to various classes of people with low income and few financial assets. It is provided in each state. Mrs. Zwick is still eligible for Medicaid although she can no longer access her drug coverage through the state’s Medicaid program. Mrs. Zwick would find Medicaid coverage more elaborate and less expensive than drug coverage via Part D of Medicare (Cordes, Ebel, & Gravelle, 2005). B Medicare policies on reimbursement for additional care The Deficit Reduction Act of 2005 identifies medical conditions that are preventable through application of appropriate benchmarks. Hospitals do not receive additional payment for cases and conditions not identified on admission (POA). The U.S Medicare and Medicaid Services policy prohibits billing of the difference between lower and higher premium rates for the beneficiary by the hospital. Instead, healthcare providers are advised to prevent the possibility of an adverse outcome on the patient and improve the quality of health care they give to Medicare patients. The Catheter-associated urinary tract infection acquired by Mrs. Zwick during her skilled nursing care is identified as one of the hospital-acquired conditions. Therefore, Medicare would not cover Mrs. Zwick’s hospital-acquired urinary infection (Stone, 2009). The Catheter-associated urinary tract infections are considered as one of the most preventable conditions. Such conditions are not supposed to occur. The Centers for Medicare and Medicaid (CMS) would not reimburse a facility that has caused urinary infections, unless the condition was already present during admission. The CMS describes Mrs. Zwick’s medical condition as a serious, preventable, and costly medical error. The ethical issue which arises is whether the hospital should be allowed to bill the condition. Mrs. Zwick would have to cover the costs of her treatment although her condition was caused by medical malpractice. She also has to pay for coverage of the extra nineteen days in the skilled nursing home. Mrs. Zwick’s case illustrates failures of the healthcare system notwithstanding rapid advance in technology. It is therefore unethical for skilled nursing facility to leave Zwick to cover for the costs that their errors have caused. Nursing should therefore create a culture of safety through best practices that would not bring harm to the patient and cause huge cost to medical facilities (Stone, 2009). Scenario 2 C. Consolidated Omnibus Budget Reconciliation Act The Consolidated Omnibus Reconciliation Act would allow Mr. Davis to receive health insurance coverage after sudden job loss. Mr. Davis’s employer had more than 20 employees, and therefore Davis is automatically eligible. Davis is required to pay up to 102 percent of the insurance plan, the amount of which he may never afford because of his unemployment and long absence from work. Davis has to remember that he risks losing his coverage if he goes beyond the scope of the coverage or if his employer stops giving health coverage, or enrollment in Medicare after choosing COBRA. Davis has to rely on state and local governments for medical assistance. Davis should therefore notify COBRA of his option to continue with the exact insurance that he had during employment within sixty days of employment termination. COBRA temporarily allows maintenance of employer’s insurance for up to 18 months. Davis should also seek election form from his former employer, and should be aware of the premiums his employer used to pay, as well as administration costs. David should ensure that the first to the last premiums during his employment are made retroactively and paid by his employer’s insurance. This would ensure that he enjoys benefits such maternity and preventive care benefits that may be absent in his individual plan. However, this would be expensive for him to maintain because he has to pay the figure equivalent to his former employer’s monthly premium and administration fee (American Cancer Society, 2011 ). D. Challenges to State Governments The state and the local governments have to grapple with the growing population of people without health insurance covers as well as declining levels of funds available for assistance. The state and the local governments have been forced to tighten monetary policies and place stringent restrictions on individuals who apply for assistance. The state and the local governments should therefore increase levels of both state and local taxation. This would help raise more funds that would address the increasing population needing insurance cover. The American public health insurance programs are mandated to assist the low-income families and children. The Medicaid and the State Children’s Health Insurance Programs are aimed at providing free or less expensive coverage to children without private health insurance. Therefore, public health coverage plays a critical role. Davis’ employment would cover for his children (Mann, Rowland, & Garfield, n.d). Germany has universal public health care system. If he was to live in Japan, he would pay 30 percent of healthcare costs, while state and local governments would pay the other 70 percent. Hospitals and clinics are non-profit. In Switzerland, there is a universal healthcare coverage within three months and healthcare costs are free but medications are not. In Great Britain, the prescription medication would cover his medical care. In these countries, adults pay a nominal amount for prescription medication. Other state and local programs are used if they fail to pay. Medication for children is free in Britain. However, in the United States, there are restrictions on pre-existing conditions. Unlike these countries, not everyone is eligible for health insurance. Davis may find it challenging to relocate to these countries because of existing immigration policies that are stringent and demand proof of financial responsibility. Conclusion Medicare Part A covers stay in a health facility if the annual deductibles have been paid. Medicare Part B covers for outpatient care including doctor’s visits, home health care, and medical equipment costs. Medicare D is a plan for prescription of medications. It is voluntary just like plan B. Medicaid programs provide health care insurance to various classes of people with low incomes and few financial assets. COBRA allows for temporary extension of insurance after a job loss, divorce, or reduction in work hours. The state and the local governments have to grapple with the growing population of people without health insurance cover as well as declining levels of funds available for assistance. References American Cancer Society. (2011 , June 27 ). COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986). Retrieved April 4, 2012, from American Cancer Society: http://www.cancer.org/Treatment/FindingandPayingforTreatment/ManagingInsuranceIssues/HealthInsuranceandFinancialAssistancefortheCancerPatient/health-insurance-and-financial-assistance-cobra#skipnavigation Cordes, J. J., Ebel, R. D., & Gravelle, J. (2005). The encyclopedia of taxation & tax policy. Washington: Urban Institute Press. Delehanty, H., Ginzler, E., & Pipher, M. (2008). Caring for Your Parents: The Complete Family Guide. Toronto: Sterling Publishing. Mann, C., Rowland, D., & Garfield, R. (n.d). Historical Overview of Children’s Health Care Coverage. Health Insurance for Children , pp. 31-53. Matthews, & Berman, D. M. (2012). Social Security, Medicare & government pensions : get the most out of your retirement & medical benefits. Berkeley, Calif: Nolo. Matthews, J. (2012). Medicare Part A (Hospital Insurance): A Beginner's Guide. Retrieved April 4, 2012, from MSN Health: http://health.msn.com/health-topics/caregiving/end-of-life/articlepage.aspx?cp-documentid=100230489 Stone, P. W. (2009). Changes in Medicare reimbursement for hospital-acquired conditions including infections. American Journal of Infection Control , 17A-18A. Read More