Healthcare Utilization and Finance - Research Paper Example

? Healthcare Utilization and Finance Urinary Tract Infection Urinary Tract Infection (UTI) refers to a condition that affects the urinary tract, which is caused by bacteria (West, 2006). The main parts of the urinary tract affected are kidney and bladder. The infection causes a lot of pain during urination. It may also affect the whole process of urination whereby the infected person experiences frequent urination (Bernard, Hunter & Moore, 2012). This paper discusses some of the Medicare available for Mrs. Zwick, who is suffering from UTI, together with some other issues associated with Medicare insurance. Medicare Part A (Hospital insurance) This refers to hospital insurance plan, which helps the patient in paying the hospital bills such as those incurred when admitted, and those for purchasing facilities required in nursing, sanatorium, and health care required after discharge from the hospital (West, 2006). Mrs. Zwick is suited for this medical cover since she is over 65 years and meets the citizenship required as stated in the conditions for this medical cover (Bernard et al., 2012). This Medicare will help Zwick pay for the following: i. Inpatient hospital care: this care is paid for up to 90 days for each period of benefit, in addition to 60 reserve days for a lifetime, which takes place in a general hospital. Also covered is up to 190 days in a lifetime, which takes place in a Medicare-certified psychiatric specialty hospital. Under this care, specific costs that will be covered include comprehensive rehabilitation, respiratory therapy and pain management. ii. Skilled nursing facility (SNF) care: this offer is valid up to 100 days for each period of the benefit. For Zwick to qualify for this, she must have spent at least three successive days in hospital prior to admission. If she qualifies, she will require skilled nursing throughout a week, or occupations, or physical or speech rehabilitation services for five days of a week. Under this category, the specific costs that will be covered include skilled nursing care and rehabilitative services among other services related to this. iii. Home health care: this will be enjoyed for up to 100 days. For Zwick to qualify for this, she must have spent at least three days in the hospital during the two weeks prior to this Medicare, and she must be based at home. The doctor will decide on limited costs to be covered under the home plan, including medicines and consultancy charges. iv. Hospice Care: For Zwick to qualify for this, she must have been certified as terminally ill by a doctor, in addition to having a life expectancy of six months at most. Under this category, the costs that will be covered include expenses for providing a team oriented method which caters for mental, physical, social and spiritual needs. In addition, the patient’s caregivers and family will be supported. Consequently, Medicare part A will cater for the full cost for up to 601 days that Zwick will spend in the hospital, but she must have paid a deductible of $ 1, 156. Thereafter, she will have to part with $289 coinsurance for 61 to 9 days, which is pad each day. In addition, she will pay $578 everyday – this is based on the lifetime reserve days. Medicare Part B (Medical insurance) This part is known as medical insurance and helps the patients to cover doctor’s services, care given to outpatient, equipments required and health services rendered at home (Kilmartin, 2005). Zwick is eligible for this scheme as she is over 65 years of age. The patient is required to pay a monthly premium and any relevant surcharges. Not all health care services are covered under this Medicare. A part from most prescription drugs, the items and services paid for part B must be prescribed or ordered by a Medicare-certified provider. Medicare part B will help Zwick pay for the following specific costs to cater for his health care: i. Doctor’s services- these include costs that are medically essential such as outpatient/ inpatient and preventative services. ii. Durable medical equipment, which must be hired from a Medicare-certified supplier. These include oxygen supplies and equipment, wheelchairs, and hospital beds as recommended by the doctor. iii. Ambulance services when the patient wants to be taken to the hospital. iv. Occupational therapy treatment and assessment to help the patient regain her normal activities such as bathing or dressing. v. Glaucoma tests, which are covered annually if the patient is at high risk of eye glaucoma. vi. Outpatient speech, physical, and occupational rehabilitation services vii. Chiropractic care, if she suffers from bone dislocation viii. Lab tests and X-rays ix. Some prescription drugs such as anti-cancer drugs. Medicare Part D (Medicare drug benefit) Eligibility for enrollment in this scheme includes entitlement to coverage under Medicare part A and/or Part B. The benefits that Part D plans must provide includes payment of a $ 320 deductible, and then 25% drugs costs coinsurance that goes up to a maximum of $2,930. After this maximum is reached, Zwick is entitled to pay the entire cost of her prescription until the total pocket expenses reaches $4,700, which is referred to as catastrophic coverage (Kilmartin, 2005). Zwick will have to pay costs by herself up to a yearly limit, after her part D has paid coverage up to a particular sum for prescription drugs – this is called ‘coverage gap’. The following are the benefits under part D. i. Offer him help due to his limited means, including assistance with deductibles and premiums. ii. Offer him a preference for at least two drug plans, which will cover both generic and brand name drugs iii. Offer him access to well-located pharmacies iv. Assure him an automatic enrolment in a drug plan, if she has both Medicare and Medicaid benefits. The drugs covered under part D include each therapeutic category, but those with flexibility to institute chosen lists of drugs. Generally, those drugs that are not included under Medicare or Medicaid Parts A or B are excluded under Medicare part D. Mrs. Zwick extra attention is required due to a hospital-acquired infection (UTI) In 2008, the Centers for Medicare and Medicaid Services (CMS) withdrew compensation for certain preventable mistakes, including some hospital-acquired infections. This policy amendment is likely to have significant financial effect on Zwick’s health care if her hospital-acquired condition falls under this bracket. The hospital should devote a substantial amount of funds and human resources to prevent such occurrences. However, even if the nurses and physicians entirely acknowledge the need to control hospital infections, the management may fail to recognize its value as it focuses on other immediate priorities. Zwick should pay attention on the carefulness of the hospital to prevent such occurrences, because it can be very costly for her. Ethical implications of hospital-acquired infection Ethically, the hospitals should be accountable for payment of the hospital-acquired conditions, which are preventable. For example, the urinary infection, which Zwick acquired from the hospital, was out of the hospital’s negligence, and it would be ethical if the hospital comes up with their own nonpayment policy to be offered alongside Medicare (Centers for Medicare and Medicaid Services, 2009). Consolidated Omnibus Budget Reconciliation Act (COBRA) This is a crucial US government act enacted in 1985. This act safeguards employees from neglect by their employers once they are no longer able to perform their duties due to illness (Bagley & Savage, 2010). The law requires the employer to provide health insurance for some specified time to their employees and their dependants. The law applies to companies with employees exceeding 20, and there is a similar law for small businesses. The law forces Mr. Davis’ employer to continue funding for his health expenses even after termination (Bagley & Savage, 2010). This is because the company terminated him from work without any other mistake. Generally, COBRA beneficiaries are covered up to a maximum of 18 months following termination of employment. The patients are required to pay a premium, which do not exceed 102% of the plan’s costs, plus 2% for administrative expenses (Gebbie, 2001). Challenges that state or local government experience in providing care Despite the strong need for provision of health care by the local government, the quality, cost, and accessibility of health care remains a major challenge. First, this is because considerable surge in the cost of health care has imposed significant pressure on local government’s budgets. Second, even after controlling for major challenges such as source of funds and cost, many Americans are left uninsured, either because they cannot afford the high cost of health care, or simply because they do not understand the importance of health care insurance. Recommend one step that state or local government could take to address one of the challenges you have discussed. The local government should create innovative programs to manage the health care for the large population that is left uninsured. These programs could operate just like Medicaid and Medicare. In this respect, the local government can look for funds to finance those public hospitals that are willing and able to offer care to patients who are not insured. Primarily, these programs should targets those individuals with very low incomes. Those individuals who are not insured, but have good incomes could be enrolled in educational programs that make awareness on the importance of insuring their health (Bagley & Savage, 2010). Health covers in other countries In countries such as Britain, Japan, and Germany, there is a well-organized health strategy for all citizens. In Britain, all citizens are eligible for coverage under the national health services (NHS). Unless clearly provided by law, all services are offered free at the point of care. Patients have access to specialist care only through their general practitioner, whom they are free to choose within their region. In addition, social care is provided for the elderly, and those with disabilities and mental illness (Northrop et al., 2007). The government offers medical coverage for all citizens, and the price falls to the state’s budget. For those employed, the government should ensure full implementation of COBRA act to make sure the employers provide comprehensive health insurance. In Germany, the in-patient health care is provided by both private and public providers. The health schemes coverage includes spouses and children of employees, who are covered with no extra charge. The children from social insurance plans were excluded by 2007 health reforms, but that does not mean that children are deserted as this only involves switching of funding from one source to another. In Japan, the government has devoted a substantial share of the health plans fund for coverage of the elderly due to the enormous enrolment of this group. The access for Medicare is open to all patients, and they can seek care from private clinics or hospital as they may deem fit. However, financially the service is less equitable because lower income earners are subjected to higher copayments and premiums. Japan reflects the best medical planning for Zwick as the elderly in this country are given a priority (Northrop et al., 2007). References Bagley, C. E., & Savage, D. W. (2010). Managers and the legal environment: Strategies for the 21st century. Mason, OH: South-Western Cengage Learning. Bernard, M., Hunter, K., & Moore, K. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urologic Nursing, 32(1), 29-37. Centers for Medicare and Medicaid Services. (2009). Hospital-Acquired Conditions (Present on Admission Indicator). Retrieved from http://www.cms.hhs.gov/HospitalAcqCond/. Gebbie, K. M. (2001). Privacy: The Patient's right. American Journal of Nursing, 101 (6), 69-73. Kilmartin, A. (2005). The patient's encyclopaedia of urinary tract infection, sexual cystitis, interstitial cystitis. Chula Vista, CA: Bay Port. Northrop, D. E., Cooper, S., Calder, K., & Northrop, D. E. (2007). Health insurance resources: A guide for people with chronic disease and disability. New York: Demos Publishers. West, K. (2006). Urinary tract infections. New York, NY: Rosen Publishing Group. Read More