Heath Care Delivery Systems - Report Example

Heath Care Delivery Systems The primary health care delivery system in my organization is the Medicare. Medicare is the government’s health insurance program for people who are aged 65 years and above, those not over 65 but who have disabilities, those who have permanent kidney failure, or those with amytrophic lateral sclerosis (Medline Plus, 2010). Basically, the Medicare serves as assistance in the cost of health care: however, it does not cover all medical expenses or cost of long-term care. It has four parts: Part A covers hospital insurance. In most cases, there is no premium needed for this coverage. It covers “inpatient care in skilled nursing facilities, critical access hospitals, and hospitals” (Medicare Consumer Guide, 2008). Hospice and home health care are also part of Part A. Part B covers fees for medical services which are not covered by Part A. Part B is used to pay for medically necessary services and supplies which are provided by Medicare. There is a premium, in most cases, in order to be covered under Part B (Medicare Consumer Guide, 2008). It covers “outpatient care, doctor’s services, physical or occupational therapists, and additional home health care” (Medicare Consumer Guide, 2008). Part C is otherwise known as Medicare Advantage. In case a person qualified for Medicare is covered by Parts A and B, he can choose Part C to receive all of one’s health care through a provider organization, like and HMO (Medline Plus, 2010). In essence, it is a combination of Part A and B, the main distinction being that Part C is administered through private insurance companies which are approved by the Medicare. Through this program, a person can have lower costs and gain extra benefits (Medicare Consumer Guide, 2008). Lastly, Part D is prescription drug coverage. This part of Medicare helps pay for medications (Medline Plus, 2010). It is a stand-alone prescription drug coverage insurance. Most of those covered under Part D do not have to pay premium to avail of this privilege. Part D covers different plans and drugs, but all medically essential drugs are covered through Medicare. The patient can choose the drug plan which would best suit his plans (Medicare Consumer Guide, 2008). In contrast with Medicare, private health insurance requires premium payments to be made to an insurance company who would then later cover a person’s hospitalization bills. Private health insurance policies usually have a network of hospitals, doctors, and pharmacies and other health care providers (National Endowment for Financial Education, 2006). The insurance coverage of the patient depends on the type of policy which was purchased and coverage often depends on the terms of the insurance policy. There are other policies which give a person the choice as to insurance coverage within or outside the provider network. There may be preferred provider organizations or point-of-service plans which depend on the participating providers (National Endowment for Financial Education, 2006). If a patient prefers some of his doctors or providers for care, then he can check with his insurance company if his doctors are members or are included in his insurance. A member having private insurance has different payment options. Some insurance policies set forth annual deductibles with an initial amount of costs which the member must pay on his own before the insurance company will pay (National Endowment for Financial Education, 2006). Higher deductibles will usually imply lower monthly premiums for the member. The deductibles however may not cover all services, such as preventative care and some policies may also have separate deductibles for other services like hospital care and prescription drugs (National Endowment for Financial Education, 2006). While the Medicare does not necessarily need premium payments for coverage, private health insurance requires premiums to be paid by the member. The coverage for private insurance may also be more comprehensive as compared to Medicare, especially when the member pays higher premiums for full coverage. The coverage for private insurance companies includes hospital and doctor care, laboratory tests, medical equipment, prescription drugs, rehabilitation, and mental health care (National Endowment for Financial Education, 2006). The state licensing and regulatory impositions have impacted on the Medicare in the sense that hospitals have now been required to retrieve patient medical history and physical examination not more than 30 days prior to or 24 hours after admission and such documentation have to be placed in the medical records within 24 hours after admission (Medical News Today, 2006). The state licensing authorities also require exams and histories to be conducted no more than seven days before admission. Verbal orders for drugs and biological also have to be documented and signed by the prescribing physician (Medical News Today, 2006). Drugs (which have a potential for abuse) and biologicals must also be secured in locked areas. The regulatory authorities also require individuals to administer anesthesia for post-anesthesia evaluations (Medical News Today, 2006). In order for those under Medicare to receive the best possible care, state licensing and regulatory agencies provide rules and regulations which require providers to operate smoothly and efficiently. And these changes and impositions actually serve the health care industry as a whole (Medical News Today, 2006). The current economic crisis has to be considered of significant impact to the Medicare. US spending on entitlement programs have been mostly locked into place and this includes spending for the elderly and for those with disabilities (Cowen, 2008). The situation has become even more ominous with the increasing number of Americans reaching the age of 65 years and with the lengthening of life span of the average American. “Even if the government is conservative in its spending, just paying out promised benefits implies that tax rates will rise to a crushing level – a range of 60 to 80 percent of income – well before the end of this century” (Cowen, 2008). Some critics point out that the Medicare policies place too much of an imposition on the government and at the rate it is going, it will not be sustained over the next 50 years and will run into financial difficulties within the next 15 years (Cowen, 2008). There is a need for the government to pay out benefits more efficiently – choosing to cover individuals who actually need it and targeting social programs for those who are poor. And for those who can afford to pay their health bills, the government must choose to minimize coverage (Cowen, 2008). There is a need for the government to come up with ways to manage the issuance of benefits for those entitled to Medicare – focusing on those who are poor and who have less political clout. “Thus this idea goes, we should try to make transfer programs as comprehensive as possible, so that every voter has a stake in the program and will support more spending” (Cowen, 2008). And still this train of thought or line of program may still not work when we consider the reality that Medicare costs will still start to increase taxation levels at more than 50 percent. There will still be coverage gaps in the future and these gaps will increase as the costs of Medicare will continue to increase and when the taxes can no longer cover the increase in costs. National trends in health care and in the economy indicate that the average amount spent per person in terms of health care spending is very much skewed (Kaiser Family Foundation, 2009). Ten percent of individuals make up for 63% of spending on health services; and 21% for only 1% of the population. Health care spending is in between the private and the public sectors and private spending is covered at 54% of health spending based on 2007 figures (Kaiser Family Foundation, 2009). Health insurance covered by private insurance companies amounts to 64% of private health expenses and 22 % of private expenses comprises out-of-pockets payments by individuals; and the rest (13%) is covered by private contributions. The different CMS projects which are shared with private firms will decrease to 49% by 2018 primarily because of the increase in public spending with the baby boomers reaching the age of coverage under the Medicare (Kaiser Family Foundation, 2009). These trends will mean that the public will be prompted to pay out-of-pocket expenses and will now experience higher premiums on their health insurance as well as the taxes imposed. Increase in medical costs means that one in five families will experience serious financial problems due to their high medical bills. They will also experience medical care-related impact due to their health care costs. Moreover, the growth in premium levels would mean that workers would be paying higher amounts as compared to previous years. Because of these trends, adjustments in costing are now being imposed by the government on taxes imposed and on citizens in general. The Medicare Quality Monitoring System (MQMS) is part of the Centers for Medicare and Medicaid Services to monitor the quality of the care delivered to Medicare beneficiaries (CMS, 2010). Quality indicators include aspects of health care involving the characterization of Medicare beneficiaries and their utilization of health care; acute myocardial infarction; heart failure; stroke; pneumonia; cardiovascular surgeries; cancer surgeries; diabetes preventive services; patient safety; and preventable hospitalizations (CMS, 2010). Such indicators affect the price of Medicare in the sense that with higher Medicare fee-for-service spending, a lower quality of Medicare service for beneficiaries may be seen. “For every 11,000 increase in Medicare spending per beneficiary, a state’s quality ranking dropped 10 positions” (The Commonwealth Fund, 2010). Moreover, higher rates in spending is sometimes linked to the greater use of hospital resources, however, it is not associated with higher patient satisfaction. Studies indicate that states who have higher primary care practitioners reflect improved performance on quality indicators and lower costs for their beneficiaries. Nevertheless, quality demands for Medicare services dictate higher costs of taxes imposed to cover Medicare costs. Works Cited Cato Handbook for Policy Makers (n.d) Cato Institute. Retrieved 27 May 2010 from http://www.cato.org/pubs/handbook/hb111/hb111-16.pdf CMS Publishes Final Rule On Hospital Regulations For Participation In Medicare, Medicaid (2006) Medical News Today. Retrieved 27 May 2010 from http://www.medicalnewstoday.com/articles/57764.php Cowen, T. (2008) Means Testing for Medicare. New York Times. Retrieved 27 May 2010 from http://www.nytimes.com/2008/07/20/business/economy/20view.html?_r=1 Medicare (2010). Medline Plus. Retrieved 27 May 2010 from http://www.nlm.nih.gov/medlineplus/medicare.html Medicare Program Quick Overview (2008) Medicare Consumer Guide. Retrieved 27 May 2010 from http://www.medicareconsumerguide.com/ Medicare Quality Monitoring System (2010) Centers for Medicare and Medicaid. Retrieved 27 May2010 from http://www.cms.gov/QualityInitiativesGenInfo/15_MQMS.asp Quality of Care and Medicare Spending at the State Level (2010) The Commonwealth Fund. Retrieved 27 May 2010 from http://www.commonwealthfund.org/Content/Performance-Snapshots/Variations-in-Care/Quality-of-Care-and-Medicare-Spending-at-the-State-Level.aspx Trends in Health Care Costs and Spending (2009). Kaiser Family Foundation. Retrieved 27 May 2010 from http://www.kff.org/insurance/upload/7692_02.pdf Understanding Private Health Insurance (2006) National Endowment Financial Education. Retrieved 27 May 2010 from http://healthinsuranceinfo.net/managing-medical-bills/Understand_Private_Health_Insurance.pdf Read More