Introduction
It is essential that nurses understand the issues related to health care, which are local and state financing, national healthcare policies, and initiatives that affect healthcare delivery. As a patient advocate, the professional nurse is in a position to work with patients and families to access available resources to meet health care needs. Nurses also have an ethical responsibility to be fiscally prudent in all practice settings to eliminate inefficiencies, and to promote best practices.
Task: Scenario 1: Note: For parts A and B, the suggested length is a combined total of 1–2 pages.
Mrs. Zwick, a 77-year-old widow and permanent resident of the United States, was admitted as an inpatient and hospitalized for five days following a mild stroke. She was transferred to a skilled nursing home for rehabilitation. The original projected time she would spend in the skilled nursing home was around 21 days. Mrs. Zwick was diagnosed with a hospital-acquired urinary tract infection 10 days into her stay at the skilled nursing home and required IV antibiotics. She was very weak and unable to participate in her rehabilitation for a full week. She remained in the skilled nursing home for a total of 40 days. A recently hired new graduate complained that the facility was not following the current evidence-based protocol related to urinary catheter care. Upon discharge from the skilled nursing home, Mrs. Zwick is prescribed several medications and a walker. Mrs. Zwick has Medicare Part A, Part B, and Part D. Her daughter is involved in her discharge plan and will be handling all of her medical bills. The daughter admits that she does not understand Medicare and confuses it with Medicaid. Before taking her mother home she asks you, the nurse, for assistance. Neither Mrs. Zwick nor her daughter is aware that the urinary tract infection was considered a hospital-acquired condition.
A. Discuss with Mrs. Zwick’s daughter, based on coverage requirements, which of Mrs. Zwick’s costs will be fully or partially covered by the following:
1. Medicare Part A
2. Medicare Part B
3. Medicare Part D
B. Explain how Medicare policies would affect reimbursement for the additional care Mrs. Zwick needed when she developed a hospital-acquired infection.
1. Discuss the ethical implications of Mrs. Zwick’s incurring costs related to her hospital-acquired condition.
Scenario 2: 2 pages.
Mr. Davis was diagnosed with sickle cell anemia in childhood. He is very familiar with his chronic condition that requires laboratory testing, hospitalization to manage sickle cell crisis, blood transfusions, oxygen, medications, vitamin supplements, hydration, pain management, and rest. In the past year, he has been hospitalized twice and, due to his long absence, was terminated from his factory job where he was covered by a group health insurance. The factory has more than 100 employees. Mr. Davis is very frustrated with the healthcare delivery in the United States. He says he wishes he lived in some other country where he could have better access to healthcare.
C. Explain how the Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow Mr. Davis to continue his insurance coverage while he is out of work.
D. Discuss two challenges that state or local government face in providing care for patients like Mr. Davis who lack insurance coverage and have long-term, chronic illnesses that require ongoing care.
1. Recommend one step that state or local government could take to address one of the challenges you have discussed.
E. Discuss whether it would be better for Mr. Davis if he were a citizen of Great Britain, Japan, Germany, or Switzerland based on his healthcare concerns. In your discussion, include the following points:
• Access for children, the unemployed, and retired persons
• Coverage for medications
• Requirements to get a referral to see a specialist
• Coverage for pre-existing conditions
F. Include all in-text citations and references in APA format.
A. Discuss with Mrs. Zwick’s daughter, based on coverage requirements, which of Mrs. Zwick’s costs will be fully or partially covered by the following:
For one to qualify for Medicare they be U.S. Citizens and answer at least one to the following questions: 1) Are you 65 years or older? 2) Are you under 65 years with certain disabilities? 3) Do you have end stage renal disease that requires transplant or dialysis? Therefore, since Mrs. Zwick is a U.S. Citizen and over the age of 65 years, she is qualified for Medicare benefits.
1. Medicare Part A- Mrs. Zwick is fully covered on her hospital stay at least three days of requirement; she stayed for five days as an inpatient in the hospital. She is qualified for skilled nursing facility for rehabilitation because it is related to hospital diagnosis. Her total days in skilled nursing facility were 40 days. Medicare A will cover the first 20 days in full and the remaining 20 days is covered with co-pay. However, Medicare A would not cover the newly diagnose urinary tract infection treatment including the medication. The walker is considered as home use medical equipment and Medicare A covers the walker.
2. Medicare Part B-Mrs. Zwick needs to pay premium unless the state covers the deductible or premium based in income. Medicare B covers most other service that Medicare A does not cover. Medicare B includes doctor's services, outpatient care, and preventive care.
3. Medicare Part D- Part D is prescription coverage in addition to Mrs. Zwick medical Medicare plan. Mrs. Zwick must enroll first and pay premium like co-pay, co-insurance, or deductible. The benefit of Medicare part D is to lower their prescription drug cost and to protect against future costs.
B. Explain how Medicare policies would affect reimbursement for the additional care Mrs. Zwick needed when she developed a hospital-acquired infection.
1. Discuss the ethical implications of Mrs. Zwick’s incurring costs related to her hospital-acquired condition.
Beginning October 1, 2008 the Centers for Medicare and Medicaid Services will no longer pay for any of the 10 hospital-acquired conditions. This is due to negligence and hospital responsibility for any nosocomial infection acquired during admission unless exceptions apply. Unfortunately, urinary tract infection is one of the conditions. This means Medicare will not pay for the treatment of Mrs. Zwick's hospital-acquired infection. Under the new rule, the hospital will have to absorb the cost of the urinary tract infection.
The ethical implication of Mrs. Zwick's medical cost is an issue of concern. Since the projection of recovery from rehabilitation is 21 days. However, Mrs. Zwick had a complication from urinary tract infection; in which Medicare consider a hospital-acquired infection, and the facility should be responsible. Due to extended stay of Mrs. Zwick from 21 days to 40 days, it imposes a substantial medical bill. The daughter has the right to complain and deserves an explanation since it hinders Mrs. Zwicks recovery. If the facility is proven for negligence, the daughter deserves to be reimbursed for any co-payment paid.
Scenario 2: Note: For parts C through E, the suggested length is a combined total of 1–2 pages.
Mr. Davis was diagnosed with sickle cell anemia in childhood. He is very familiar with his chronic condition that requires laboratory testing, hospitalization to manage sickle cell crisis, blood transfusions, oxygen, medications, vitamin supplements, hydration, pain management, and rest. In the past year, he has been hospitalized twice and due to his long absence, was terminated from his factory job where he was covered by a group health insurance. The factory has more than 100 employees. Mr. Davis is very frustrated with the healthcare delivery in the United States. He says he wishes he lived in another country where he could have better access to healthcare.
C. Explain how the Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow Mr. Davis to continue his insurance coverage while he is out of work.
Under Federal Law, Mr. Davis is eligible for continuation of his insurance under Consolidated Omnibus Budget Reconciliation Act or COBRA for 18 months. Federal law mandated employers having more than 20 or more employees to have an option for continual coverage of health insurance in case of termination of hours or employment. Mr. Davis is entitled for COBRA coverage.
D. Discuss two challenges that state or local government face in providing care for patients like Mr. Davis who lack insurance coverage and have long-term, chronic illnesses that require ongoing care.
One of the challenges under COBRA rules is the coverage of the medical bill. The employer pays 65% while the affected worker, Mr. Davis pays the remaining 35%. The government credits the employer as a tax deduction. By giving tax deduction to employers especially during the previous year of recession, the government funds declined. The second challenge would be recapturing the tax loss from the beneficiary who gain or benefited from COBRA. By giving credit to employers, the government tries to recapture the tax loss through the beneficiary, in this case the COBRA receiver. The second challenge for the state or local government facing during COBRA reimbursement is recapturing the premium from the beneficiary. In this case, Mr. Davis is unemployed and has a chronic disease, therefore finding a job won’t be easy and collecting money by the government would be a difficult task.
1. Recommend one step that state or local government could take to address one of the challenges you have discussed.
Building revenue by the government would be a challenging task and one way of collecting money is through tax. The government might have to increase the tax like payroll, real estate, and sale. Once revenue increases, the government can continue to support all federal and state programs like COBRA.
E. Discuss whether it would be better for Mr. Davis if he were a citizen of Great Britain, Japan, Germany, or Switzerland based on his healthcare concerns. In your discussion, include the following points:
• Access for children, the unemployed, and retired persons
• Coverage for medications
• Requirements to get a referral to see a specialist
• Coverage for pre-existing conditions
Great Britain has a universal health care system called National Health Service. It is financed by taxpayers’ revenue, and the government owns the hospital. The basic goal is to have all British citizens to have access to free health insurance. These citizens include children, the unemployed and retired people. There is no medical bill, premium, or deduction thus residents are not concern of expenses in regard to medical treatment. All treatment is free with the exception of certain charges in prescription. However, prescriptions are free to children, the elderly, and the unemployed. The only requirement for a patient to see a specialist is a referral from a gate keeper. Gate keeper would be a doctor in general practitioner or family practitioner. Pre-existing condition has limited coverage; however, Mr. Davis sickle cell anemia is a genetic disorder.
NHS covered the therapy and treatment specifically preventing complications before it happens like pneumonia or stroke. NHS will refer a patient with sickle cell anemia to a set of care specialist who will manage the treatment in prevention of complication. Care teams will organize screening at early stage, and treatment before complication will occur. NHS will cover his hospitalization that includes lab works, blood transfusion, oxygen, and drugs. Mr. Davis would benefit from universal health care compared to America's health care system because there is no medical bills including doctors visit, premium, and deduction. Finally, he does not need a job to qualify for health insurance.
