Introduction
- Summary
- Medicaid
- Medicare
Analysis of challenges to Medicaid in terms of improving access to care, quality of care, and reducing the cost of care.
Analysis of challenges to Medicare in terms of improving access to care, quality of care, and reducing the cost of care.
Conclusion
• Conclusions about the future of managed care in each program
- Will it grow or decline?
- What will be the challenges for success?
Introduction
This research encompasses a study of managed care in United States of America as perceived under Medicaid and Medicaid provisions as health care coverage for citizens of America and permanent residents. Managed care is also perceived as managed health care. It is a term describing United States of America cost reduction health care initiative. It is expected to provide more health benefits at a lower cost to the provider and perhaps, ultimately lower quality health care to the recipient. Distinct techniques are adapted to regulate services, which could be accessed within the policy. Organizations that adapt these managed care polices function as providers to other organizations recommended within the framework. They are known as managed care organizations (MGOs). In describing managed care functioning from the perspective of financing it is termed managed care delivery systems (MCDS). This simply means delivery of care to specified enrollees with particular eligibility, who accept the techniques and concepts of the protocol (Kongstvedt, 2013)
Summary
- Medicaid
United States Medicaid is classified a social health care service program for low income Americans who cannot afford to pay for healthcare. Importantly Medicaid is perceived as government insurance system by The Health Insurance Association of America. The mechanism carters for people whose income cannot buy exorbitant health insurance plans (America's Health Insurance Plans (HIAA), pg. 232). Importantly, this is the largest health care funding initiative in the country (House Ways and Means Committee, 2014).
Medicaid is the largest source of funding for health-related services for low income persons within the society. This means-tested strategy is a joint funded state and federal government financial venture. Significantly, individual states have great privileges of designing medical eligibility for its residents. Precisely they are not obligated to participate in the program, but there are huge benefits to their comminutes if they do offer this service to residents. In order to receive be Medicaid eligible the person must be a United States Citizen or legal permanent resident. Undocumented immigrants are not eligible for Medicaid except for under very special circumstances such as pregnancy ( House Ways and Means Committee, 2014).
However, provisions under the patient protection act has greatly strengthened Medicaid eligibility among low income persons living in the society. For example, American Citizens and permanent legal residents with a poverty line income of 133% all eligible for Medicaid. Adult individuals with no dependent children are now eligible. Some states have, however, selected to maintain the former eligibility rules in order to control health care cost within their states. So far twenty seven of fifty two states in the United States of America have agreed and implemented Medicaid expansion (Kongstvedt, 2001).
- Medicare
United States, Medicare system is considered a national supplemental insurance for citizens and permanent residents over 65 years of age. It has been in operation from 1966 and is supplemented by 30 private insurance companies in providing services to the eligible population. This health care government designed program ensures that persons 65 years old and over have some medical benefits and resources to access health care in the country. However, to be entitled to Medicare these persons had to make a financial contribution to the fund while gainfully employed during their younger years. The amount of contributions made over the years determines the type of health care benefits they would be entitled to at the time of enrolment (Beeuwkes, Haviland, McDevitt & Sood, 2011).
The program also entitles insurance coverage for the elderly at a reduced cost. Younger citizens who have disabilities, end stage renal disease and amyotrophic lateral sclerosis are also eligible for Medicare coverage. Further, Medicare has been perceived to have a risk portfolio or underwriting in that employee who contribute the fund may never need to use it upon retirement they might have adequate coverage from their jobs apart being in a financially stable positon to obtain coverage from insurance companies without applying for Medicare benefits. However the social role of Medicare is different from Medicaid and private health insurance. Importantly, is disperses the financial risk of health care smoothly across the population (Center for Medicare and Medicaid, (2014).
Precisely, with this expectation of Medicare offering the best health care options to elderly Americans and permanent residents who have made their financial contributions to the fund 48 million Americans with disabilities were provided with health insurance in 2010. Forty million were age 65and over. The remaining 8 million were younger people suffering from disabilities. Statistics reveal that Medicare supported payments for an estimated 15.3 million inpatient hospitalizations in 2011. This accounted for approximately 47.2 % ($182.7 billion) of the total aggregate health care costs in United States of America (Beeuwkes et.al, 2011).
As a health care delivery strategy Medicare covers an estimated 48% of medical bills for the elderly and disabled Americans eligible for enrollment in the program. Ultimately, the remainder of the costs these individuals must cover. This process is facilitated through supplemental insurance scattered across the country. If they are not eligible for this type of insurances the costs must be paid out-of- pocket. another option relates to spousal eligibility. If an enrollee did not pay enough to into the fund to cover all health care services needed he/she can benefit from a spouse’s contributions. The combined contributions would make the deficient spouse entitled to more services. Medicare does no cover long term care and in some cases dental, vison. Most supplemental insurances cover vison and dental in their role to provide additional coverage (Center for Medicare and Medicaid, 2014).
Analysis of challenges to Medicaid in terms of improving access to care, quality of care, and reducing the cost of care.
The analysis of Medicaid delivery and function challenges, specifically, relate to quality of care, costs and accessibility. According to Gail Wilensky (2005) while both Medicaid and Medicare are causing concerns for federal budget it is Medicaid, which has the more depressing symptoms. For example, the current budget for Medicaid is alarmingly high due to federal spending in acute and long term care for low income citizens and permanent residents. The tendency has been for these minorities to be more ill and in need of more health care than persons of a higher income bracket. As such, Medicaid is challenged by a huge deficit in the health care budget (Wilensky, 2005).
Besides, health care cost in America is unaffordable for the low income society that does not have the resources for obtaining a proper diet along with exercise programs that would help deter the leading causes of acute /long term illnesses such as diabetes, hypertension, cancer, HIV/AIDS and heart disease. Consequently, in adapting managed care to control the huge cost of health care to people who cannot afford it (Wilensky, 2005).
Besides, the situation has been further complicated with the recent Medicaid expansion whereby more Americans now qualify for free health care under the program. With an already depleting resources services had to be curtailed under a scheme called managed care in an attempt to reduce costs while really reducing quality of care and accessibility? Research has shown where for almost 15 years participating Medicaid states have experimented with reducing health care cost for those who are eligible for Medicaid. Costs have escalated instead of going down because more people are becoming ill. Spending has been attributed to more persons being enrolled in the expanded program. Meanwhile the nation poor suffers from inadequate access to quality care, which is ridiculous. Medicaid covers a limited amount of services and with managed care the customer/patient does not have many choices if any( Keizer Health News (2014).
Analysis of challenges to Medicare in terms of improving access to care, quality of care, and reducing the cost of care.
Health care in America has been ad still continues to be challenged whether it is Medicaid or Medicare. Irrespective of how these challenges are perceived or worded they surround three important delivery features encompassed in quality of care, cost and accessibility. Managed care is expected to reduce cost, but can it guarantee quality improvement. Here the challenge lies in how could quality and accessibility of care could be measured when Medicare is just a supplemental insurance venture. The elderly still have to pay huge out of pocket costs despite coverage form other insurance companies known as HMOs PPOs ultimately the elderly even though many of them paid into the fund all their working lives still do not access the quality of care they deserve on many occasions because their choices are limited in the present managed care system. Yet still federal and state agencies complain that the cost of Medicare is equally high as Medicaid (AdvaMed, 2003).
Research shows where beside financial Medicare has its own acute administrative difficulties summarized in educating/Informing beneficiaries; applying information technology as required mechanism for administrative Tasks; arriving at National Coverage Medicare Determinations; administration of private plans within the system; eligibility determinations criteria; collecting premiums; implementation the appropriate payment systems and contractor selection difficulties. Other very sensitive features requiring orient attention pertain to addressing waste. fraud and abuse occurrences within the system. Essentially effort to main quality of services have often been compromised. As such, recommendations are for support in Medicare research and demonstration, which is delinquent (Gluck & Sorian, 2004).
Conclusion
Conclusions about the future of managed care in each program
- Will it grow or decline?
The future of Medicaid and Medicare seems very uncertain except if the federal and states devise a new system to fund health care in America. Obviously these two are not working. Adequate health care would reduce sickness and death, but this one has brought America to the 12th in life expectancy, globally in recent years. Incidentally America’s health care cost is the highest among nations of its economic caliber (Gluck & Sorian, 2004).
- What will be the challenges for success?
Obvious challenges to success would be health care providers who benefit from the revenue incurred by Medicaid and Medicare billing systems. Patients who have enticing coverage revive care that they do not need, while those who have meagre coverage are denied what they really need. Healthcare is a huge business in America when considered from the premise of med Medicare, Medicaid and health insurance policies. Managed care, it appears, has simply helped health care crooks to manage their businesses better.
References
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