Abstract
Over the years, Americans rely on Medicare and Medicaid to take care of their health care necessities. However, despite of their commitment to ensure quality health care access, these two publicly funded health programs which were considered as national treasures proved to be poorly coordinated. Access to care and quality of service were the common issues these programs struggled with. Beneficiaries are facing problems such as discrimination and inefficient service from health providers. There were cases of Medicare’s improper payments to providers with incorrect claims. In addition, Medicaid’s program shares more than 20% of the state’s disbursement which is a continuing pressure on the state budget. Its insufficient fiscal regulation result to misappropriation of federal funding. These irregularities could definitely lead to financial destruction to the states and the federal government placing these two programs at high risk. The government needs to reform its policies and procedures in order for these programs to work effectively. Upgrade their enrollment standards and procedures to reduce fraud. Revise their system on pre-payment and post-payment claims to help identify payment errors and overpayments. Strengthen their control of contractors on prescription drugs to narrow down waste and abuse. These reforms are the key factors to well-coordinated and reliable public health programs.
Keywords: Medicare, Medicaid, beneficiaries, misappropriation
In the United States, health care system is provided by various district associations both private and public sectors. Insurance programs such as Medicare and Medicaid are the two health providers administered by the government. Medicare program was signed into law by President Lyndon B. Johnson on July 30, 1965. This program is funded by federal government associated by people who are 65 or older and some younger people with disabilities. Medicaid program is funded by the state and federal government. It provides health coverage specifically for lower income people, the elderly, families and children and people with disabilities. Both programs are similar in a lot of ways but there are significant differences between them.
Medicare provides two types of coverage namely: Hospital Insurance (Part A) which is funded entirely by the government and Medical Insurance (Part B) which is partly paid by the beneficiary. Medicare’s benefit plan coverage costs less due to low administrative expenses. There are no accredited providers so a beneficiary can use private insurance plan and can choose any health providers or use his regular physician for routine health care. The program also covers certain rehabilitation treatments necessary for patients. Their benefits remain with them wherever they wish to live or relocate. While Medicare’s system and coverage is uniform in every state, Medicaid managed care benefit coverage vary in every state. The state provides list of accredited physicians and control their service fees. In return, these physicians are guaranteed of their payments from the government and continuous stream of customers. Individuals and families under low income bracket are provided with basic and specialized health care that do not require payment participation except for certain medical treatment. Medicaid pays for long term care services for individuals that require a nursing home medical care.
Though Medicare and Medicaid are strong government programs, they also have their share of weaknesses. Medicare does not pay for long term care so it has limited coverage for members who are suffering from chronic diseases with no known cure. Payments for nursing home patients are terminated after 100 days and may refuse to pay certain treatments. The Private Medicare Advantage offers many different plans but due to its complicated insurance benefit packages, it causes confusion among beneficiaries. Most of these plans set limits for seniors in their choice of physicians, hospitals and nursing facilities. On the other hand, Medicaid program sets limitations on the type of treatments and may not cover a certain procedure which affects the health of a patient and causes problems to the physician in terms of service. Reimbursements are low and take too long to process discouraging doctors to accept Medicaid patients and discriminate them. The level for home healthcare or nursing facility care is limited leaving the patients no choice on the type and location of care since care or treatment comes only from an accredited Medicaid provider. Unlike Medicare, it is not possible for a Medicaid beneficiary to maintain coverage while relocating to another state due to varying programs in every state.
The Centers for Medicare and Medicaid Services (CMS) provides Electronic Health Record Incentive program for Medicare wherein eligible professionals, hospitals and critical access hospitals can receive up to $44,000 after five years of payment and an additional incentive of 10% to those who provide services in a Health Professional Shortage Area (HPSA). To qualify for incentive payments, providers must demonstrate meaningful use every year. For Medicaid, Electronic Health Record Incentive program is run by its State Medicaid Agency. It provides incentives of up to $63,750 after six years of payment. Payments don’t have to be consecutive and there are no medical payment adjustments.
Medicare ensures that the elderly and disabled individuals will have access to quality health care. However, some people with chronic conditions, on low income and without back up insurance were faced with problems. They are not receiving primary care services because physicians are more careful in accepting patients with Medicare service payments. As for Medicaid, both adult and children patients have more problems in obtaining access to care. More doctors are refusing to accept Medicaid due to the program’s low reimbursement rates which make it harder for the patients to find access to primary and specialty surgeons. Cases of discrimination are common in nursing homes where patients have been turned down with their admission request when using Medicaid benefits to pay for their stay.
Elderly people have to utilize Medicare benefits to reduce medication and prescription costs. One of its major risks is that due to the rising numbers of elderly people compared to the working people who pay taxes, the government may not be able to sustain the plan in the coming years. The new Obamacare committee on cost-effectiveness will cut doctors’ services and reimbursements which will result to shortage of doctors causing patients to have limited access to treatments. The same thing happened to Medicaid’s managed care. Its long-term services and support faces a great risk due to the states pressure to cut costs by reducing services or cutting payment to providers to increase profits. This could lead to loss of vital services and reduction of consumer’s choice of treatment locations and providers. For beneficiaries, this cost cutting program could be a barrier to access quality care which could result to a more complex illness.
With the continuous cost cutting scheme among these two programs, will the elderly and disabled Americans continue to rely on Medicare and Medicaid? These are the issues that the government should take into consideration.
References:
Barrie, M.,(December 1, 2007). Useful List of Medicaid Disadvantages.
Life Health Pro. Retrieved from
http://www.lifehealthpro.com/2007/12/01/useful-list-of-medicaid-disadvantages
Siegel, M., (September 27, 2010). Medicare: Advantage or Disadvantage? Fox News.com. Retrieved from
http://www.foxnews.com/health/2010/09/27/medicare-advantage- disadvantage/
