MEDICARE
Scenario 1
- Medicare PART A,B,C
Different countries have distinct systems of healthcare put in place for providing diagnosis and treatment of health problems. In the United States, financing of healthcare is fundamentally via Medicare Insurance and it is categorized into Medicare Plans A, B, C, and D (Christiane, 2005). Individuals’ eligible for Medicare includes persons aged 65 years and over, the disabled, and individuals with end stage kidney problems.
Therefore, this is a case of Mrs. Zwick, a 77-year-old widow, admitted and booked for inpatient care for five days after she experienced a mild stroke. After being diagnosed, she was found to have obtained hospital acquired urinary tract infection during her stay at the nursing institution, and this implied that she needed intravenous antibiotics. Considering the condition of her health, the first part of this research paper evaluates her condition and her eligibility to either Medicare part A, B, and D (Isabelle & Burnand, 2009).
Based on the presented facts, Mrs. Zwick is eligible for Medicare Part A, which caters for admission in hospitals together with hospitalization costs and expenses, hospice or palliative care, and home healthcare expenses. Therefore, in this case, the expenses of Mrs. Zwick on inpatient as well as at the specialized nursing home are liable for coverage. Nonetheless, Medicare Part A , normally pays only a portion of the hospital costs of a patient usually calculated based on the length of time the patient has spent in the healthcare facility (Moon, 2006). This period of time is calculated starting with the initial day of admission till discharge that runs for 60 consecutive days.This means that the 5 days she spent in the facility were fully covered by Medicare part A.
Medicare part B on its part covers outpatient expenses and these comprises of doctors and nursing services fees, outpatient hospital procedures, diagnostic and laboratory tests, physical therapy, radiologic expenses, and fees charged on durable medical equipments (DME) like canes ,wheelchairs, and walkers. In this particular case, Mrs. Zwick is reserved for both inpatient and hospitalized nursing care, after which she is discharged to a skilled nursing home , whose costs are covered by Medicare part A . Considering the severity of her condition, durable medical equipment (DME) is required, and in this case being a walker, whose cost is shared between the health program and the patient on a 80 to 20% basis (Mitka, 2012).
Medicare part D would offer a cover for drug prescription for all individuals with Medicare legibility. Medicare part D prescription plans possess distinct features for different plans that range from Stand-Alone Prescription Drug Plan (PDP) to Medicare Advantage plan (MA). The unique feature with this plan is that it’s provided by private health insurance organizations and entities, which the government contracts .The plan is also optional for majority of people hence the idea to enroll and the tariff to choose largely depends on the patient medical needs and drug requirements. Though her distinct plan under Medicare part D is not clearly established, she still qualifies for Part D by virtue of being a Medicare holder (Green & Rowell, 2007).
- How Medicare policies would affect reimbursement for the additional care Mrs. Zwick needed when she developed a hospital-acquired infection.
There ought to be maintenance of due conscientiousness in the delivery of the patient care as Medicare does not cover for infections or diseases acquired while one is admitted in hospital. Infections and diseases resulting from medication errors or from omission or commission of activities that otherwise could be prevented are not considered for reimbursement (Christiane, 2005).In this scenario, Mrs. Zwick is said to have acquired some infections affecting the urinary tract while being treated as an inpatient at the hospital. Therefore, considering that Medicare cannot cover treatment expenses for such occurrences, the hospital is served with outright responsibility of treating Mrs. Zwick at no extra cost because the UTI was contracted during her stay in the hospital. In addition, there is no possible reimbursement by Medicare towards such treatment expenses (Moon, 2006).
B. 1. The ethical implications of Mrs. Zwick’s incurring costs related to her hospital-acquired condition
Hospital acquired infections are a major cause of injury as well as unavoidable deaths .Some of these infections are linked with unhealthy conditions in hospitals together with poor medical practices. Nursing professionals and clinicians and legally and ethically obliged by law and nurses code of ethics to uphold the best and quality treatment practices to hinder infections while a patient is in hospital. The infections of Mrs. Zwick took place in the hospital as she underwent treatment, and through this, she is protected by law from paying a bill for its treatment. In fact, suppose the infections were due to negligence or acts of omission and commission, the nurses and healthcare professionals involved are liable for legal suits and disciplinary actions from regulatory bodies based on their poor health practices (Pozgar, 2012). From an ethical point of view, it is not ethically right for Mrs. Zwick to pay towards a treatment for infections acquired during her stay in the hospital, and the hospital should maintain its reputation by covering all expenses on treatment and care relating to hospital acquired urinary tract infection.
Scenario 2
- How the Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow Mr. Davis to continue his insurance coverage while he is out of work.
The COBRA health policy states that in the event that an individual is unable to continue work or losses a job for any reason and was actively involved in the healthcare plan of an organization before leaving, the individual enjoys the right to continue his insurance coverage while he is out of work. This would only happen if he wishes to retain the health coverage for at least 18 months, a phase in time that may as well be lengthened in consideration of various conditions and eventualities for example due to disabilities or other health related conditions recognized by the Consolidated Omnibus Budget Reconciliation Act (Green & Rowell, 2007).
Based on this scenario, Mr. Davis is legible for the extension (continue his insurance coverage while he is out of work) for the reason that his employer has over 100 employees, a number that exceeds the minimum required of 20 workers, and before losing his job he was an active contributor and participant in the group health plan .Since Mr. Davis did not lose his jobs as a result gross misconduct but due to health complications at his workplace, he qualifies for the extension and on his part he is required to continue paying the premiums to fully enjoy the program services (Moon, 2006).
- 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.
Previous research studies have shown that majority of people who suffer from serious and long term illnesses are poor and lack insurance coverage. Because of this, it is essential for the government and policy makers to develop and implement healthcare insurance programs that cater for health needs of the poor and the uninsured in the society (Swartz, 2009). The cost of healthcare for individuals with long term and chronic health conditions is very high, and this exhibits massive challenges to state or local governments. Since many state and local governments budgets concentrates more on development and infrastructure creation, the health sector in most occasions is left with minimal funds to cater for complex and long term health needs. In fact, such cost could be affordable if such affected individuals possess insurance programs (Christiane, 2005).
Similarly, the cost of treatment and management of chronic and long term medical conditions has increased significantly in the recent past, and this is attributed to advancement in technology and establishment of more complex diagnosis and treatment regimens. Though the cost is high, most individuals possess health insurance plans that are either covered by the government or employers. Majority of insurance plans are on a large scale privately financed leaving the sick at the mercy of insurance companies. This means in many occasions the state or local government have no effective role or control on the care being provided. In other words, people get care depending on the amount they are willing to pay and these strains the available health resources in turn undermining the quality of healthcare delivery. Therefore, this research paper recommends the government to establish a universal health insurance plan that covers all individuals regardless of their economic status and health conditions. (Swartz, 2009). The health insurance market should also be managed by the government to curb exorbitant tariffs charged by the insurance companies.
- 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 many countries over the globe, health care backing comes first and surpasses other apprehensions of the public sector. However, in most western countries health care is somewhat ignored making the cost of healthcare expensive for majority of people. In Great Britain for instance, slightly more seventeen million individuals live with serious long term medical conditions, and most of the services provided are aided by the National Health Service and not private health insurance firms (Isabelle & Burnand, 2009). The NHS advocates for provision of free or affordable long term care to all members of the public that is based on the clinical needs rather than the capacity to pay. Since the NHS program covers chronic conditions among the unemployed, Mr. Davis would highly benefit from this plan. The German health program on its part advocates for a uniform and ‘equitable’ access to all healthcare services, and just like the Great Britain and Canada it does not discriminate on basis of economic status and employment. This means that this health scheme would also benefit Mr. Davis for the reason that it advocates support for individuals previously contributing to a health insurance scheme (Christiane, 2005).
Just like the US healthcare system, Japan health system is also in tartars and would not in any way confer any added benefit or advantage to Mr. Davis. In Japan, the national health program does not cover chronic medical conditions and it’s only the rich who have access to practically all types of healthcare while the poor only select from the reasonably priced options available often regarded as ‘ The General Healthcare Services’. Switzerland on the other hand has a comprehensive and obligatory health insurance program for all citizens .This program caters for both hospitalization and medication expenses and would be beneficial for Mr. Davis for the reason that the country’s health program also supports individuals’ chronic conditions via the chronic diseases management programs (Green & Rowell, 2007).
References
Christiane, L. (2005). Healthcare policy and reform in Germany and Sweden in the 1990s. San Francisco: GRIN Verlag.
Green, A. M., & Rowell, C.J. (2007). Understanding Health Insurance: A guide to billing and reimbursement. Mason, OH: Cengage Learning.
Isabelle, P. B., & Burnand, B. (2009). Inventory and perspectives of chronic disease management programs in Switzerland: an exploratory survey. International Journal of Integrated Care, 9(Oct 2009), 1-8.
Mitka, M. (2012). Medicare advantage, The Journal of the American Medical Association, 307(2), 134
Moon, M. (2006). Medicare: A policy primer. Washington, DC: The urban institute.
Pozgar, G. (2012). Legal and ethical issues for health professionals. Sudbury: Jones & Bartlett Publishers.
Resnick, B. (2007). Medicare, Journal of Clinical Nursing, 12(1), p.56.
Swartz, K. (2009). Health care for the poor: For whom, what care, and whose responsibility. Focus, 26(2), 69-74.
