Medicare
Medicare and Medicaid
Consider how people qualify to receive Medicare and/or Medicaid and write a paper that addresses the bullets below. There should be four (4) sections in your paper; one for each bullet below. Separate each section in your paper with a clear brief heading that allows your professor to know which bullet you are addressing in that section of your paper. Start your paper with an introduction and include a “Conclusion” section that summarizes all topics. This paper should consist of at least 1750 words and no more than 2000.
This week’s assignment reflects upon the Medicare and Medicaid programs to address the following:
- Describe the Quality Improvement Organization (QIO) and explain how the QIO improves policies and healthcare for Medicare beneficiaries.
- Briefly define the qualifications for Medicare and Medicaid benefits. How can qualifications be modified to serve more people who are considered a vulnerable population?
- Discuss the impact (including at least two positive and two negative aspects) that the ACA has had on benefits and coverage for Medicare and Medicaid recipients.
- Describe your role(s) as a healthcare leader as it applies to the practice of advocating for cost effective care for vulnerable populations.
Sample Answer
Medicare and Medicaid
Public health insurance in the US has experienced tremendous changes over the years. Medicare and Medicaid programs are some of the public insurance packages that have transformed healthcare finance in the US. After President Lyndon B. Johnson signed the Social Security Act, these two programs came to life, a bill proposing them into law on July 30th, 1965 (CMS, 2015). Initially, Medicare had two parts, including Medical Insurance (Part B) and Hospital Insurance (Part A). The two parts are currently known as “Original Medicare.” Congress has made changes to Medicare over the years by increasing eligibility and more benefits. Medicaid has also grown over the years. The program gave medical insurance to people only receiving cash assistance. However, the program currently covers pregnant women, low-income families, people with disabilities, and those in need of long-term care.
The Quality Improvement Organization (QIO) and Its Impacts Medicare Beneficiaries
The QIO
A QIO is defined as a group of clinicians, health quality experts, and consumers organized to improve the quality-of-care Medicare beneficiaries receive. QIO is categorized into two groups, including the Beneficiary and Family-Centered Care (BFCC)-QIOs and the Quality Innovation Network (QIN)-QIOs working under the management of CMS in support of the program (CMS, 2020). The BFCC-QIOs help individuals under Medicare to exercise their right to high-quality healthcare services. The BFCC-QIOs manage all complaints filed by the beneficiaries and ensure that they receive feedback as soon as possible. The BFCC-QIOs also evaluate the quality-of-care review to ensure that all the review processes are consistent and consider the local factors vital to the beneficiaries and their families (Digmann et al., 2019).
This branch of QIO also handles beneficiaries’ cases to challenge the health provider’s decision to discontinue some types of services or discharge them from hospitals. The QIN-QIOs bring providers, communities, and beneficiaries together in data-driven initiatives to improve the health of communities, patient safety, clinical quality, and coordination of post-hospital care (Fu et al., 2020). The QIN-QIOs consider the cultural factors and local conditions when bringing all the Medicare stakeholders together. 14 QIN-QIOs are serving the 50 states, and three terrifies within the US.
Impact of the QIO
The QIO has initiated a lot of programs that highly impacted healthcare for Medicare beneficiaries. For instance, the program undertook the 8th Statement of Work (SoW) between 2005 and 2008 (CMS, 2020). This SoW was focused on improving the quality of home health agencies, nursing homes, physician practices, and hospitals through organizational changes to produce measurable and rapid improvements in care (Digmann et al., 2019). the QIOs worked closely with healthcare providers to make internal systemic changes, such as applying healthcare informatics and redesigning processes to improve the quality of care beneficiaries receive. The QIOS also engaged in the 9th SoW, which occurred between 2008 and 2011 (CMS, 2020). The focus of the 9th SoW was to improve patient safety, preventive care, reduce disparities in diabetes management and preventive services, reduce readmissions, improve testing, management of chronic diseases, and protect Medicare beneficiaries against less-quality care.
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The SoW also focused on improving ways to solve beneficiaries’ queries and complaints. After implementation of the program, there was significant progress in using pay-for-performance, and pressure ulcers were greatly reduced. The SoW was presented to Congress, which applied it in making changes to Medicare. The QIOs also performed the 10th SoW between 2011-2014, and their focus was to reduce disparities in access to quality care and improve the quality of health among priority populations (Fu et al., 2020). The QIOs also worked to reduce adverse events, improve the use of healthcare information technologies, improve palliative and end-of-life care, and increase care efficiencies. The QIOs are currently working on the 11th SoW, which commenced in 2014 (Digmann et al., 2019). In summary, all the programs initialed by the QIOs aimed at improving the quality of care and services Medicare beneficiaries receive.
The Qualifications of Medicare and Medicaid Benefits and How Qualifications can to Serve More Vulnerable People
Qualifications for Medicare and Medicaid Programs
People must have certain qualifications before being enrolled in Medicare and Medicaid programs. People eligible for Medicare part A include younger people with disabilities, individuals aged 65 years and above, persons with End-Stage Renal Disease, and those enrolled in part B. The individual or spouse should have paid taxes for more than ten years (Meyers et al., 2019). One must be a US resident and be either a US citizen or an alien processed lawfully for permanent residence. The permanent resident alien must have stayed in the US for more than five years before applying for Medicare part B (Meyers et al., 2019). Medicaid is a joint state and federal health program that provides coverage to millions of Americans and the Children’s Health Insurance Program (CHIP).
The mandatory eligibility for the Medicaid program includes people with disabilities, individuals aged 65 years and above, children, and pregnant women below the federal poverty level (Blumberg et al., 2020). Individuals between 19 to 64 years below the federal poverty level, caretakers and parents of dependent children, people receiving Supplemental Security Income, children aging out of foster care, and children in foster care are also eligible (Blumberg et al., 2020). The people must satisfy state and federal requirements about immigration status, residency, and documentation of citizenship.
How to Modify the Qualifications to Include More Vulnerable Populations?
Medicare Medicaid programs can be modified to consider more vulnerable populations not included in the current qualification requirements. One of the modifications is giving states a mandate to determine the financial eligibility for Medicaid and CHIP. States in the US have different economic statuses, some are high, and others are low in terms of economy. Therefore, making eligibility criteria in a single state will increase the number of vulnerable people who can qualify for the program. The qualifications can also be modified by increasing the funding of the programs. Trust for America’s Health (2019) notes that the American healthcare system is greatly underfunded, which has undermined the functionality of healthcare programs, such as Medicaid and Medicare.
The US budget only spends $274 per person on health spending (Trust for America’s Health, 2019). If the budget allocated to the two programs is increased, their eligibility criteria can be modified to include more vulnerable people. Lastly, the qualifications can be modified by introducing a new law directing the CSM and states to include more people in the programs. The Affordable Care Act is one of the laws created to modify the eligibility criteria for the two programs to include more vulnerable populations.
The Impacts of Affordable Care Act on Medicare and Medicaid Recipients
Positive Impacts
One of the positive impacts of ACA on Medicare is reducing the payments to Medicare Advantage plans over six years. Before the ACA, the federal government paid Medicare Advantage plans 14% higher than the cost of the same beneficiaries under the initial Medicare program, which increased the cost of care. Second, the ACA included requirements to improve benefits for people under Medicare by offering free coverage for preventive services, such as screening. The improvements increased Medicare spending for parts B and D. ACA also led to the expansion of the Medicaid program, leading to improved affordability of care, utilization of services, access to care, and financial security among people with low-income. For instance, it expanded Medicaid to all US citizens under 65 years, and their family income is at or below the federal poverty level. The ACA also increased federal spending on Medicaid.
The federal government covered 100% of the program expansion cost and started covering 90% of expansion costs by 2020. The ACA also improved the management of Medicaid programs at the state level by requiring states to submit their yearly report on Medicaid enrollment. The ACA included eligibility for family planning services. Lastly, the ACA also positively impacted Medicaid by streamlining enrollment, eligibility, and renewal process. For instance, a person was only required to have a single application for subsidized exchange coverage, CHIP, and Medicaid.
Negative Impacts
Though the ACA had many positive impacts on Medicare and Medicaid programs, the law also negatively affected the two healthcare coverages. One of the negative effects of ACA is that the federal government had to increase taxes to fund the expansions recommended by the law and the ones to pay the taxes are Americans, including the beneficiaries. Another negative impact is that the law has not ensured coverage of all Americans from low-income families. According to the law, states can choose to expand the Medicaid programs or not. More than ten states have not expanded the Medicaid programs, thus denying Americans from these states the privilege to affordable care.
Role of a Leader in Advocating for Cost-Effective Care for Vulnerable Populations
Patient advocacy is one of the fundamental roles of healthcare leaders. Vallée-Tourangeau et al. (2019) note that advocacy is one of the ways nurses can show their empathy towards patients and that they are protective of them. As a healthcare leader, a nurse leader can advocate for cost-effective care for special populations. One of the roles is to develop proposals that aim to improve healthcare processes and reduce the cost of care. A healthcare leader can advocate for cost-effective care by proposing changes that will improve care processes and, at the same time, reduce the cost of care. Second, a healthcare leader can advocate for cost-effective care by pushing for and supporting health policies that aim to improve the quality of care and reduce medical errors. Healthcare leaders can push for and support health policies that aim to reduce care costs and present their points to the management during managerial meetings. They can also meet local leaders and communicate about the policies and their impact on the healthcare sector.
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Healthcare leaders can also advocate for cost-effective care by voting for organizational policies that aim to reduce care costs. Healthcare leaders are also part of organizational management and are pivotal in policy development. They can use the opportunity to vote for policies that aim to improve the cost of care and make care services affordable to vulnerable populations. Lastly, healthcare leaders can advocate for cost-effective care by pushing for the application of healthcare technologies in care provision. Rotty et al. (2021) note that healthcare technologies can reduce the cost of care by allowing patients to receive care at the comfort of their homes. For instance, wearable devices can allow nurses to monitor the health status of patients with diabetes away from a hospital setting, hence saving the cost of transport. Healthcare technology can also reduce the cost of care by decreasing incidences of medical errors and adverse effects.
Conclusion
QIOs are groups of clinicians, health quality experts, and consumers organized to improve the quality of care Medicare beneficiaries receive. The QIOs impact beneficiaries by improving the quality of home health agencies, nursing homes, physician practices, and hospitals through organizational changes to produce measurable and rapid improvements in care. The QIOs also improve patient safety, preventive care, reduce disparities in diabetes management and preventive services, reduce readmissions, improve testing, manage chronic diseases, and protect Medicare beneficiaries against less-quality care. People eligible for Medicare part A include younger people with disabilities, individuals aged 65 years and above, persons with End-Stage Renal Disease, and those enrolled in part B. The mandatory eligibility for the Medicaid program includes people with disabilities, individuals aged 65 years and above, children, and pregnant women below the federal poverty level. The ACA impacted the Medicare and Medicaid programs by expanding them and increasing federal funding in the programs.
References
Blumberg, L. J., Simpson, M., Holahan, J., Buettgens, M., & Pan, C. (2020). Potential eligibility for Medicaid, CHIP, and marketplace subsidies among workers losing jobs in industries vulnerable to high levels of Covid-19-related unemployment. Washington, DC: Urban Institute. https://www.urban.org/sites/default/files/publication/102115/potential-eligibility-for-medicaid-chip-and-marketplace-subsidies-among-workers-losing-jobs-in-industries-vulnerable-to-high-levels-of-covid-19-related-unemployment_0_0.pdf
Centers for Medicare & Medicaid Services (2015). Medicare and Medicaid. Milestones: 1937-2015. https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf
Centers for Medicare & Medicaid Services. (2020). Quality improvement organizations. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityImprovementOrgs
Davoodvand, S., Abbaszadeh, A., & Ahmadi, F. (2016). Patient advocacy from the clinical nurses’ viewpoint: A qualitative study. Journal of Medical Ethics and History of Medicine, 9, 5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958925/
Digmann, R., Thomas, A., Peppercorn, S., Ryan, A., Zhang, L., Irby, K., & Brock, J. (2019). Use of Medicare administrative claims to identify a population at high risk for adverse drug events and hospital use for quality improvement. Journal of Managed Care & Specialty Pharmacy, 25(3), 402-410. https://doi.org/10.18553/jmcp.2019.25.3.402
Fu, C. J., Agarwal, M., Dick, A. W., Bell, J. M., Stone, N. D., Chastain, A. M., & Stone, P. W. (2020). Self-reported National Healthcare Safety Network knowledge and enrollment: A national survey of nursing homes. American Journal of Infection Control, 48(2), 212–215. https://doi.org/10.1016/j.ajic.2019.08.016
Meyers, D. J., Belanger, E., Joyce, N., McHugh, J., Rahman, M., & Mor, V. (2019). Analysis of drivers of disenrollment and plan switching among Medicare Advantage beneficiaries. JAMA Internal Medicine, 179(4), 524-532. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725083
Rotty, M. C., Suehs, C. M., Mallet, J. P., Martinez, C., Borel, J. C., Rabec, C., … & Jaffuel, D. (2021). Mask side-effects in long-term CPAP-patients impact adherence and sleepiness: The InterfaceVent real-life study. Respiratory Research, 22(1), 1-13. https://doi.org/10.1186/s12931-021-01618-x
Trust for America’s Health. (2019). The impact of chronic underfunding on America’s public health system: Trends, risks, and recommendations. https://www.tfah.org/report-details/2019-funding-report/
Vallée-Tourangeau, G., Promberger, M., Moon, K., Wheelock, A., Sirota, M., Norton, C., & Sevdalis, N. (2018). Motors of influenza vaccination uptake and vaccination advocacy in healthcare workers: Development and validation of two short scales. Vaccine, 36(44), 6540-6545. https://doi.org/10.1016/j.vaccine.2017.08.025