Financial Models and Reimbursement
This Competency Assessment assesses the following outcome(s):
MN507-2: Analyze financial models of reimbursement and their effects on patients and health care providers.
For this Assignment, you will distinguish between Medicare and Medicaid. Your paper must include the following topics:
- Provide a brief history of both Medicare and Medicaid.
- Define the populations that they are intended to serve.
- Determine whether your state has expanded Medicaid.
- Articulate the reasons that states choose not to participate in Medicaid expansion.
- Analyze your role in your specialized area of nursing practice when interfacing with Medicare and/or Medicaid recipients.
The word count for your paper, excluding the title page and references page, will be 800–1200 words. You must include a minimum of (5) different scholarly references.
Before finalizing your work, you should:
- be sure to read the Assignment description carefully (as displayed above);
- consult the Grading Rubric (under the Course Resources) to make sure you have included everything necessary; and
- utilize spelling and grammar check to minimize errors.
Your writing Assignment should:
- follow the conventions of Standard English (correct grammar, punctuation, etc.);
- be well ordered, logical, and unified, as well as original and insightful;
- display superior content, organization, style, and mechanics; and
- use APA formatting and citation style.
Brief History of Both Medicare and Medicaid
Medicare and Medicaid were established through an amendment of the Social Security Act that was signed by President Lyndon B. Johnson on 30th July 1965. The amendment sought to create a healthcare program for older adults above 65 years through their social security contributions. The amendment was part of the social reform movement by the President, which was known as the Great Society. The goal of the reform was to eliminate racial injustice and poverty. The idea of having a national health system began as early as 1900, but no major development was made over the years. President Harry S. Truman in 1945 called for the establishment of a national health insurance fund, but the bill was not passed by congress. The amendment by president Lyndon took effect in 1966, although it was signed in 1965. President Johnson enrolled Truman as the first Medicare beneficiary and the wife as the second. The first Medicare had only part A and part B (Piatak, 2017).
The Population that Medicare and Medicaid aimed to Serve
Medicare was intended to serve older American adults over the age of 65 years. At the time of creation, most Americans had no health insurance after their retirement making health care inaccessible. Medicare was a solution as older adults gained insurance through their social security contributions. The older Americans were not served efficiently by the insurance market due to the existence of employment-linked group coverage. Those who recommended and championed the establishment of the program believed that it was an initial plan of moving towards the achievement of health coverage for all. Medicaid, on the other, provided federal matching funds to the state to facilitate the provision of additional health insurance to elderly people with low incomes and people with disabilities. The Medicare program started as a mandatory plan covering the hospital and not physician costs. This was part A of Medicare. Part B of the program covered physician costs (Piatak, 2017).
Whether Maryland State Has Expanded Medicaid
Maryland has an expanded Medicaid, which was implemented under the Affordable Care Act. The state authorized the expansion in May 2013, took effect on 1st January 2014. The eligibility limits in the state are generous compared to other states. Medicaid program in Maryland is known as Medical Assistance. The state has the highest income limits required for qualifications for Medicaid. Qualifications include 259% of the federal poverty level (FPL) for pregnant women, 317% of the FPL for children aged between 0 to 18 years, and 138% for parents and other adults (Norris, 2021). Individuals who qualify for Medicaid in the state receive assistance through the Medicaid program with Medicare premium costs, expenses not catered by Medicaid, and prescription drug expenses. Residents in Maryland benefit from payment for long-term care. The state undertook the expansion after thorough research on the impact that the expansion would have on individuals and the state. The state estimated that Medicaid expansion would have a positive impact on the economy, such as the creation of 27,000 jobs by 2020 and an estimate of $25 billion in Medicaid funding from the federal government (Norris, 2021).
The Reasons That State Choose Not to Participate in Medicaid Expansion
A total of 12 states are yet to participate in Medicaid expansion, citing many reasons for their decision. One of the reasons is that Medicaid expansion harms the poor. According to the states, expanding Medicaid will create competition for patients who cannot afford other insurance coverage, decreasing access to care for the vulnerable population. According to Van Houtven et al. (2020), studies indicate that Medicaid expansion may be associated with increased access to long-term care for middle-aged and young adults with no disability. Such individuals do not fall under the vulnerable population, who are the priority for the program. This puts the vulnerable population comprising of the old and those with disabilities at a disadvantage as they may suffer decreased access to care characterized by a longer waiting period to access care. The states also fear increased barriers to accessing care as health care providers may drop out. Studies indicate that Medicaid beneficiaries often report facing discrimination based on their insurance and experience provider-patient interactions decreasing the likelihood of receiving preventive health services (Allen et al., 2017).
The states also cite the risk of Medicaid exploding. States argue that Medicaid spending has increased by more than 250% since 1990. The states estimate that Medicaid spending will rise as the federal matching rates associated with the expansion begins to drop. The states estimate that additional spending will crowd out funds that should be channeled towards education, parks, transportation, public safety, and other projects essential to the public. Other reasons include worsening of the cycle of dependency, which increases the risk of harm to the economy, crowding of private coverage, and increased problem of uncompensated care.
My Role in Specialized Area of Nursing Practice When Interfacing with Medicare and/or Medicaid Recipients
As a family nurse practitioner, I focus on providing preventive care treating chronic illness and other health issues. In Maryland, I have full practice authority, meaning I can practice independently and care therefore provide healthcare in private practice. This provides an opportunity to improve the experience of Medicare and Medicaid recipients and outcomes. Studies establish a link between the full scope of practice for nurse practitioners and improved access to care and cost-effective health care (Barnes et al., 2017). I have an opportunity to enroll a significant number of the beneficiaries in my practice. These increases care access for the recipients.
As a private healthcare provider, I can accelerate the transition to value-based care. Value-based care comprises redesigning health care delivery to provide more value to the patients. Studies show that Medicaid and Medicare recipients report discrimination, strongly associated with poor healthcare-seeking behavior. As a primary care provider, I can improve the experience of the beneficiaries by providing quality care and improving their experiences to improve healthcare-seeking behavior and outcomes. I can achieve this by maintaining proper provider-patient relationships based on respect and mutual trust. I will use open communication to maintain the relationships. A breakdown in the patient-provider relationship manifests as unsatisfactory communication between the patient and the provider. A good relationship between a provider and a patient is characterized by the ability of the patient to share vital information that promotes accurate diagnosis and a better understanding of the patient’s needs (Kee et al., 2018). I intend to achieve a good relationship to improve the experience of recipients of Medicaid and Medicare.
Allen, E. M., Call, K. T., Beebe, T. J., McAlpine, D. D., & Johnson, P. J. (2017). Barriers to care and healthcare utilization among the publicly insured. Medical care, 55(3), 207. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5309146/
Barnes, H., Maier, C. B., Altares Sarik, D., Germack, H. D., Aiken, L. H., & McHugh, M. D. (2017). Effects Of Regulation and Payment Policies on Nurse Practitioners’ Clinical Practices. Medical Care Research and Review, 74(4), 431-451. https://journals.sagepub.com/doi/abs/10.1177/1077558716649109
Kee, J. W., Khoo, H. S., Lim, I., & Koh, M. Y. (2018). Communication Skills in Patient-Doctor Interactions: Learning from Patient Complaints. Health Professions Education, 4(2), 97-106. https://www.sciencedirect.com/science/article/pii/S2452301116301225
Norris, L. (2021). Maryland and the ACA’s Medicaid Expansion.
Piatak, J. S. (2017). Understanding the implementation of Medicaid and Medicare: social construction and historical context. Administration & Society, 49(8), 1165-1190.
Van Houtven, C. H., McGarry, B. E., Jutkowitz, E., & Grabowski, D. C. (2020). Association of Medicaid Expansion Under the Patient Protection and Affordable Care Act with use of long-term care. JAMA network open, 3(10), e2018728-e2018728. https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2771117