Signature Assignment: 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 reflect 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.
Length: 1750-2000 words in length
Structure: Include a title page and reference page in APA format. These do not count towards the minimal word amount for this assignment. Your essay must include an introduction and a conclusion.
References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment.
- Nickitas, D. M., Middaugh, D. J., & Feeg, M. D. (2019). Policy and politics for nurses and other health professionals: Advocacy and action. (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers. Read Chapters 11 & 12.
Medicaid and Medicare
Medicaid and Medicare are government-run programs that have several differences. The two programs are normally funded and operated by different parts of the government, and also the programs serve diverse groups. Medicaid program is regulated by both the federal and the state governments. It provides health insurance to low-income earners. On the other hand, Medicare is a program that is under the federal government. It provides health insurance to the elderly. One must be 65 plus years old. It also provides health coverage to individuals who have disabilities irrespective of their income and are below 55 years old. Medicare has four parts whereby each part covers different things; Part A, which is hospitalization coverage; medical insurance is covered under Part B. Part C, also commonly referred to as Medicare Advantage (MA) plans include part A and B, and provides extra coverage such as the vision and hearing. Part D covers the cost of prescription drugs. A person can be eligible for both programs if they tick all the requirements. This paper focus on the criteria that Medicare and Medicaid beneficiaries must meet, the impact of the ACA, and quality improvement organizations. The paper also addresses the responsibility of a health care leader in advocating for cost-effective care.
Quality Improvement Organizations
Quality improvement organization (QIO) comprises health quality experts, care providers such as clinicians, and healthcare consumers, whose aim is to improve the quality of care received by Medicare beneficiaries (Nathan, Thumma, Ryan, & Dimick, 2019). The quality improvement organizations have been divided into two main types, including beneficiary and family-centered care, which handles complaints from the Medicare beneficiaries, and quality innovation networks. The QIOs usually work under the direction of Medicaid and Medicare services in support of the quality improvement organization program. The quality Innovation Network unites the Medicare providers, communities, and Medicare beneficiaries through data-driven initiatives to promote patient safety, enhance post-hospital care coordination, increase the health of communities, and improve the quality of health care services for the Medicare beneficiaries. The program is federally based, and its mission is to enhance the cost-effectiveness, accuracy, and quality of care services provided to Medicare beneficiaries. The beneficiary and family-centered is a type of QIO that assists the Medicare beneficiaries to have their right to high-quality care exercised. This type of QIO helps handle the complaints from those enrolled in Medicare and also assesses the quality of care reviews to enhance uniformity in the review process. Beneficiary and family-centered care-QIOs also handle cases involving the beneficiaries appealing a health care provider’s decision to discontinue any service or discharge them from the hospital (Sonnenfeld, Li, Lichtenfeld, Shang, Herzer, Flemming, & Fleisher 2021).
How the QIO Improves Policies and Healthcare for Medicare Beneficiaries
One of the ways through which QIO improves policies and healthcare for Medicare beneficiaries is by ensuring the most current evidence-based interventions and practices are being used to deliver quality and safe care. They do so by working directly with health care providers and other healthcare stakeholders. QIO plays the role of conveners and local leaders as well as mobilizing state-wide efforts to support the health care improvement goals that the US department of health has put forward. This plays a vital role in improving the policies, and also it helps ensure that the healthcare services that beneficiaries receive are improved (Sonnenfeld, Li, Lichtenfeld, Shang, Herzer, Flemming, & Fleisher, 2021). The QIOs also foresee the modification of existing policies and healthcare by analyzing patient records and data to identify areas that need improvement. They also ensure that individual and community complaints are addressed, leading to improved healthcare (Digmann, Thomas, Peppercorn, Ryan, Zhang, Irby, & Brock, 2019).
Qualifications for Medicare and Medicaid Benefits
People eligible for Medicare enrollment include those aged 65 years or older who are End-Stage kidney disease patients and younger people with disabilities. There are four options under Medicare from which a person can select if they qualify, including part A, B, C, and D (Albrecht, Wickwire, Vadlamani, Scharf, & Tom, 2019). People who are 65 years or older can get premium-free part A Medicare if they worked and paid Medicare taxes about ten years or their spouse did the same. At the age of 65, if a person qualifies to get Social Security or Railroad benefits and have not yet filed for them, or the Railroad Retirement Board or Social Security are giving them retirement benefits or they were in government employment that was Medicare-covered makes them qualify to get part A Medicare without having to pay premiums. Those who are 65 years or older and failed to pay Medicare taxes during their employment years are allowed to buy Part A Medicare if they are a citizen or reside permanently in the US. Other people who qualify to get Part A without paying for the premiums are below 65 years old and have undergone a kidney transplant or undertaken kidney dialysis sessions, and those entitled to Social Security or Railroad Retirement Board disability benefits for 24 months (Kirchhoff, 2018).
Medicaid is regulated by both the state and federal government and provides health insurance to over 72.5 million people. The individuals covered by Medicaid include pregnant women, low-income families, children, and those who qualify for Supplemental Security Income (Poisal, & Jensen, 2019). There are other additional options that states include regarding Medicaid coverage and hence may opt to provide coverage to other groups such as children in foster care who are not otherwise eligible and individuals receiving community and home-based services. To be eligible for Medicaid, other non-financial eligibility criteria are usually considered, including being a resident of the state that they intend to receive Medicaid, must be a US citizen, or being a recognized permanent resident (Brown, 2019).
How can Qualifications be Modified
The qualifications can be modified by removing the citizen requirement to serve more people who are considered as a vulnerable population. This is important because there are a lot of people living in the United States and are part of the vulnerable population who have not yet applied for citizenship, while other people have applied for American citizenship, but the application process has been delayed. Removal of the citizen requirement will help most people considered a vulnerable population has access to quality health care.
Impact of ACA
One of the positive impacts of ACA is that it helped in Medicaid expansion coverage to nearly all low-income. The qualification for children was expanded to about 133% of the federal poverty level in each state (Carey, Miller, & Wherry, 2020). Also, states were allowed to increase eligibility to accommodate adults with income below or at 133% of the federal poverty level. According to Courtemanche, Marton, Ukert, Yelowitz, and Zapata (2018) states, that participated in the expansion of Medicaid reported an increase in insurance coverage which was equivalent to 9.5%, reduction in the possibility of reporting cost being a barrier to receiving care which was equivalent to 5.6% and an increase the number of beneficiaries having a primary care doctor which was equivalent to 3.4%. Another positive impact of ACA is that it came up with a new way for determining income qualification for Medicaid recipients, which is calculated on the basis of Modified Adjusted Gross Income. This positively impacted the recipients because it became easy for people to enroll and apply for the appropriate program by using one set of income counting rules.
ACA also bridged the Medicare Part D coverage gap. This was of great benefit to the recipients of Medicare because it helped reduce prescription drug spending. Initially, the Medicare beneficiaries were supposed to incur the total cost of the prescription drug in the coverage gap; however, the introduction of ACA helped reduce the costs by negotiating for government subsidies and manufacturer discounts. It also expanded Medicare preventive coverage to all Medicare beneficiaries. As a result, certain Medicare Part B services can now be completely covered for Medicare beneficiaries. Examples include depression screenings, alcohol misuse screenings, and counseling, obesity screening, HIV screening, etc.
One of the negative impacts of ACA is that it extends the services of Medicare and Medicaid to Americans only, and it does not apply to non-Americans. Another negative impact is that Medicare payments to health care providers, including hospice, home health, and skilled nursing facilities, were reduced following the introduction of ACA (Cabral, Carey, & Miller, 2021). Another negative impact is that Medicare Disproportionate Share Hospital payments were reduced, yet the payments compensated hospitals for providing care to uninsured and low-income patients. In 2020 the amount that Medicare Advantage plans received was mainly determined by patient encounter data. This is a rule that most insurers did not want.
Role of the Healthcare Leader
As a healthcare leader, I advocate for cost-effective care for vulnerable populations by educating insurance companies on the benefits of enrolling individuals from the vulnerable populations to different insurance premiums and how that will assist them in receiving quality care at an affordable rate. My other role is to connect people from the vulnerable population to health providers who provide affordable care without discrimination. As a healthcare leader, it is also my role to support bills and policies that aim at ensuring that individuals from the vulnerable population receive quality care at an affordable cost.
In conclusion, QIO comprises health quality experts and providers such as clinicians and consumers, who aim at improving the quality of care administered to Medicare beneficiaries. The organizations ensure the most current evidence-based interventions and practices are being used to deliver quality and safe care. The QIOs also act as conveners and local leaders and mobilize state-wide efforts to support the health care improvement goals. QIOs also identify areas that need improvement by analyzing patient data and records. Medicaid is regulated by federal and state governments and provides health insurance to people considered low-income earners. It also covers pregnant women, children, and people receiving Supplemental Security Income. Medicare covers people who are 65 plus years old, patients with End-Stage Kidney Disease, and younger people with disabilities. The introduction of ACA brought both positive and negative impacts on benefits and coverage for Medicare and Medicaid beneficiaries.
Albrecht, J. S., Wickwire, E. M., Vadlamani, A., Scharf, S. M., & Tom, S. E. (2019). Trends in insomnia diagnosis and treatment among Medicare beneficiaries, 2006–2013. The American Journal of Geriatric Psychiatry, 27(3), 301-309. https://www.sciencedirect.com/science/article/abs/pii/S1064748118305384
Brown, E. R. (2019). Medicare and Medicaid: The Process, Value, and Limits of Health Care Reforms. In Readings in the political economy of aging (pp. 117-143). Routledge.
Carey, C. M., Miller, S., & Wherry, L. R. (2020). The impact of insurance expansions on the already insured: the Affordable Care Act and Medicare. American Economic Journal: Applied Economics, 12(4), 288-318. https://www.aeaweb.org/articles?id=10.1257/app.20190176
Cabral, M., Carey, C., & Miller, S. (2021). The impact of provider payments on health care utilization: Evidence from medicare and medicaid (No. w29471). National Bureau of Economic Research. https://www.nber.org/papers/w29471
Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., & Zapata, D. (2018). Effects of the Affordable Care Act on health care access and self-assessed health after 3 years. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 55, 0046958018796361.
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://www.jmcp.org/doi/full/10.18553/jmcp.2019.25.3.402
Nathan, H., Thumma, J. R., Ryan, A. M., & Dimick, J. B. (2019). Early impact of Medicare accountable care organizations on inpatient surgical spending. Annals of surgery, 269(2), 191. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058185/
Kirchhoff, S. M. (2018). Medicare coverage of end-stage renal disease (ESRD). Congressional Research Service (R45290).
Poisal, K., & Jensen, K. (2019). Medicaid 201: Home and Community Based Services. Center for Medicare & Medicaid Services (August 27, 2019), available at< http://www. advancingstates. org/sites/nasuad/files/hcbs/files/4. https://www.eiseverywhere.com/file_uploads/c7c2883947785bc940012cde99d0c012_Medicaid201presentation.pdf
Sonnenfeld, N., Li, J., Lichtenfeld, J., Shang, K., Herzer, K., Flemming, R., … & Fleisher, L. (2021). Centers for Medicare and Medicaid’s Qin‐Qio Targeted Response Intervention Associated with Reductions in COVID‐19 Incidence in Nursing Homes. Health Services Research, 56, 52-52. https://onlinelibrary.wiley.com/doi/abs