A Brief Note On The Health Care Program

The Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.

The U.S. health care system is way more complex than what meets the eye. A major difference between the health care system in the U.S. and other nations, is that the U.S. does not have universal health care. Lack of a universal health care opens up the doors for competition amongst insurance, physicians, technology, hospitals and outpatient services.

rehend the PPACA, one must understand the history of the United States’ health care system. The most successful and known reform would be the passage of Medicare and Medicaid. President Johnson’s main objective with his program was to provide health insurance to those over 65 years old, who otherwise wouldn’t be able to receive coverage due to retirement or being financially unfit to purchase health insurance. It has since been expanded to cover those with disabilities, and lower income families (“Overview,” 2015). Brady (2015) examines President Clinton’s attempt to massively overhaul health care in the United States. His plan, the Health Security Act (HSA), required employers to offer health insurance to their employees, and mandated that every US citizen purchase health insurance. This plan would have most likely expand health insurance to many more Americans; however, many feared the large tax increases, restricted options for patients, and with the lack of general support for the bill, it failed in Congress and was never implemented (p. 628). President Clinton’s failed attempt at health care reform opened up the door to future reforms, and it even shared multiple similarities to the PPACA. Smith (2015) updates the history of the health care system in America stating that “In the mid-2000s, America’s uninsured population swelled to nearly 47 million, representing about 16 percent of the population” and how “16 million Americans […] were underinsured” (p. 2). People

The United States health care system is lacking the needs to create a reliable system to achieve quality, access, cost, and educate for the consumers. Despite the efforts of the government to find a common ground to meet the standard for the societies, the system has yet to have a major improvement. These issues must be reexamined to fix the broken system. The United States health care expenditure is another issue that needs to be addressed to achieve the future goals of the healthcare system in the United States. Healthcare societies will need to interact differently by incorporating consumer’s empowerment, technology, and education to meet the future goals of the health care system. Also, the consumer must be highly educated on the purpose of preventive care to lower the risk of chronic diseases which account for a lot health care spending. The process of correcting the United States health care system will take time and effort from all individual to achieve greatness.

Health care in America is a serious issue as it involves families that are unable to receive accessible, affordable and quality medical treatment. Middle class or impoverished families are unable to receive the benefits of health care due to low income levels and a volatile economy. Politicians discuss the reformation of the health care system, but people who are uninsured suffer the consequences of a system that overlooks middle class families in favor of wealthy families, a dominant issue for conflict theorists. Some argue that the health care system is not in need of reform and state that

While our understanding has evolved with respect to certain advantages of MCO’s, our understanding of the disadvantages has also grown. This analysis will evaluate the use of MCO’s as a gatekeeper to controlling health care cost and offerings. It will evaluate the advantage MCO’s provide in a rapidly growing market due to the aging of baby boomers. The analysis will evaluate disadvantages that can arise with relying on MCO’s. These disadvantages work against the insurance company forcing a polarizing balance between how much control the MCO should retain over recommendation and provision of services.

TRICARE is formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and is a health care program of the US Department of Defense Military Health System. Following WWII and the Korean War, access to care in military facilities became less available by civilians and active-duty personnel due to a lack of resources, or a constraint of them, and growing demands on the system, and “space-available basis” was first addressed. As a solution, Congress passed the Dependents Medical Care Act in 1956 and the Military Medical Benefits Amendments in 1966. Such acts allowed the Secretary of Defense to work with civilian health care providers and contract their services. This health civilian health care program became known as the CHAMPUS in 1966. The responsibility of maintaining the health care initiative within the Military lies upon the U.S. Department of Defense Military Health System, which organized the Tricare Management Activity (TMA). The TMA consists of a contract-structure between several large health insurance corporations to provide claims processing, customer service and other administrative functions to the TRICARE

Desperate and in need of help family members may look towards the military as the possible solution to their situation. Tricare, the name of the military health care, is provided to every service member and their family in return for their four to five years of service. Tricare states that the company “provides services including dental insurance, mental health care, pharmaceutical needs, special needs coverage and vision care based on the variety of coverages a member receives” (Tricare 1). All of these health care services provided could help those in need. Providing health insurance is one of the military’s special tools for gaining volunteers. Instead of forcing people to join, offering services to others in need helps draw volunteers.

The health care, policy-making process is composed of three major stages; the formulation stage, legislative stage, and the implementation stage. The policy process refers to the specific decisions and events that are required for a policy to be proposed, considered, and finally either implemented and/or set aside. It is an interactive process with multiple points of access providing opportunities to influence the multiple decision makers involved at each stage (Abood, 2007). Each stage presents a unique set of events for a policy to be proposed, considered, and either implemented or rejected. In the formulation stage there is

Tricare is a health care policy for those in the military, their families, and retirees. Tricare is managed by the defense department. Tricare covers the uniformed services, including the Army, Navy, Marines, Air Force, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration. Tricare compromises families three choices of health care benefits which consist of Tricare prime this is a health maintenance organization, Tricare extra which is a managed care network or health care providers that families can use on a case-by-case basis without a required enrollment and Tricare standard which is a fee-for-service plan. Tricare also offers a plan for those Medicare eligible military retirees and Medicare eligible family members. This program offers the opportunity to receive health care at a military treatment facility for individuals aged 65 or older who are eligible for both Medicare and Tricare. Tricare billing consists of several elements which are; check in process information that is needed such as benefit verification, pre-authorizations, and forms used, coding from the medical such as what forms are needed for the process of coding, then a scenario with the actual ICD-9 and or CPT codes, the type of claim forms that were used and the claims verification process and finally, the claims payment process such as verification and accuracy of payment. Also the possibility of rejection and how to resolve issues that may become present.

What is TRICARE? A question that many of us really do not know how to answer. TRICARE is a major part of the Military Health System, its purpose is to combine the resources of military hospitals and clinics with civilian health care networks, provides access to high-quality health care, supports military operations and readiness. In order to participate in TRICARE benefits, beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) before you can reap these benefits.

Merriam-Webster dictionary defines social insurance as, “protection of the individual against economic hazards (as unemployment, old age, or disability) in which the government participates or enforces the participation of employers and affected individuals” (1). The United States government operates several national social insurance programs. Medicare is the United States’ first medical social insurance program. This program was designed to provide health insurance to the elderly and protect them from financial hardship due to illness. A thorough investigation of this program reveals the overall history, financial cost, and the total effect that it has had on the healthcare system.

Tricare, which was formerly known as the Civilian Health and Medical Program of the Uniformed Services, is a health care program of the United States Department of Defense Military Health System. Tricare provides civilian health benefits for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. There are three types of medical plans with Tricare: Standard, Extra, and Prime.

The external stakeholders are the community, patients, MedKey System members, CMS, HMOs (ie. Blue Cross Blue Shield and Tri-Care), and any other private insurances (Richards & Slovensky, 2004). Medicare reimbursement in Alabama was the lowest rate in the nation. This was a constant struggle for the hospital administrators to try to operate on such low reimbursements for their services, which is a threat. Eighty percent of patients were Medicare or Blue Cross in which there was difficulty-negotiating prices with Blue Cross due to monopoly. Buyers have high bargaining power as reimbursements rates are low from Medicare and Blue Cross held monopoly in the services area so negotiating prices was difficult. Suppliers have lower bargaining power due to low Medicare reimbursements and difficulty negotiating prices with Blue

In Michigan, there are many health care programs available to adults, children, and families. The goal of the health care programs are to make sure that necessary health care services are made available to those who otherwise don’t have the financial resources to purchase it. In Michigan, each health care program has certain eligibility requirements.