Case Study Of Underuse: Lack Of Preventive Care

There are major challenges faced by policy makers such as trying to control the cost of Medicaid spending because Medicaid is the biggest payer of these services. Policy makers must ensure that they are also keeping the individual served front and foremost in their decisions. Ensuring that quality services are met is one piece of the puzzle. As stated, unfortunately it seems that those who have lesser insurance or who cannot afford these services are provided with less than

There is broad evidence that Americans often do not get the care they need even though the United States spends more money per person on health care than any other nation in the world. Preventive care is underutilized, resulting in higher spending on complex, advanced diseases. Patients with chronic diseases such as hypertension, heart disease, and diabetes all too often do not receive proven and effective treatments such as drug therapies or self management services to help them more effectively manage their conditions.

The dysfunction of the American health care system implies that not everyone has access to the right medication and medical treatment. Middle-class families and chronically ill patients do not always have access to health care, and when they do they do not receive adequate treatment with regards to hospitalization and medical services or quality of service. The lack of payment reform results in

In a survey conducted in 2003, it highlighted that the recurrent problem is the reimbursement rate from Medicaid to the physician (O’Shea, 2007). The Center for Studying Health System Change (HSC) show that 21% of physicians that state they accept Medicaid have reported they will not accept a new Medicaid patient in 2004-2005(O’Shea, 2007). This number would only logically be assumed to have risen in 2013 A survey conducted by the U.S. National Health reported that researchers have found two standout trends among Medicaid beneficiaries: they have more difficulty getting primary care and specialty care and they visit hospital emergency departments more often than those with private insurance (Seaberg, 2012). The lack of primary and specialty care access is mostly contributed to the following barriers; unable to reach the MD by phone, not having a timely appointment with the MD and lastly unable to find a specialty MD that will accept Medicaid. In a recent report released by the Partnership to Fight Chronic Disease, it stated that about 30% of Medicaid patients experience “extreme uncoordinated care”, there is a strong correlation between this situation and higher Medicaid spending and less quality of care given (Bush, 2012). After January 1st 2013, healthcare providers have experienced a 2% reduction in payments for Medicaid beneficiary, this will only create more of a problem for these patients to seek the

Emergency room over utilization is one of the leading causes of today’s ever increasing healthcare costs. The majority of the patients seen in emergency rooms across the nation are Medicaid recipients, for non-emergent reasons. The federal government initiated Medicaid Managed Care programs to offer better healthcare delivery, adequately compensate providers and reduce healthcare costs. Has Medicaid Managed Care addressed the issues and solved the problem? The answer is ‘Yes’ and ‘No’.

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

The Issue is that physician payments in Medicare and Medicaid, are already well below the prevailing rates in the private sector. On the average, physicians who take Medicare are paid 81 percent of private payment. Doctors who take Medicaid are paid 56 percent of private payment. This type of payment plan (Obamacare) has resulted in access problems for Medicare patients, and the even lower Medicaid payments have already caused serious access problems for lower-income people and made hospital emergency room overcrowded. During recent research study on the The Affordable Care Act they found that 67 percent of primary care physicians said that under current laws and conditions new Medicaid enrollees will not be able to find “suitable primary care

According to the Garber & Skinner (2008), the United States spends more on health care than other nations but continues to score below other nations in numerous areas of measurement. These scores in, consideration with amount spent, suggest that healthcare is the United States is inefficient. Additionally, the United States has a significantly large portion of under

In the current U.S. system the free market prevails and companies, in this case, major insurance providers “compete” for business. This competitive business approach should in theory drive costs down. For some reason, however, an argument can be made that it has produced the opposite result in profiteering. The nation’s largest insurer, UnitedHealth, boasted over a 10 percent revenue increase in 2013 according to Forbes (2013). Health insurance affordability contributes to the disparity in access to health care, as evidenced by the fact that there are millions that are still uncovered. A greater majority of certain minorities lack both health insurance and the financial resource to seek out either health care or insurance. While insurance companies reap huge profits the percent of private sector companies offering health insurance has dropped to less than 50 percent (Kaiser, 2013). There is decidedly a lack of coordination of care for this at risk population as well, since treatment is rendered sporadically and with continuously changing providers. The last major challenge is that of improving the quality of health care. According to a 2010 report by the U.S. Department of Health and Human Services, Office of Inspector General (OIG), an estimated 13.5 percent of Medicare beneficiaries experienced adverse events during their hospital stay and an additional 13.5 percent experienced a temporary

However, prior to the existence of the ACA, the American healthcare system left a lot to be desired and still today leaves room for improvement. The basic issues underlying efforts to improve the United States (US) health care system remain, as they have for decades, concerns for costs, access, and quality (Sultz, 2006). Even though knowledge, technology, and

Another factor that has contributed to the over-utilization and increased treatment charges is the fact that providers set the prices for services. Patients were free to seek any type of healthcare services that they thought they required for their well-being, while providers set the costs for each service that was billed to indemnity insurance companies (Shi & Singh, 2015). Insurance companies had little control on the types of services that the patient received and prices billed for each service. The fee-for-service model encourages excessive and unwarranted procedures and offers no incentives to utilize economical services

An aspect of Medicare and Medicaid that is important to look at is disease management because this affects budget and financial costs for both patient and government. Before we can look at the issue itself we need to be able to define what Disease Management is. According to Wikipedia.org (Wikipedia, 2008) disease management is “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant. It is the process of reducing healthcare costs and/or improving quality of life for individuals by preventing or minimizing the effects of a disease, usually a chronic condition, through integrative care.” The Centers for Medicare and Medicaid (CMS) organized a study to determine if disease management programs helped reduce costs for long term care for chronic conditions. Approximately 300,000 Medicare participants took part in about 35 programs. The idea was to assist these Medicare patients with chronic illnesses such as COPD, severe heart conditions, cancer and other conditions between office visits to prevent hospitalizations. The goal was to reduce the costs that accumulate with hospital visits, help the patient to have a better quality of life and the program save money (American Journal Health Pharmacy, 2009). The program worked as follows: health care providers were supposed to work with patients in return for receiving a small fee from CMS. The

The Health Affairs published an article in about a proposed Medicare reform regarding the high levels of use of Medicare although there was little impact on individuals. Though this article dates back to 2002, the issue still remains true to this day. In this article, the authors explain that the high level of Medicare spending was mostly due to the increase number of physician visits, specialist consultations, and hospital stays, especially among those that had chronic illnesses. Although the spending is higher among such Medicare patients, this did not mean better effective care or health care outcomes. On the contrary, according to the article, more than 20% of the total

Unnecessary services are provided far too often because there is little coordination across sites or among providers, yet care management, cross disciplinary care, and preventive care are often uncovered or poorly reimbursed. Notably, 45% of the U.S. population have chronic conditions requiring care management. Of this population, 60 million, or roughly half of those with chronic conditions, have multiple conditions. Current care delivery systems are not designed to support the care of these complex patients, which requires multiple providers and services.

I just wanted to add a bit more to the discussion of clinical grasp, as I find it quite an interesting concept to deliberate. The concept of clinical grasp should be carefully considered. Clinical grasp is associated with modus operandi thinking or “detective-like thinking” (p. 29). This type of thinking occurs when what was originally seen by the clinician is inaccurate and a new intervention is implemented instead. An interesting consideration pertaining to clinical grasp is that despite how developed best practice guidelines or clinical reasoning may be, when “clinical puzzles “(p.30) arise the issues cannot be solved without the use of clinical grasp or reasoning. I think the risk of blindly following best practice guidelines can be brought