Medicaid In Healthcare

The purpose of this paper is to give an overview of two federally and/or state funded programs. The programs that will be discussed are Medicare and Medicaid. In this paper will be information about who receives Medicaid/Medicare, the services offered by these programs, and those long term services that are not.

Medicaid has help many qualified Americans who were historically unable to access health care. At the same time, it has raised questions and controversies as how efficient is the plan overall. Various research studies were conducted and contradicting results were presented. According to Paradise and Garfield (2013), some said that having no coverage at all is better that having a Medicaid coverage. On the other hand, some expressed that Medicaid paved a way to improved health due to increased access to services that provides prevention of diseases, health maintenance, and effective treatment (Paradise & Garfield, 2013). As for me I am in favor of the later, health care access for all. It comes down to equitable distribution of resources

Medicaid is defined as being a jointly funded state-federal health care program administered in Texas by the Health and Human Services Commission. Medicaid was established in 1967 and also stemmed from Patient Protection and Affordable Care Act P.L. 111-148 (Strategic Decision Support Team, 2010). Some of the goals and objectives within Medicaid are to make it less of a struggle for clients to get care, protects against out-of-pocket through the roof cost, and also to achieve cost savings for the state and federal government through the many improvements in coordination, as well as care (Eighty-First Texas Legislature, 1967).

In order to more fully delve into this issue, this literature review will be focusing on three main areas of study as it applies to the topic of Medicare/Medicaid reimbursement and its relation to the Affordable Care Act. These areas of focus will include

Medicaid initially established that each state is responsible for designing their medical costs to pay medical care for the poor. Also, Medicaid created as a voluntary program for each state; they have to have the choice to participate. For one thing, because of the rising costs of healthcare, it has been difficult to bring Medicaid recipients into the “mainstream” of United States (U.S.) medical care. Donald R. Barr notes, “between 1975 and 1989, the cost of the Medicaid program increased by an average of 11.9 percent per year before adjusting for inflation” (172). The rising costs of healthcare are necessary for each state to determine if it is beneficial for them to participate in the Medicaid program. As the government level of payment is determined by each state economic condition. For instance, a state with lower per capita income will receive more government funding. A state with higher per capita income receives less reimbursement for program costs. Therefore, on December 31, 2010, many states continued to experience budget cuts. As a result on August 2010, Congress increased reimbursement rates through June 2011.

There is expected to be roughly 17 million individuals becoming newly insured through the Medicaid Expansion of the PPACA by 2019 (Carrier, Yee, & Stark, 2011). The expansion of Medicaid will create a major supply and demand issue within the health care services. Simply put, the demand for primary care services will exceed the capacity of the current primary care infrastructure. This will only add to health care spending because the newly insured individuals will not have many options to obtain primary care services and they may be forced to use inappropriate services such

On January 1, 1991, The Medicaid Drug Rebate Program was set into place. The purpose of the Medicaid Drug Program was to help manage the cost of prescription drugs. The program allows each state to control a specific list of drugs covered, their generic counterparts, and alternative treatment options (Medicaid History).

The delivery system reform include: Mandates that the Secretary of Health and Human Services adopt value-based purchasing and payment methods for Medicare reimbursements for both physicians and hospitals. Creates incentives to reduce preventable hospital admissions. Creates a new Center for Medicare and Medicaid Innovation that will research, develop, test, and expand innovative payment and delivery arrangements. Encourages the formation of Accountable Care Organizations (ACOs) that allow hospitals and doctors to work together to manage and coordinate care and provides that these ACOs will receive a share of the savings they achieve for Medicare

Medicaid provides medical assistance to citizens in the United States who fall within the eligibility requirements. Medicaid has been enacted since 1965 and has faced many changes. One change most recently was the Patient Protection and Affordable Care Act, and the attempt to require states to expand Medicaid coverage to include more citizens. However, Medicaid is a states’ right and therefore Congress decided to leave expansion up to each individual state. As some states decide to move forward with expansion and some do not, this paper will discuss the pros and cons to each option and the financial impact that Medicaid expansion has on healthcare entities.

Mrs. Jones, like many older adults, is on a fixed income, has Medicare for health coverage, but lacks prescription drug coverage. She was recently prescribed a new medication by her physician, which she cannot afford. As Mrs. Jones nurse, it is my responsibility to advocate for her by providing education and sharing information on the multiple different avenues available to decrease the cost of the medication prescribed. I will identify three strategies in which I can help Mrs. Jones afford her medication. First, I will provide education on her insurance plan and explain Medicare Drug Plans and their enrollment process. Secondly, I will identify a financial assistance program which she might qualify for. Finally, I will identify different ways to lower the cost of the medication such as coupons, drug discount cards, switching to a generic medication, and store programs ("Prescription Drug," 2014). All of these options are a solution to Mrs. Jones problem. In the meantime, it may be beneficial to obtain free samples from the physician 's office if possible, but this only makes sense if there is a strong likelihood that she will eventually be able to afford the new medication.

The HRSA allowed those eligible entities, even those with in-house pharmacies to contract with outside pharmacies, “In one year, from April 2010- April 2011, the number of contract pharmacy arrangements grew by 161 percent. Based on historical contract adoption rates, by 2019, 90% of DSH hospitals will have contracts with pharmacies as part of their 340B operations. Since, DSH hospitals account for 81 percent of total 340B sales; they will be the primary driver of 340B utilization growth through contract pharmacies,” (Vandervelde, 2014, & Avalere Health, 2011). Pharmacy expansion contracts were supposed to help small clinics without their own in-house pharmacy, but, it seems all 340Be entities are benefiting even the large non-profit hospitals. Hence, those clinics that are treating the uninsured and indigent are not truly the entities benefitting from the

Even though Medicaid is a health insurance program for low income individuals, having coverage does not guarantee access to a physician and many of these patients are going without needed care (American College of Physicians, 2015). In the past Medicaid has been known to pay well below what private insurance and Medicare pays for primary care services and is one of the top reasons many providers do not participate in Medicaid (American College of Physicians, 2015). “In 47 other states Medicare pays up to 67% less than Medicare for the same primary care services” (American College of Nurse-Midwives, 2015). A study published in the New England Journal of Medicine states that

In my hometown state of Colorado, one of the piloting states who are implementing a new method of delivering and paying for Medicaid beneficiaries’ care to coordinate a broad range of health and social serves by shifting some of the financial risk for the costs and quality of care to providers. Colorado’s Accountable Care Collaborative Program is providing Medicaid beneficiaries care through an accountable care organization (ACO) delivery model. Medicaid contracts with one regional care collaborative organization (RCCO) that works with providers that are part of the Primary Care Medical Providers (PCMP). “Medicaid oversees that the regions get the medical management, admin support, while they seek to ensure care coordination to the Medicaid enrollees and integrate smoothly with the care in hospitals, with social services and specialist” (Ellis, Gifford, & Smith, 2014). Many of the ACA’s provisions affecting Medicaid eligibility and enrollment went into effect during 2014, most significantly the Medicaid expansion implemented as an option for states. All states were required to streamline Medicaid enrollment and renewal processes, transition to a uniform income eligibility standard and coordinate with the new marketplaces (Ellis, Gifford, & Smith, 2014). Colorado has also set out to integrate behavioral and clinical health care through incentives to providers. Colorado’s first annual report indicated progress and success for what the ACO set out to

If the pharmacy would offer discounted drugs, they could expect to see customers who are self-pay or do not have a prescription plan. Self-paying customers and those on a monthly budget would be attracted to discounted prices that the pharmacy could offer. Pharmacist could provide detailed information about the prescription and what drugs may counteract them, continuing the health management plan provided by the physician. After establishing the need for customer base, they would have to look at the competition and their buying patterns. One thing this pharmacy has is the availability to patient’s medical health history on hand; this would make the patient at ease knowing the pharmacist has knowledge of their medical history. According to Williams & Torrens (2008), “As patients and health care professionals have turned increasingly to medications as cost-effective alternatives to invasive surgery and hospitalization, spending on prescription medications has naturally increased” (263). Medicine is providing patients to live longer, healthier lives even though they might suffer from a chronic illness or disease. Showing stakeholders this information of increased prescription medications might help influence their decision to support the new pharmacy. An incentive of more financial income to the

Medical rationing is a very delicate topic. If you consider a patient with Medicaid who can benefit from a specific medication but, due to cost and healthcare benefit package, the medication gets substituted for one that is less expensive and or covered by the Medicaid. In this case, I agree with you that medical rationing can be prevented if providers takes cash pay services only but, in a situation where by the individual is unable to afford it, then it will cause a delay of services. Rationing medical care is unfair for the poor, but does not affect the rich as much. Why will they not include all these medications in the healthcare benefit packages for all individual whether private insurance or Medicaid?