Medicaid Patients: A Case Study

Many experts in healthcare economics point out that chronic medical conditions are directly associated with higher costs (G., 2010). This association is mainly attributed to the high usage of all types of care (Kongstvedt, 2013). Reports show that the number of people suffering with chronic conditions is radically rising and forecasts suggest that the number of American’s with one or more chronic conditions will continue to grow by an estimated 37% between 2000 and 2030 (G., 2010). It is in our patient’s main interest to shift our current focus from treatment for acute conditions to target a better utilization of the recorded 78% of health spending devoted to people with chronic conditions. The new strategic approach is one of developing quality medical care for people with chronic conditions which require ongoing care and care management to improve their health status (Kongstvedt, 2013).

There have been many studies performed focusing on the rising costs of health care and some of the findings state that the rising cost of healthcare premiums is a worldwide problem. However, I believe they are higher in the U.S. In 2015, U.S. health care costs were $3.2 trillion. That makes healthcare one of the largest U.S. industries, equaling 17.8 % of the Gross Domestic Product (GDP) in comparison to the late 1960s; where healthcare costs were only $27 billion, or 5% of the GDP, which averaged $9,990 per person each year. The main reason for the rising cost of healthcare is a combination of government policies and lifestyles changes. Examples included lack of coverage or costly coverage, lack of available coverage for

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

Patients with long-term, chronic illnesses like Mr. Davis’s, care can be very costly, especially when the patient is unable to maintain routine medical care or visits and medications. Without routine medical care and maintenance medications, patients like Mr. Davis tend to have more frequent emergency room visits and hospitalizations; increasing costs for state and local government as well as tax payers. Though Mr. Davis is able to receive care during an emergency room visit, the providers are not fully aware of his health history and are only able to provide a temporary fix of his symptoms and not address his health care needs.

Medical costs are getting too expensive. Ever fought with your insurance providers because they refused to pay for care, or struggle to find an “in-network” provider? I know a woman whose name I will change for her privacy and the struggles she is going through are a perfect example of an issue many people face when dealing with insurance; Nancy’s (name changed for privacy) story is a perfect example of how our healthcare system is no longer working for the people. Nancy is this woman whose husband recently passed away. Nancy used to work for county and county workers cannot receive social security; and Nancy is too

In the state of Texas Medicaid is funded by state and federal programs. Those eligible to receive Medicare benefit is the low income individuals, families, children, pregnant women, elderly and individuals who suffer with disabilities (Hegar). The Texas Health and Human Service commission (HHSC) distributes the Medicaid (Hegar). Those receiving Medicaid benefits in the fiscal year of 2010 were found to be 55 percent female and 77 percent under the age of 21 (Hegar). Children accounted for 66 percent of all Texas Medicaid recipients in that year; however, 32 percent of those children actually received health care (Hegar).

Following the death of a Medicaid recipient, the program not only can but must attempt to recover costs from the estate of the deceased. Medicaid's official site says:

Usually Medicaid beneficiaries have one or more additional sources of coverage. Medicaid is a federal and state medical assistance program; and coverage will vary from state to state. The program provides medical care for low-income families; with emphasis on children, pregnant women, elderly, disabled, and parents with dependent children who do not have any other way to pay for healthcare. Third Party Liability (TPL) is the legal obligation of certain individuals, entities, insurers, or programs to pay part or all of expenditures for medical assistance furnished under a Medicaid state plan. Therefore, by law, any and all other available third-party resources must meet their legal obligation to pay claims before Medicaid pays for the care

The Affordable Care Act (ACA) highlighted the importance Medicaid played in insuring every American receive healthcare coverage. (42 U.S.C., 2010) Medicaid provides health benefits to over 71 million across the country. While involvement is optional, all 50 states participate in the program and requirements differ across the nation. The flexibility given to each state has allowed them to make their own decisions to work towards improvements that they believe would best benefit their region (Feldstein, 2015, p. 125-126).

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

As Congress considers potential options to reform Medicaid, it is important to keep in mind patient access to prescription drugs and other healthcare services. Retail community pharmacies believe that Medicaid prescription drug benefit reform efforts should be focused on maintaining a Medicaid prescription drug benefit, maintaining patient access to adequate provider networks, fair and appropriate cost-based provider payments, and facilitating patient access to pharmacist-provided health care services.

In 2010 the ACA was passed that expanded Medicare eligibility to include those with incomes up to 133% of the federal poverty level (“ObamaCare Medicaid Expansion,” n.d.). This helped the most impoverished people by providing them with health coverage. Because states cannot be forced to participate in the ACA's Medicaid expansion, not all states have expanded their Medicaid programs to cover individuals with household incomes below a certain level (“ObamaCare Medicaid Expansion,” n.d.). This created a Medicaid coverage gap in between those who can afford health insurance and those who qualify for Medicaid (“ObamaCare Medicaid Expansion,” n.d.). This means that not all U.S. citizens have any type of insurance coverage or access to health

Recommendations for this program would be to solve the issue of double billing and holding the hospice agencies accountable. They are choosing to get paid for the healthcare but end up outsourcing specific jobs. Health care providers should make patients aware of their palliative options, instead of pushing curative treatment. Providing the option of hospice to individuals sooner will all them to have a more positive experience with hospice.

Some families meet the financial qualifications to receive government assistance, but the West Virginia Medicaid program only covers vision care for most adults every three years. Preventive exams are not paid for annually. West Virginia is one of eighteen states that Medicaid will only coverage emergency services for dental care. Preventative care is not covered with Medicaid insurance. (Haney, 2016, July 25, 2017, February 13) The Medicaid expansion program has increased the number of West Virginians on Medicaid. Almost half of the West Virginian population is considered to live in a rural Appalachian area and are more likely to be dependent on Medicaid insurance. West Virginia is the state with the highest percentage of its

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.