Medicare Case Summary

There is also something known as the coverage gap. For some plans, a patient can reach a

Since 1965, Medicare has been attempting to provide low cost, guaranteed access to much needed healthcare for senior citizens over the age of 65 and other age groups that suffer from disabilities and terminal diseases. These people represent some of the most vulnerable population groups in the United States. Most do not work, and rely on Medicare to provide them the access to healthcare they need. Unlike privatized health insurance companies, Medicare is a social insurance program that is paid for through federal mandates and tax payer funds. Billions of dollars are spent annually on over 50 million Americans in need (Alonso-Zaldivar 1). The care structure itself is broken into several main parts: Medicare Part A covers hospital costs, Part B cover most outpatient care costs, and Part C and D cover prescription drug costs through dealing with other private insurance. Yet, the upcoming election in November is threatening to change and alter the structure. Each candidate has his own plan to deal with Medicare; both are trying to reign in the costs of operating Medicare, but with some elements being obviously more beneficial for Medicare recipients than others.

Over the years, the insurance companies have searched for ways to increase their profit margins at the expense of the hard working Americas striving to maintain their health at an affordable cost. The exchange appears to be working under the guise that they are trying to improve the quality of the health care delivered to patients. However, this does not seem genuine when closely examined. Inspection of performance of hospitals and providers is normal for certifying bodies such as the Joint Commissions and The Centers for Medicare & Medicaid Services (CMS), not insurance companies. Fraudulent claims normally investigated by insurance companies are normally caught and the company recovers some of that cost or denies the claim altogether if fraud is suspected. With this, it appears that the exchange is trying to branch off into a section of health care that it has not normally concerned itself with over the time that insurance companies have existed. It could be argued that the exchange may be

Inflated billing. This is more common in hospital settings. However, it can still happen at the practice level. A patient goes in for surgery to correct his badly broken ankle. His insurance company receives a bill that is bloated with overcharges. Medical screws costing $2000 each for example. This kind of mistake is generally not so

According to the Federal Bureau of Investigation (FBI) “health care fraud costs the country an estimated $80 billion dollars a year” ("Health Care Fraud," n.d., p. 1). Because health care costs continue to rise more rapidly than the rate of inflation the threat of health care fraud continues to rise. The Affordable Health Care Act has put new policies in place to identify and stop health care fraud. The FBI along with other government, insurance, and public agencies have joined together to combat fraud at every level. New rules in identifying, investigating, and prosecuting fraud before payments are made to medical providers could save billions of

The Patient Protection and Affordable Care Act (PPACA), also referred to as the "Affordable Care Act" or "ACA" or "Obama Care") is the major health care reform bill passed into law on March 23, 2010. The debates surrounding the PPACA have been volatile at times, and continue to be the most intense public examinations of any piece of legislation in our recent history. The affordable Care Act (Obamacare) is ripe for repeal. For the American public, there are ample reasons for dissatisfaction: higher costs; arbitrary and sometimes absurd rule-making; bureaucratization of an already overly bureaucratized sector of the economy; incompatibility with personal freedom and religious liberty; enormous spending and heavy taxation; and widely acknowledged design flaws, evident in the ACA’s hopelessly complex and unworkable subsidy schemes, boondoggle bailouts, and collapsing co-ops. Nonetheless, other ACA legal challenges were still facing the healthcare law. In December 2015, the Association of American Physicians and Surgeons (AAPS) submitted an amicus brief to the Supreme Court arguing against the constitutionality of the employer insurance mandate within the Affordable Care Act. The law contains a number of experiments designed to drive down health costs, such as Accountable Care Organizations. The whole idea is to move the system away from paying for volume and toward paying for value. We still don't know whether that will happen. But it's fair to say that reducing the cost of health care will make it easier to expand coverage. The nation’s gains in health care coverage and delivery system design over the last several years have made measurable differences in the lives of millions of Americans. There are many ways to achieve a high-performing health system. But it’s critical that the nation remain committed to this goal.

Medicare, which was first enacted by Congress in 1965, is a popular, yet failing, program because of a rapidly increasing population of retirees and their increasing costs; despite program’s flaws, Medicare is difficult to change because of the political influence of the elderly, who approve of the benefits they receive from the program. Medicare provides health benefits to citizens who are eligible for social security benefits(Fiorina, Peterson, Johnson & Mayer 2009). The program is embraced by the public, but Medicare’s increasing cost makes it difficult to sustain. Due to its popularity, the program is also very difficult to change, but without limitations the program will continue to decline in the future.

Attempts to stop fraud were enhanced under Public Law 104-191, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The purpose was to improve the Medicare program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the efficiency and effectiveness of the health care system. This public law encouraged the development of a health information system through standards and requirements for the electronic transmission of certain health information (aspe.hhs.go). The Act established a program to take action against fraud committed against public and private health plans. The legislation required the establishment of a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the Secretary of the Department of Health and Human Services (HHS) acting through the Department 's Inspector General (HHS.gov). The HCFAC program is designed to coordinate Federal, State and local law enforcement activities with respect to health care fraud and abuse. The Act requires HHS and Department of Justice (DOJ) detail in an Annual Report the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such deposits. (HHS.gov) I will summarize the impact of these laws as it pertains to how they are impacting the healthcare delivery system. (HHS.gov)

The essential target of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) was to furnish seniors in the United States with moderate scope for their physician endorsed solutions through the new Medicare Part D professionally prescribed medication advantage. After the MMA was implemented—however before Part D was actualized—there was a disagreement about the cost of the program. In March 2004, the Medicare Chief Actuary affirmed before the House Ways and Means Committee of United States Congress that he was requested by the (Centers for Medicare and Medicaid Services) CMS Administrator to smother his assessments of the ten-year cost of the program, which were considerably more noteworthy than unique Congressional Budget

The U.S has many payer systems which many believe it to be its downfall among other countries. This may be because many view it more as an economic business and not an overall wellness plan. The United States’ main public program of funding is Medicare, which once followed a standard form of payment. It is now envisioned as a futuristic model that encompasses the payments of providers. Medicare is a national social insurance program that is run by the government since 1966. Also unlike Great Britain system, the program provides health care to Americans over 65 years of age for those who have paid their work dues in the system. Medicare has also extended its reach to those Americans who may be veterans or disabled. Another huge form of payment to providers is through Managed care which can be beneficial to physicians in the fee for service and capitation aspect. While this form of payment is similar to Great Britain’s programs, their execution of it remains vastly different. Managed Care is a type of healthcare system with health care plans that has restrictions on its selection of facilities and health care providers at a reduced cost for the patient. Rather than come to a conclusion about better ways to negotiate with payers, U.S providers continue to rage war against

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

Medicare currently pays for many preventive services that can detect health problems early when they’re easier to treat, give better access to claims and personal health information, and allow for savings on brand-name and generic when coverage gaps are met. The actual benefits of Medicare will not be changing. There will however be a new plan that is key to the Affordable Care Act that will take place in 2014. This plan is the Health Insurance Marketplace that allows individuals, families, and employees of small businesses to get health insurance. (Services, 2013 ) The Marketplace offers insurance plans through private companies that will provide essential health benefits regardless of gender, preexisting conditions, or preventative

The first article I read about was based on a doctor named by Dr. Henry Lora and Isabel Medina. Henry Lora had written prescriptions for patients that were receiving Medicare benefits. Those prescriptions were not medically necessary and they were prescribed for in return of bribes. Lora faced federal charges for the conspiracy of $20 million Medicare fraud schemes. Plea was scheduled, it carried a 25 year sentence in prison. Medina pleaded guilty of the charges with a 9 year sentence in prison. Both had made false records of patient’s qualification of Medicare

In Massachutettes, health plans wanted to eliminate “continuous open enrollment, assess the full annual penalty for any significant period of continuous un-insurance, impose waiting periods for certain services and bar consumers from buying in the merged market if they had access to employer sponsored coverage” (case study). Doing these things, the insurance companies hoped to lower premiums. Bill 2585 did pass but the law did not go as far as the insurance companies had hoped. It only “limited open enrollment in the merged market to twice a year in 2011 and once a year after that” (case study), which didn’t really help much. Due to loss in the small market group in 2009, health plans “planned double digit premium increases in 2010” (case study), but the government stepped in and put a stop to it. Even though the big name hospitals were driving up cost, the insurance companies were seen as the bad guys. This caused local plans to “record sizable operating losses for the first quarter of 2010 and had to draw on reserves to cover expected losses resulting from the rate rollbacks” (case study). The insurance companies, especially the smaller ones, suffered financially.

According to Ingols and Brem (as cited in Swayne, Duncan, and Ginter, 2006), Massachusetts is known across the world for computer technology, education, and health care. In the words of the authors, Massachusetts' "health care expenditures per capita were between 27 and 29 percent higher than the national average from 1990 to 2000." At the time, there was a general consensus that Boston's health care was relatively expensive as a result of the region's cutting edge and high quality services (Ingols and Brem, 2006). During the 1990s, a number of healthcare insurance plans at the national level chose to merge in an attempt to further enhance their ability to compete effectively. This trend according to Ingols and Brem (as cited in Swayne, Duncan, and Ginter, 2006) was also replicated in Massachusetts where the eventual formation of three large competitors had far-reaching consequences. One consequence of the increasing power of these three formations in the marketplace was reduced payments.