Medicare Part A Case Study

First implemented in 1985 by Aetna (previously U.S. Healthcare), P4P programs were used to reward top performers and improve outcomes (Bruno, 2012). The incentives were meant to improve the quality of patient care by basing incentives on patient outcomes. Conversely, fee-for-service reimbursements are based on the treatments and set limits on the amount reimbursed for services. Because of these limits, incentives for use of pharmaceuticals and non-invasive procedures can impact how physicians practice.

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

Part A covers hospitalization, emergency hospitalization, subacute care, home health, and end of life care depending on the situation. Part B covers Doctors’ visits, and covers subacute, end of life, and in home care that Part A will not cover if the patient qualifies. While part C covers medications and needed medical equipment (Center for Medicare and Medicaid Services, 2014). What Medicaid pays for depends on what state you live in, and what your specific situation is. Universally Medicaid covers hospitalization, day procedures, doctors’ visits, nursing facilities, home care, child health check, nurse practitioners, and transportation to doctors’ visits (Medicaid.gov, n.d). Medicaid offers different services in each state, but the aforementioned are the mandatory areas of coverage for every state. Medicare is aimed at helping the older population, while Medicaid is aimed at people in every stage of life. But who exactly is covered under which

Medicare is the federal health insurance program for people with certain disabilities, end stage renal disease, and for those who are over the age of 65. There are four different parts to Medicare, part A, part B, part C, and part D. Medicare Part A, also known as hospital insurance, covers inpatient hospital stays, care in nursing facilities, hospice care, and some in home health care. Part B is often referred to as medical insurance; it covers certain doctors’ services, outpatient care, medical supplies, and preventative care services. Medicare Part C, otherwise known as Medicare advantage plan is offered by a private

The Affordable Care Act was enacted to improve health care and to lower health care cost in America. The ACA developed different strategies to meet these goals called the “pay for performance” programs. These strategies are aimed at the different providers to improve quality care. The strategy that I selected is the “Hospital Readmissions Reduction Program” this program/strategy is also known as the HRRP and was begun in October of 2012. HRRP is aimed at hospitals and penalizes hospitals that have a high 30 day readmission rate. The penalties are assessed and based on a number of comparisons, those such as, performance, patient demographics, comorbidities and frailty.

Medicare is the nation’s largest health insurance program. Generally, you are eligible for Medicare if you or your spouse worked for at least ten years in Medicare-covered employment and you are 65 years old and a citizen or permanent resident of the United States. Medicare-covered services include hospital insurance, inpatient hospital care, skilled nursing facility care, home health care, hospice care, and medical insurance (Medicare U.S.) With such an encompassing effect on the health insurance field, Medicare provides a haven for older individuals, and end-stage renal disease (ESRD) patients who require the best medical care for whatever possible reason. The only problem with this scenario is

Healthcare in the U.S is most expensive than any other developed country. The U.S spends far more on per capita as compared to any other developed. U.S scores low on many outcome measures, inefficiencies and wastes and quality measures as compared to other countries. The Patient Protection and Affordable Care Act is developed to strengthen these failures in the health care system. The U.S healthcare is transforming care from volume based reimbursements to value based payments. The healthcare law works around providing more patient centered care and better preventive care. One of the payment reforms with Obamacare is to penalize the hospitals with high readmission rates for the three conditions – Acute Myocardial Infarction, Heart Failures and Pneumonia.

The Medicare Access and CHIP Reauthorization Act (MACRA) was initi-ated by the U.S. Department of Health and Human Services to bring about big changes in quality of care by altering payment methods of doctors. MACRA was signed into law in April 2015 by former President Obama. The Medicare Access and CHIP Reauthorization Act (MACRA) is bipartisan legislation that was passed quietly by Congress without controversy. MACRA significantly alters how the government pays physicians and doctors who treat Medicare patients. It is transforming the way Medicare pays doctors and hospitals for their services by moving away from the traditional fee-for-service method and towards a new payment method that is based on how successful treatments are for

In addition, it also measures the quality of care and patient satisfaction. In 2015, the US Secretary of HHS has announced a goal of 85 percentages of Medicare Fee for Service payments tied to quality or value. In addition, many new payment models are associated with HRRP; for instance, forthcoming Skilled Nursing Facility VBP program and Dialysis Adequacy measure , potentially specifies preventable readmission measures. As the system is moving from quantity to quality, it is beneficial to implement quality of standards to optimize future benefits for the community and Central Health as well. Currently, Central Health has higher readmission rate than national average with an overall rating of 2 out of 5. Penalties incurred due to below standard of care could strain hospital resources to utilize for the betterment of our facility. Furthermore, the incentive structure has concerned Central Health to reevaluate the mode of practice and care provided engaging healthcare providers and patients. Central Health is committed to reducing readmission rates by identifying and sharing best practices for long term benefits. Given the flexibility of penalty under the 21st Cure Act, the initial program will focus on readmission prevention within 30 days of hospital

Karikari-Martin (2010), states that the definitions of healthcare access are directly related to the concerns of the system. She continues saying that these definitions pertain most prominently to insurance, number of available providers and the efficiency of healthcare services (Karikari-Martin, 2010). Prior to enactment of the Patient Protection and Affordable Care Act (PPACA) in 2010, the United States population was held hostage by an insurance industry that was poor secondary to insufficient government controls. The insurance companies made good insurance policies more difficult to attain with premiums that were constantly increasing, denials of insurance for those with pre-existing conditions or premiums so high they couldn’t afford it.

Medicare, as nationwide social insurance passed into law as title XVII of the Social Security Act of 1965, currently using about 40 private insurance companies across the United States. The primarily purpose of Medicare was to provide financial support to elderly age sixty-five and older or younger people with a permanent disabilities. There are four different parts of Medicare plans to select from: “Part A provides hospital and skilled nursing coverage’s through Hospital Insurance Trust Funds. Part B covers physician services, ambulatory surgical services, and other miscellaneous services paid by Medicare beneficiaries. Part C is managed care coverage offered by private insurance companies. It can be selected in lieu of Part A and B). Medicare Part D covers

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

On viewing this video “The Story of Medicare” I was able to understand that the role of Medicare(MR) and Medicaid (MD) centers is to cover all people over the age of 65 or older regardless of their income, health status or residence. Medicare also provides benefits for people of any age that have certain disabilities. MR & MD services is a program that allows low-income families whether healthy or sick to receive health care coverage. Medicare has successfully increased the life expectancy of Americans over decades as before Medicare coverage, the life expectancy of white Americans was 61 years and black Americans 48. This number has increased for both white and black Americans adding 15+ years of life expectancy. I believe that Lindon B. Johnson

Medicare is designed to give people of 65 years of age or older, people who are younger than 65 years of age but have certain disabilities, and people of any age with end stage renal disease, medical coverage. This is funded through the federal government. Medicaid is for low income adults, children, pregnant women, elderly adults, and people with disabilities medical insurance. This is funded jointly by the state and federal government. In the United States, Medicare costs increased by 4.5% in 2015, Medicaid spending increased by 9.7%, private health insurance increased 7.2%, and out of pocket spending increased by 2.6% (NHE fact page, 2017). Virginia has increased in Medicaid costs by 7.78% since 2015 (Medicaid and CHIP in Virginia,

Ralph, a 67 year old male, suffers from with degenerative osteoarthritis of the hip. His arthritis progressed so much it’s nearly rendered him immobile and his doctor has recommended a hip replacement. In the United States, the average cost of a hip replacement is $75,399. Fortunately for Ralph, he is a Medicare beneficiary which means that Medicare Part A plan is going to cover about 75% of the total cost of the surgery lowering his out-of-pocket expense to $18,849.