Last Updated on March 4, 2024 by Admin
Compare and contrast each of the three questions related to Managed Care Organizations, Medicare, and Medicaid with one another and explain how they were similar and different to each other
Complete ALL of the bullet points below:
Compare and contrast each of the three questions related to Managed Care Organizations, Medicare, and Medicaid with one another and explain how they were similar and different to each other.
- Managed care organizations emphasize physicians‘ responsibilities to control patient access to expensive hospitalization and specialty care, a principle dubbed “gatekeeping.” Some argue that “gatekeeping” is unethical because it introduces financial factors into treatment decisions. Others say it improves quality by promoting the use of the most appropriate levels of care.
- Medicare is an area that often gets overlooked and is seen as a burden financially. Discuss alternatives to ease the drain on Medicare resources.
- Medicaid is shouldering an ever-increasing burden of cost for long-term care for the elderly, with enormous impacts on state budgets throughout the nation. Discuss alternatives to ease this drain on Medicaid resources.
Please submit one APA formatted table, (minimum 3 pages) that highlights the above content make sure to include a title and reference page. The assignment should have a minimum of two scholarly sources, in addition to the textbook.
Expert Answer and Explanation
Gate-Keeping, Medicaid, and Medicare Management
The increasing healthcare costs have always become one of the major barriers of accessing the right levels of healthcare in the US. Healthcare insurance comes in handy in reducing this burden, and ensuring that individuals receive subsidized healthcare services through the financial aid such as Medicare and Medicaid (Sohn & Timmermans, 2017). The increased demand for healthcare services, especially among the aging populations, however, has led to a significant drain in Medicare and Medicaid resources, creating questions as to whether these insurance services would be able to serve in the coming years.
Healthcare givers have also bought the idea of ‘gate-keeping,’ where they refer primary care patients to specialists who help them access better services based on their specific needs (Barnett et al., 2018). These improvements in care, unfortunately have numerous financial implications on the patients. Whereas healthcare services in the US are said to be almost free, the idea of insurance and gatekeeping raises several cost concerns that should be addressed using relevant policies.
Gate-Keeping Effects on the Quality of Primary Care
Whenever healthcare givers perform gate-keeping activities on their patients, the immediate reactions of most patients is that they feel that these primary healthcare givers are either not willing to do their job, or are completely incapable and do not deserve it. This is because patients feel that their trust on the primary health providers is completely broken when they are referred to other specialists (Barnett et al., 2018).
However, it should be understood that gate-keeping has led to improved first-contact coordination and utilization of care. Primary health care providers can no longer take ‘too much than they can chew,’ and they leave the experts to solve the conditions of patients in the most professional way (Barnett et al., 2018). While gate-keeping results in areas with more scarcity of medical resources, it is one of the reasons why the costs of primary healthcare has increased considerably over the years.
Alternative to Medicare Resources Increased Usage
Social security and Medicare takes up to 40% of the budget, and plans to limit spending on Medicare seems almost impossible. Among one of the ways reducing the drain on resources of Medicaid is expanding bundled payments and promoting alternative models of payment. This is one of the ways in which efficiency and coordination can be improved in the entire Medicare program. Another way to reduce this resource drain is reducing preventable admissions and the occurrence of unnecessary complications.
In this program, the government could impose fines on facilities that do not give holistic care to patients, and hence contribute to patient medical errors, avoidable complications, and readmissions (Caswell & Goddeeris, 2020). A reduction of payments to post-acute providers could also serve a long way in reducing the drain on Medicare resources. Other ways that can be utilized to improve the Medicare service provision through a control of the resource drain is reducing the prices of high-cost drugs and adding competitive bidding to the advantage of Medicare (Caswell & Goddeeris, 2020). With these techniques, Medicare would be sure to avoid most of the financial strains it encounters.
Saving the Resources of Medicaid
There are many ways in which the increasing drain on Medicaid resources can be controlled. One of these is the implementation of Medical Homes that are more patient-centered. Besides improving the ease of access of care, these homes serve as ways of boosting care giving activities, which eventually lowers the total quality of care. Health homes, which are almost same as patient centered medical homes, target patients who have chronic conditions. At the federal level, heath home programs show significant decrease in the specific-service spending, and this relates to decrease in Medicaid spending.
Another way to ease Medicaid spending is the application of accountable care organizations in healthcare, which informs different expectations for Medicaid and hence assists in planning (Perez, Benitez, & Seiber, 2018). Medicaid should also tighten the financial eligibility rules for patients who are receiving long-term care. These rules could include limiting asset transfers, including retirement accounts as part of the patients’ countable assets, and increasing the efforts of state recovery (Perez, Benitez, & Seiber, 2018; Sohn & Timmermans, 2017). The government bodies associated with health insurance should also promote private long-term health insurance as this directly easens the burden on Medicaid.
Conclusion
Among the ways of improving health insurance include building on private insurance, which distributes the increased demand of healthcare insurance among government insurance services. For Medicaid to reduce the financial drain on its resources, it should implement policies such as tightening financial eligibility rules using things such as including in the countable assets of patients, the retirement accounts.
A strain on Medicare resources, on the other hand, can be reduced through things such as imposing fines on some of the healthcare facilities that do not give holistic care to patients. There is need for regulation of gate-keeping activities among primary care providers as too much of referrals to specialists outside the scope of primary care increases care costs, despite the increased outcomes.
References
Barnett, M. L., Song, Z., Bitton, A., Rose, S., & Landon, B. E. (2018). Gatekeeping and patterns of outpatient care post healthcare reform. Am J Manag Care, 24(10), e312-e8.
Caswell, K. J., & Goddeeris, J. H. (2020). Does Medicare Reduce Medical Debt? American Journal of Health Economics, 6(1), 72-103.
Perez, V., Benitez, J., & Seiber, E. (2018, May). Elasticity of Medicaid Access with Respect to State Financial Distress. In AEA Papers and Proceedings (Vol. 108, pp. 384-87).
Sohn, H., & Timmermans, S. (2017). Social Effects of Health Care Reform: Medicaid Expansion under the Affordable Care Act and Changes in Volunteering. Socius, 3, 2378023117700903.
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FAQs
What is the difference between medicare and medicaid for the elderly?
Medicare and Medicaid are two different government-run healthcare programs in the United States. While both programs provide healthcare coverage for certain groups of people, there are some key differences between them.
Medicare is a federal health insurance program that primarily covers people who are aged 65 or older, as well as some younger people with disabilities or certain medical conditions. Medicare is available to most U.S. citizens or permanent residents who have paid into the Social Security system for at least 10 years. Medicare is divided into several parts, including Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage).
Medicaid, on the other hand, is a joint federal and state program that provides healthcare coverage for low-income individuals and families, including elderly people who meet certain income and asset requirements. Unlike Medicare, eligibility for Medicaid is based on income and assets, and it is available to people of all ages, not just those who are elderly or disabled. Each state has its own Medicaid program, which must follow certain federal guidelines, but can vary in terms of eligibility criteria, covered services, and cost-sharing requirements.
In summary, while both Medicare and Medicaid provide healthcare coverage, Medicare primarily serves elderly and disabled individuals, while Medicaid is geared towards low-income individuals and families, including the elderly.
Medicare vs medicaid chart/medicaid vs medicare
Here is a chart that summarizes some of the key differences between Medicare and Medicaid:
| Medicare | Medicaid | |
|---|---|---|
| Eligibility | Age 65 or older, younger people with disabilities | Based on income and asset requirements |
| or certain medical conditions | ||
| Coverage | Hospital insurance (Part A), medical insurance (Part | Varies by state, but typically includes hospital |
| B), Medicare Advantage plans (Part C), prescription | services, doctor visits, prescription drugs, | |
| drug coverage (Part D) | long-term care, and more | |
| Cost | Monthly premiums, deductibles, copays | Varies by state and individual circumstances, |
| may include premiums, copays, and deductibles | ||
| Funding | Funded by payroll taxes, premiums, and government | Funded jointly by federal and state governments, |
| subsidies | with some funding coming from taxes and other sources | |
| Administration | Administered by the federal government | Administered by state governments, following |
| federal guidelines and regulations | ||
| Scope | Nationwide coverage | Varies by state, with different eligibility criteria |
Note that this chart is just a brief overview, and there may be additional details or variations in coverage depending on individual circumstances and the state in which you live. It’s always a good idea to consult with a healthcare provider or insurance specialist for more specific information.
Who is eligible for both medicare and medicaid?
There are some individuals who are eligible for both Medicare and Medicaid, and they are known as “dual-eligible” beneficiaries. Dual-eligibles are typically people who are elderly or have disabilities, and who also have low incomes and limited assets.
In general, to be eligible for Medicare, you must be aged 65 or older, or have certain disabilities or medical conditions. To be eligible for Medicaid, you must meet certain income and asset requirements, which vary by state. Some states have expanded Medicaid eligibility under the Affordable Care Act (ACA) to cover more low-income individuals and families.
Dual-eligible beneficiaries may receive a range of benefits from both programs, including hospital and medical coverage, prescription drug coverage, and long-term care services. In some cases, Medicaid may help pay for Medicare premiums and cost-sharing, such as deductibles and copays, for dual-eligible beneficiaries.
It’s worth noting that eligibility and benefits for dual-eligible beneficiaries can be complex, and may vary depending on individual circumstances and the state in which you live. If you think you may be eligible for both Medicare and Medicaid, or if you have questions about your coverage, it’s a good idea to speak with a healthcare provider or insurance specialist who can help guide you through the process.