In this discussion, you will compile the key points and the recommendations you made to improve the policy you selected for Final Project Two in a PowerPoint presentation to share with your peers. Int

Running Head: MEDICARE POLICY Of 2019 0

Medicare Policy of 2019

Maria Williams

Southern New Hampshire University

06/07/2020

Introduction

Description of the Medicare Policy of 2019

Patient Safety and Quality Improvement Act (PSQIA) is one of the most important health care policies in the United States. The Act was passed in 2005 to protect health care professionals and workers who report unsafe conditions in hospitals. The policy was formulated to encourage the reporting of adverse events and malpractices that occur in health care centers. Such events may include medical errors and accidents. The law seeks to protect the identity of professionals who report such incidences while maintaining the patients’ confidentiality. To protect patient privacy, the law imposes fines for confidentiality breaches (Nash, 2011). The policy also bestows the Agency for Healthcare Research and Quality (AHRQ) with the responsibility to publish a list of patient safety organizations that record and assess patient safety data. The Office of Civil Rights also enforces the policy among national health care facilities. The primary goal of this policy is to encourage health professionals to improve the safety and quality of health care and to understand the underlying causes of hazards in the delivery of healthcare (Nash, 2011). The policy also seeks to encourage the sharing of such results in all states within a protected legal framework, thereby minimizing any risks that are associated with patient care. In so doing, the policy hopes to reduce potential risks that patients are exposed to.

Rationale and Professional Relevance

Maintaining patient safety and quality of care are some of the most important goals of healthcare professionals. The policy goes a long way in encouraging all health care professionals to observe safety and quality standards. The Institute of Medicine regards patient safety as indistinguishable from delivery of quality care (Mitchell, 2008). Health professionals should observe patient safety practices such as use of stimulators, bar coding, computerized order entry, and crew resource management to avoid errors and improve health care processes (Mitchell, 2008). In order to comply with the legislation, nurses and other professionals should focus their attention on defining and measuring quality long before national and state level stress on quality improvements. Nurses have the responsibility in patient safety to avoid medication errors and prevent patient falls.

Stakeholder Analysis

The success of a policy depends on stakeholder participation and compliance. The key stakeholders of the policy can be broadly categorized as internal or external stakeholders. Within a health care institution, internal stakeholders include health professionals such as nurses, physicians, pharmacists, and clinical officers. External stakeholders, on the other hand, include patients, community members, government regulators, policymakers, as well as the scholarly community. The scholarly community may include researchers who investigate the outcomes of the policy and its efficacy and advise health institutions and policymakers accordingly. Government regulators at federal and state levels enforce patient safety laws.

Evaluation

Purpose

The purpose of the Medicare program is to provide health insurance for people who have attained 65 years of age and over. Medicare is also intended to assist people below 65 years but have specific disabilities through health insurance. The health insurance program is also aimed at increasing affordable quality healthcare services among people across all age groups affected with End-Stage Renal Disease (Centers for Medicare and Medicaid Services, 2020). People with a disability aged below 65 are also eligible for Medicare.

Scope

The scope of Medicare includes provision of health insurance coverage for the aforementioned populations. It concerned with the health interests of minority or underrepresented individuals such racial or ethnic minority groups, rural populations, the disabled, and members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) (CMS, 2020). The Ministry of Health (MOH) CMS office actively takes part in health-policy development, regulations, planning, and coordination of minority healthcare initiatives through stakeholder engagement (CMS, 2020). Besides, the CMS of Minority health researches, collects, and analyzes data to identify target groups and identify healthcare disparities; eliminate barriers to affordable healthcare; and develop appropriate solutions (CMS, 2020). Medicare is also applied to collect data and share knowledge on the quality, access, and costs of the available healthcare services relating to minority groups and the eligible populations.

Stakeholders

The main stakeholders of the Medicare healthcare program are healthcare workers and institutions such as physicians and nurse managers, and public and private healthcare facilities. Other stakeholders include health insurance companies; pharmaceutical firms and suppliers of the required healthcare resources such as wheelchairs; government institutions and healthcare organizations such as the MOH, Centers for Disease Control and Prevention (CDC) (CMS, 2020). Beneficiaries such as minority groups and races, and the eligible populations such as people of age 65 and older, and disabled individuals aged below 65 years are also part of the Medicare stakeholders.

Constituents

Medicare consists of three parts namely Part A. Part B and Part C. Part A is concerned with hospital insurance and covers hospital-based inpatient care. Services covered include critical hospital access, skilled nursing facilities, and hospice care for some healthcare homes ((CMS, 2020). Formally employed people pay for the premiums through payroll taxes. Part B covers medical insurance. The services include doctors’ and outpatient services. It further covers some services not covered in Part A such as physical and occupational therapy, and specific home care services (CMC, 2020). Part D covers prescription drugs and is available for all Medicare-eligible populations. Eligible populations have to apply for Medicare-approved plans offering Medicare prescription drug coverage (CMS, 2020). Premiums for Part D are paid on a monthly basis.

Development of Medicare

Medicare was signed into law in 1965 by the then President Lyndon Johnson with the intention of ensuring that senior citizens in America experience the benefits of modern medicine. Since then, Medicare has undergone several amendments including 1972 inclusion of people with disability and minority groups. The total national spending on Medicare currently consists of about 20% of the US total national expenditure on healthcare, and 14% of the total federal budget, which has significantly filed the financial gaps in diabetes healthcare services (Lee, 2018). Medicare was idealized in the theme of political incrementalism. Its eligibility restriction to the elderly populations and benefits to hospital care, and integrating healthcare services with Social Security the Congress sought to enact Medicare as the first federal health insurance program. The American Medical Association (AMA) attempted to resist it as being 90% evil and 1% effective citing the possible negative impacts on private practice (Lee, 2018). Even President Ronald Reagan cautioned in 1962 that after Medicare enactment, other laws would follow that would undermine people’s fundamental freedoms.

Even though Medicare was more popular in the Congress than previous healthcare Bills, there was a shortage of one vote for the crucial House Ways and Means Committee, implying that it could not pass the Congress. However, Democrats enacted Medicare when they were the majority both in the Senate and Congress in 1965. Medicare was expanded in 2019 to include prescription drugs in Part D. From the incrementalism perspective, it was anticipated that the law could later be amended to have a wider coverage to include even children and other populations. The original intention behind Medicare as a healthcare insurance for the elderly was a political strategy for enactment of another federal healthcare insurance program that would expand perpetually to the national or even global scale. The total budgetary allocation for Medicare was $793,741.7 million that were distributed equitably in four main areas of operation (CMS, 2020). A total of $3,543.9, $770 was allocated for program management, and HFAC-discretionally respectively (CMS, 2020). Furthermore, $411,084, and $378,343.8 were allocated for grants to states for Medicaid 1 and payments to Health Care Trust Funds respectively (CMS, 2020). The 2019 budget included a $45 million increment proposal for promotion of quality and effective healthcare, and fraud and waste prevention initiatives.

Rationale for choosing Medicare

My choice of Medicare is based on its crucial roles of ensuring health insurance coverage for people of 65 years and older, people living with disability, and patients with End-Stage Renal Disease. My interest in the policy has also been drawn from the challenges that the people who supported the Law experienced before it could be enacted. While there are high standards for future healthcare expectations such as the America Healthy People 2020, the efforts made in order to ensure that the standards are achieved are not enough. In as much as there are many health policies and initiatives including Medicare aimed at increasing access to quality health, healthcare disparity across races and socioeconomic settings still exists (Dickman, Himmelstein & Woolhandler, 2017). My main interest in this policy is to study the approaches that those who supported Medicare used to succeed despite overwhelming opposition even from healthcare policy-makers and leaders. I would then figure out the best ways of pushing important healthcare policies to ensure that they are accepted and legislated.

Medicare Merits and Demerits

The merits of Medicare include the consideration for everybody including those who do not pay premiums for Part A. All citizens can benefit from Medicare hospital insurance without paying premiums. The medical insurance option in Part B of Medicare is optional meaning its coverage depends on an individual person’s decision depending on socioeconomic factors or the type of family (CMS, 2020). Furthermore, the monthly premium for Part B is $144.60, which is fairer and cheaper than ACA’s Silver Plans whose monthly premium was $1,123 in 2015 (Shawahna, 2020). Furthermore, Medicare has a broad eligibility scope in Part A and B, which include all citizens aged 65 year and older, any permanent US citizen or legal permanent residents who meet the required eligibility criteria such as disability. Besides, Medicare has been accepted broadly by many stakeholders in the healthcare industry (Shawahna, 2020). For instance, 90% of US physicians appreciate Medicare; Medicare can be used in all the 50 states of Columbia; and Parts A and B can be used in Puerto Rico, Guam, American Samoa, and Virgin Islands.

There are several out-of-pocket costs associated with Medicare. People must meet Part A deductible requirement of $1,408 for every benefit timeframe before being covered, and people could incur additional costs of $704 daily for inpatient hospital stay lasting more than 90 days (Shawahna, 2020). Medicare’s Part B includes a $198 annual deductible after which people must also cater for 20% of the Medicare-approved expenditure for covered products (Shawahna, 2020). The number of service providers for Medicare Advantage is limited to specific providers approved for each plan, which means that one could incur additional costs if they settle on providers of their choice. Furthermore, there are overwhelmingly high numbers of service providers for some Medicare Advantage, which increases confusion when choosing healthcare plans. Medicare advantage only offers state-specific services, which disadvantages frequent travelers from one state to another.

Extent to which Medicare Meets the Needs of Target Populations

Medicare successfully provides healthcare insurance to most of the target populations that include senior citizens and people living with disability. There is still a big number of people who are eligible but not covered under Medicaid. For instance, one out of five people in the US who are eligible are not covered under Medicare (Barbash, Rak, Kuza & Kahn, 2017). Most of the affected people are immigrants who meet legal citizenship requirements. The poor coverage can be attributed to bureaucratic policies requiring procedures such as documentation that significantly obstruct equitable access to quality healthcare services. Furthermore, the interests of minority groups such as the disabled populations under the age of 65 years have not been met fully. For instance, in 2018, only 12.7%, 9.3%, 10.3%, and 67.6% of people with multiple disability, physical disability, cognitive impairment, and general disabilities who were eligible for Medicare benefited from the program (Barbash, Rak, Kuza & Kahn, 2017). The inefficiency in Medicare coverage for the eligible population can be attributed to inefficiency in allocation of resources, ineffective documentation approaches, and corruption among healthcare stakeholders (Barbash, Rak, Kuza & Kahn, 2017). Furthermore, the eligible populations are required to cater for 20% of the covered products, which makes the program exploitative to the population that it is supposed to protect from financial exploitation.

Unintended Impacts

Enrollment to Medicare means that all covered services are to be provided in accordance with Medicare policies, and with selected providers. The presence of predetermined providers means that the eligible populations do not have a choice regarding the type of healthcare services to seek or the physicians to consult. Consequently, people from minority races such as Black Hispanics or Asians who may opt for traditional medicine instead of modern medicine will not experience satisfaction with the Medicare program (Barbash, Rak, Kuza & Kahn, 2017). Besides, Medicare does not cater for all expenditure. Consequently, the eligible populations are often required to cater for uncovered costs, which impacts negatively on the economic states of the socio-economically underprivileged communities.

An Evaluation of the Policy’s Efficacy

The policy displays efficacy in addressing the target population’s needs by ensuring inclusion of the elderly and vulnerable groups. This group tends to be neglected by most healthcare-related services such as insurance and special treatment covers. The policy’s provision of the option of the elderly to remain in community addresses this group’s need of staying within their home environment and with their families; which makes old age much more bearable and less mentally disturbing as compared to staying in nursing homes.

Conversely, this value comes with a demerit that may water down the efficacy, as the elderly who choose to stay at home do not enjoy 24-hour care from nursing homes. They may therefore miss out on the detailed attention required in cases where their family members have to be away. Paying for Senior Care (2020) reports that participants are required to provide personal care for themselves and not wholly rely on the program for 24-hour care. The value of remaining within the community; albeit benefiting the target group-the elderly-may negatively affect the other population-the family-as they may be forced to either adjust their schedules, quit work or incur extra costs to hire a helper to stay behind on days they may be away.

Another element of the policy that meets the intended efficacy and the target group’s needs is its wide range of coverage-acceptance by 90% of America’s physicians, and availability in various Columbian states. This ensures a considerable part of the population is reached. It however has a downside as there are people who face inaccessibility based on their: location, like eligible elderlies who must be living within service areas of a PACE (Programs of All-inclusive Care for the Elderly) organization; preferred physician (in case they fall within the other 10%); status, such as immigrants; physical nature, such as the elderly disabled; and those who are compelled to pay an additional 20% to enjoy the policy. On the other hand, inclusion of all the services under one cover greatly enhances efficiency and ease of use.

Recommendations

Among the key areas of improvement to better the policy is the geographical area coverage. The Commonwealth Fund (2020) supports the need for this improvement by stating that America’s health coverage remains fragmented, with wide gaps in insured rates across the population. As identified, only 90% of American physicians accept the policy’s cover, and there are rural areas that are not covered. The percentages may be viewed as negligible, yet they still hugely impact the total population and mortality rate. Additionally, immigrants and low-income earners are locked out due to stringent paperwork requirements, and the need to partly chip in for the cover to be activated, hence the need for improvement of these groups’ covers.

I would recommend an improvement through enrolment of more physicians, and their deployment to all corners of the country to cover all regions. Secondly, immigrants should be provided with the policy’s benefits, with less bureaucracy in documentation and verification-the cover should immediately take effects upon confirmation of meeting legal citizenship requirements. Another major improvement would be ensuring the services by partner physicians and institutions provide the highest quality healthcare to citizens. This can be achieved by attaching incentives and penalties to their payments, based on their service quality and incidences of malpractice. Goodwin (2018) also supports my recommendation by advising that quality measures are critical for improvement of patient satisfaction, and suggests a Pay-for-performance system which rewards providers for achieving or exceeding benchmarks.

I advocate for the policy, as I believe it is the key to not only improved healthcare, but also provision of the service to all, healthcare being among the basic needs a government owes its citizens. I strongly believe it already benefits the population, and with implementation of the recommendations and more in future; will upgrade to cater for all the various needs of the target population, improving the offering, lives, health and management of mortality rates.

References

Barbash, I. J., Rak, K. J., Kuza, C. C., & Kahn, J. M. (2017). Hospital perceptions medicare’s sepsis quality reporting initiative. Journal of hospital medicine, 12(12), 963-

993.

Centers for Medicare and Medicaid Services. (2020). Medicare. CMS. Retrieved from https://www.cms.gov/Medicare/Medicare

Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017). Inequality and the health-care system in the USA. The Lancet, 389(10077), 1431-1441.

Goodwin., K., B. (2018) .10 State Strategies for Improving Medicaid: Quality, Outcomes and The Bottom Line. National Conference of State Legislatures (NCSL).

Lee, F. E. (2018). The 115th Congress and questions of party unity in a polarized era. The Journal of Politics, 80(4), 1464-1473.

Mitchell, P. H. (2008). Defining patient safety and quality care. In Patient safety and quality: An

evidence-based handbook for nurses. Agency for Healthcare Research and Quality (US).

Nash, D. B. (2011). The patient safety act. Pharmacy and Therapeutics, 36(3), 118.

Paying for Senior Care. (2020). Medicare PACE and LIFE programs: all-inclusive elderly care. https://www.payingforseniorcare.com/medicare/pace_medicare

Ridic, G., Gleason, S., & Ridic, O. (2012). Comparisons of health care systems in the United

States, Germany and Canada. Materia socio-medica, 24(2), 112.

Shawahna, R. (2020). Facilitating ethical, legal, and professional deliberations to resolve dilemmas in daily healthcare practice: A case of driver with breakthrough seizures.

Epilepsy & Behavior, 102, 1-14.

The Commonwealth Fund. (2020). What is the role of government? International Health Care System Profiles-Health System Features. https://international.commonwealthfund.org/features/government_role/