Task 3

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Feb 20, 2024

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Organizational Systems and Quality Leadership Task 3 Johanna Hennenfent Western Governors University

2 Healthcare Financing A. Country to Compare Great Britain and the United States A1. Access & A2A. Coverage of Medications Children in Great Britain are covered entirely regardless of health status or conditions. According to International Healthcare Systems Profiles by The Commonwealth Fund, healthcare for children is completely paid for by the government by the National Healthcare Service, they have direct access to their General Practitioners as well as specialists if needed, and hospital stays are covered 100%. Prescription medications are also covered at 100% and are even exempt from any co-pays if they meet the following criteria: they are age 15 or under, between the ages of 16-18 and enrolled as full-time students, have cancer or “certain other long-term conditions or disabilities” (The Commonwealth Fund, 2020). A perfect example of this coverage is from the PBS video special where a young boy with multiple physical and mental health disabilities was completely covered (PBS News Hour, 2021). This RN sees this aspect as especially comforting as the child’s parents were not bogged down by hospital or medication bills, they were covered by their government-provided health insurance and able to focus on the love and care of their child. In this situation, there is no need for parents to purchase private insurance for their children. In comparison, the United States (US) has a few different government programs that help to cover children in addition to; or in place of parents purchasing private health insurance. According to The Commonwealth Fund children can currently be covered under the federal matching Medicaid program (funded by state and federal taxes) from infancy up to age 18 if in a Updated on 2/21/19

3 low-income family. Parents would apply for program coverage and re-apply yearly to see if they still qualify for services and their prescriptions would also be covered. Another option is the Children’s Health Insurance Program (CHIP – funded by grants that are matched by the federal government to each state), for children in low-income families that make too much money to qualify for the Medicaid program but in all reality don’t make enough annually to be able to pay for private health insurance. This varies state by state as to whether it functions as an extra leg of Medicaid, or a separate program, and most states will charge premiums under this plan. Medications are not 100% covered, but government helps to regulate the pharmaceutical side. The third program that The Commonwealth Fund explores is the Affordable Care Act (ACA). The ACA allows children to remain on their parent’s private insurance plans until the age of 26, though medications are not 100% covered, the government also helps to regulate pharmacy costs to help make them more affordable although they may be generic rather than name brand (The Commonwealth Fund, 2020). The unemployed populations in Great Britain are also covered by the NHS (National Health Services) for basic healthcare coverage, emergency care hospital stays, general practice care, and regular or required preventative care (PBS News Hour, 2021). They also qualify for exemption from prescription copays if they fall in the “low-income” bracket, or they do not qualify for low-income status, but they have cancer or specified long-term health problems or disabilities. In a similar aspect, individuals who need multiple or large amounts of prescription drugs can purchase 3 or 12-month certificates for which they pay ahead of time at a set price that will cover all the prescriptions they require regardless of how many are needed during that set time (The Commonwealth Fund, 2020). Updated on 2/21/19

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4 The unemployed populations in the United States are, like children, covered by the Medicaid program if they qualify for low-income status, however, their care may be limited on coverage and if they cannot afford their out-of-pocket costs or cannot purchase private insurance policies offered through the ACA, they may go with minimal or no coverage at all (Cherry & Jacobs, 2019). One exception to this is those individuals who are military, spouses, dependents, or a beneficiary, it is called TRICARE and it is a program offered through the Military Health Services System (Cherry & Jacobs, 2019). As learned from the PBS special and The Commonwealth Fund, retired individuals in Great Britain are also covered by the NHS for all emergency care, hospital stays (and prescriptions while hospitalized), and outpatient prescriptions if over the age of 60. They can purchase additional private insurance as can all populations in Great Britain if they can afford it. The addition of private insurance will help cover any cost of prescription co-pays if they are under 60 or allow them to see a specialist more easily. If they cannot afford additional private insurance, they can also purchase the pre-paid certificates for prescriptions as previously discussed (PBS News Hour, 2021) (The Commonwealth Fund, 2020). The United States offers universal coverage through the Medicare program for persons ages 65 or older, or those individuals with long-term disabilities or qualifying end-stage kidney disease. Medicaid is a 4-tier program that encompasses Part A for hospital insurance and short- term skilled nursing for rehabilitation, Part B for medical insurance, Part C if the individual chooses to enroll in a private health insurance plan, and Part D (added in 2003), again through private insurance carriers for prescription medications (The Commonwealth Fund, 2020). In addition, for coverage to occur, individuals must qualify for social security benefits, and Part B, Updated on 2/21/19

5 although it covered physician supplies and services, it does require payment of premiums (Cherry & Jacobs, 2019). A2B. Referral to See a Specialist According to The Commonwealth Fund, in Great Britain, patients can choose which hospital and specialists to obtain services from within the NHS healthcare system. Most consultations by specialists are performed in actual hospitals, but a small number do still take place in GP offices (The Commonwealth Fund, 2020). The hard part of specialty care as noted in the PBS special was that if the individual is in relatively good health, they may wait several months before they can get their elective treatment or surgery. However, if the condition is deemed emergent and life-threatening, they are guaranteed treatment (PBS News Hour, 2021). In the U.S. it has been this RN’s experience that depending on the type of insurance coverage individuals have can depend on their ease of access to specialty care. Emergency care or hospitalization can make it easier to obtain specialty care for emergent conditions and the patient can be transferred to the specialist if unavailable at the current hospital, or if services are available at the facility, a specialty consultation can be obtained. According to The Commonwealth Fund, specialists in the U.S. are free to choose which form of insurance and therefore reimbursement they accept. They may not accept Medicare and Medicaid patients due to the low reimbursement rates so access and coverage for those individuals are also limited (The Commonwealth Fund, 2020). In both the US and Great Britain, GP’s act as “gatekeepers” in order to get to secondary or more advanced levels of care or referrals. Contemporary Nursing discusses that within the US and an HMO (Health Maintenance Organization) the preferred provider or general practitioner must be chosen from the HMO’s specified list, and in order to be covered by the plan. Also, for Updated on 2/21/19

6 any specialist needs, the patient must first be referred by the GP and be pre-approved for any procedures prior to performing them, or risk not covered by the insurance plan (Cherry & Jacobs, 2019). A2C. Coverage for Preexisting Conditions In Great Britain, pre-existing conditions are covered and routine monitoring and preventative care appts are encouraged and rewarded by the government even with financial incentives (The Commonwealth Fund, 2020). In the US, according to Healthcare.gov, no plan can refuse to cover, refuse to pay for treatment, change coverage, or payment for care based on any pre-existing condition (Healthcare.gov). A3. Finance Implications for Healthcare Delivery Financial implications for healthcare in both countries have been discussed throughout prior answers, but in general, Great Britain tends to have fewer individuals concerned or bogged down by medical bills or going without life-saving medications as most of their medical care and medications are covered by the government and some private healthcare plans. In the United States, coverage has improved with the different programs that have been developed and expanded upon such as ACA or Medicaid, but this RN has also witnessed firsthand, individuals skipping meds or treatments to pay other bills, or going hungry so they may take the valuable medications to keep themselves or loved ones alive. Updated on 2/21/19

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7 F. Sources References Cherry, B. & Jacob, S. (2019). Contemporary nursing: issues, trends, & management (8 th ed.). Elsevier. Western Governors University: Contemporary Nursing (vitalsource.com) HealthCare.gov (n.d.). Marketplace coverage . Department of Health and Human Services. https://www.healthcare.gov/coverage/pre-existing-conditions/ PBS News Hour. (2021, April 21). Critical care: America vs. the world [Video]. YouTube. https://www.youtube.com/watch?v=BytzrjEfyfA The Commonwealth Fund. (2020). International health care system profiles. The Commonwealth Fund. https://www.commonwealthfund.org/international-health-policy-center/system-profiles Updated on 2/21/19

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