S.Locklear-Assignment8

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1 Medicare and Medicaid Sabrina Locklear Aspen University HCA320: Healthcare Policy and Economics Professor Stacy Severin, MSN, Ed August 14, 2023

Medicare and Medicaid What does the future of healthcare look like? Currently, healthcare in the United States is the costliest but has horrible quality outcomes when contrasted to other countries. This is partly due to the number of uninsured and underinsured individuals in the US. The Affordable Care Act (ACA) passage in 2010 was an attempt to improve health care in the US. The ACA establishes more access to health care, offers incentives to provide advanced coordination and quality, and transforms the payment system to value-based care (Nickitas, 2019). Unfortunately, eligibility for healthcare in the US is mostly grounded on social characteristics such as income, employment, disability, age, parentage, and immigration status. For example, Medicare and Medicaid. The top two healthcare payers in the US are Medicare and Medicaid. Medicare covers elderly individuals, disabled, and end-stage renal disease patients. Medicaid covers low-income individuals. Medicare and Medicaid have increased the number of individuals with insurance coverage, but many changes are needed for all individuals to have the best quality of care. In this research paper we will consider the Quality Improvement Organization (QIO) and how it enhances policies and procedures for Medicare beneficiaries. There are many qualifications for Medicare and Medicaid benefits, and we will explain each in this paper. We will talk about how the qualifications can be altered to serve vulnerable populations. The Affordable Care Act (ACA) has impacted the benefits and coverage of Medicare and Medicaid recipients tremendously and we will talk about how in this paper. Lastly, we will describe healthcare leaders’ role in advocating for vulnerable populations’ cost effective care. Healthcare professionals, leaders, and organizations must push for healthier outcomes, better insurance options, and lower cost of care for all patients to improve healthcare in the future. Quality Improvement Organizations 2

One of the biggest federal programs focused on correcting healthcare quality and lowering the cost of healthcare for Medicare beneficiaries is the Quality Improvement Organizations (QIO) program. Improving the success, productivity, reduction, and quality of healthcare services rendered to Medicare beneficiaries is the mission of the QIO programs. Centers for Medicare and Medicaid Services (CMS) recognizes the core functions of the QIO programs as refining the quality of care of beneficiaries, defending the integrity of the Medicare Trust Fund, and taking care of beneficiaries by quickly addressing individual complaints. A QIP is made up of practicing doctors, healthcare experts, clinicians, and consumers working together to improve the quality of healthcare for Medicare beneficiaries. CMS consists of two types of QIOs: Beneficiary and Family Centered Care (BFCC-QIOs) and the Quality Innovation Network (QIN-QIOs). The BFCC-QIOs addresses all Medicare beneficiary complaints, quality of care reviews, early discharge concerns, and engagement of patient and family members. The QIN- QIOs work to reduce hospital acquired infections, hospital readmissions, and patient injuries related to drug events. The QIN-QIOs bring Medicare beneficiaries, healthcare providers, and populations together to make care safer by decreasing harm caused by delivery of care, ensuring patients and families members are engaged in delivery of care, and promoting effective and efficient communication and coordination of care. Qualifications for Medicare and Medicaid Benefits According to Nickitas et al. (2019), President Theodore Roosevelt advocated for passage of social insurance because he felt that healthy people resulted in a strong country. Medicare was established in 1965 to ensure Americans did not drain their savings due to illnesses and could enjoy their later years with dignity. Medicare was implemented on July 1, 1966, and over 19 million people signed up for the plan. Medicare is generally for individuals 3

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over the age of 65, but some may qualify younger than 65 years old if they have a disability, end stage renal disease (ESRD), or amyotrophic lateral sclerosis (ALS). Medicare consists of four parts: A, B, C, and D. Inpatient hospitalizations, care at a skilled nursing facility, hospice care, and some home health services are covered by Medicare part A. Medical providers, outpatient care, medical supplies, and some preventive services are covered by part B of Medicare. Medicare part C or Medicare Advantage plans cover the same and parts A and B combined and part D if offered. Prescription coverage is covered by Medicare part D. Medicare part C may be a better option for vulnerable populations because rates and premiums are cheaper. With Part C individuals agree to choose providers within the network and pay copays. Part C may also operate in a Health Maintenance Organization (HMO) program (Centers for Medicare and Medicaid Services, n.d.). Medicaid was created in 1965 and mostly insured low-income disabled and elderly individuals. Medicaid was thought of as a social welfare system that covers nursing homes, intermediate care facilities, mental health facilities, home health services, and personal care services. Over time eligibility rules have changed. Currently Medicaid eligibility is based on an individual’s age, health need, income, and resources. Medicaid is available to individuals 65 years old and older, blind, disabled, children 21 years old and younger, pregnant women, low- income individuals, and families, in need of long-term care, and individuals receiving Medicare. If someone is receiving assistance from Supplemental Security Income (SSI) or Special Assistance for the Aged or Disabled, they are automatically eligible for Medicaid. Medicare and Medicaid have improved the number of individuals with insurance coverage, but many Americans in vulnerable populations remain uninsured or underinsured. The ACA called for expansion of Medicaid to extend coverage to vulnerable populations. Medicaid 4

expansions cover more low-income individuals. Medicaid expansion widened coverage to all adults 64 and younger with incomes up to 138% of the federal poverty level (Nickitas, 2019). Impact of ACA on Medicare and Medicaid Recipients Medicare and Medicaid have increased the number of individuals with insurance coverage, but millions remain without insurance. The ACA was created by President Barak Obama to ensure all Americans have insurance coverage. In 2010 the Affordable Care Act (ACA) was signed into law and has created advantages and disadvantages for Medicare and Medicaid beneficiaries. The ACA was created to provide insurance coverage to more individuals in vulnerable populations. The ACA is purposed to enhance productivity and quality of care at lower healthcare costs. The ACA is focused on providing value-based care instead of fee-for- service. Value-based care provides reimbursements based on the quality of care provided and the outcomes of the patients. The ACA has positively impacted the benefits and coverage to Medicare and Medicaid beneficiaries including offering preventive care, rehabilitative services, mental health services, substance abuse treatments, and annual screening and wellness checks. Since the initiation of the ACA millions of individuals now have healthcare coverage at lower costs. However, there are many negative impacts such as requiring all individuals to have insurance coverage, and many cannot afford it. Another concern is with the increased number of individuals receiving Medicare and not as many working to add funds to Medicare, the funds may deplete. Also, Medicaid expansions have not been adopted in all states and many low- income individuals remain uninsured and underinsured (Nickitas, 2019). Role of Healthcare Leaders Racial or ethnic minorities, children, elderly, socioeconomically disadvantaged, underinsured, and individuals with certain medical conditions make up vulnerable populations 5

(Waisel, 2013). A lot of times these susceptible populations are uninsured and underinsured. They cannot afford health care and have poorer health outcomes. Healthcare leaders, professionals, and organizations must advocate for cost effective care for these less fortunate populations. Healthcare superiors can fight for cost effective care by advocating for reduction in unnecessary tests, procedures, and medications. Healthcare leaders must educate and inform individuals of their situation and available resources. Healthcare leaders should advocate to improve social factors of health such as more access to healthcare facilities and providers, cheaper healthy food options, etc. Leaders must push for hospital follow up phone calls and increased use of telehealth. The use of these devices will ensure individuals have all medications needed post hospitalizations to reduce risks of rehospitalization and much more. Healthcare leaders must encourage patients and family members to be involved in the decision-making process. Involving patients in the decision-making process helps the patient to be knowledgeable of their condition and options. When caring for patients in vulnerable populations, healthcare leaders must look outside of the box. Healthcare leaders must recognize the needs of the patients and get the interdisciplinary team involved to ensure all the needs of the patients are met. Providers must assess patients and document correct diagnoses for patients to qualify for Medicare and Medicaid. Nurses must assess and document the physical and medical needs of patients. Physical therapists and occupational therapists must assess patients and document the patient’s functional and physical needs. Social workers and case managers must help patients apply for Medicare and Medicaid if needed. Nursing coordinators and navigators must ensure patients have all the needed and available resources to ensure they receive the highest quality of care at affordable costs. Effective communication and proper documentation are crucial to ensure patients qualify for Medicare and Medicaid. Healthcare leaders must advocate to ensure all 6

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providers and professionals are aware of their roles and how to correctly document needed information. Conclusion What will the future of healthcare look like? Many changes have been made over the years and many more are needed. When compared to other countries the US has the most expensive healthcare system, but awful patient results. The ACA made changes to provide better quality of care and lower the cost of healthcare to individuals. It helped some but unfortunately, millions remain uninsured or underinsured. Medicare and Medicaid insure most elderly, disabled, end-stage renal disease patients, and low-income individuals but there are still loop holes. Quality Improvement Organizations are working to improve healthcare and lower costs to Medicare beneficiaries by focusing on patient complaints, engaging patients and family members in their care, and improving communication and coordination of care. Medicare and Medicaid services were implemented in 1965 to improve coverage for the elderly, disabled, individuals with ESRD and ALS, and low-income individuals and families. Unfortunately, vulnerable populations remain without healthcare coverage. The ACA has affected the payments and treatments of Medicare and Medicaid receivers. Positively, the ACA has changed care from fee- for-service to value-based care. The ACA has also improved efficiency and quality of care. It also offers more preventive care and annual screenings. Unfortunately, with the ACA’s insurance requirements some individuals cannot afford it, which leaves them in a bind. Also, not all states have adopted Medicaid expansion, so many vulnerable populations remain uninsured. Many changes have been made in the past to improve cost effective care in vulnerable populations and many changes are still needed. It is the responsibility of healthcare leaders to advocate for these changes. Healthcare leaders must advocate for better patient education, increased available 7

resources, involvement of patients and family members in decision-making processes, interaction of interdisciplinary teams, use of telehealth and telemedicine, and improving social determinants. Healthcare leaders and professionals are continuously working to improve healthcare in the future. Everyone should have equal, high-quality care, at affordable costs in healthcare. 8

References Centers for Medicare and Medicaid Services. (n.d.). Parts of Medicare. https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of- medicare Nickitas, D. M., Middaugh, D. J., & Feeg, V. D. (2019). Policy and politics for nurses and the other health professionals: Advocacy and action . (3 rd ed.). Jones and Bartlett Publishers. Waisel, D. B. (2013). Vulnerable populations in healthcare. Current Opinion in Anesthesiology (2) , 186-192. https://doi.org/10.1097/ACO.0b013e32835e8c17 9

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S.Locklear-Assignment8

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