MODULE 5 ASSIGNMENT

MODULE 5 ASSIGNMENT

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MODULE 5 ASSIGNMENT

Introduction

Medicare is a government-sponsored health insurance program that provides health coverage to people aged 65 years and above, regardless of their health status, level of income, or medical history, and to people below the age of 65 years with certain diseases and disabilities (Sultz & Young, 2017). On the other hand, the Medicaid program is a joint state-federal program that provides health coverage to low-income earners (Mullner, 2019). Managed Care Organizations (MCO) is a health plan or health care company that provides appropriate and cost-effective medical treatment (Sultz & Young, 2017).

This essay outlines the differences and similarities of Medicare, Medicaid, and MCO based on three questions posed. The first question relates to the concept of gatekeeping, where the MCO stresses the role of the physicians to control patient access to expensive specialty and hospitalization care. According to this question, some people consider gatekeeping unethical since it introduces financial element into treatment decision. In contrast, others consider it an important factor contributing to improved care quality facilitated by the utilization of the most appropriate levels of care. The second question relates to Medicare being overlooked despite bringing financial burden to its beneficiaries and requires providing alternatives for easing the drain on Medicare resources. The third question relates to Medicaid, which is associated with a higher burden of cost for elderly’s long-term car and requires providing alternatives for easing the drain on Medicaid resources. The essay is organized into two sections, with the first section addressing each of the three questions separately. The second section summarizes the key similarities and differences of the three entities deduced from the answers presented in the first section.

Section A

Question 1

Gatekeeping in healthcare entails a patient first visiting Primary Care Physicians (PCPs) who authorize their accessibility to specialty care (Sripa et al., 2019). Usually, gatekeeping is associated with a response to specialists’ shortage and a need to minimize healthcare expenditure. Liang et al. (2019) further add that gatekeeping plays a key clinical function of protecting patients from adverse effects of unnecessary care by using PCPs as entry points to medical care. Gatekeeping is among the concepts underpinning the provider-facing strategies utilized by MCO (Barnett et al., 2018). The use of gatekeeping in MCO has received mixed reactions. Some people argue that it is unethical since it introduces financial element into treatment decisions, while others claim that gatekeeping improves the quality of care by facilitating the utilization of the most appropriate levels of care.

Despite the two contrasting views, the existing empirical evidence supporting the positive impact of gatekeeping on health outcomes is sufficient to ascertain that gatekeeping is associated with better quality of care. This is supported by various scholars such as Barnett et al. (2018), Liang et al. (2019), and Sripa et al. (2019), who have empirically proven that gatekeeping improves the quality of care, resulting in better health outcomes. Contrary, research reveals that the impact of gatekeeping on health care costs remains unclear (Engels et al., 2020; Sripa et al., 2019). Therefore, it cannot be concluded that gatekeeping has adverse effects on health care costs.

Question 2

According to the second question, Medicare has been overlooked despite it being recognized as a financial burden. Even though Medicare provides its beneficiaries with protection against the cost of many health care services, it is associated with financial hardships. Supporting this statement, Kyle et al. (2019) reveal that despite Medicare’s high beneficiary satisfaction, seriously ill Medicare beneficiaries bear a disproportionate burden of health care costs, with the prescription of drugs proving to be the most burdensome. Also, as the economic hardships cause few employers to provide supplemental coverage to their retired employees, Medicare beneficiaries with low income are suffering the most onerous annual premiums, which are more than $500 higher than Medicaid beneficiaries (Davis et al., 2019).

One of the alternatives for easing the drain on Medicare resources is encouraging people to have access to health care from a young age. Usually, the efforts of upstream procedures such as prevention will be more effective, and there will be a huge reduction in the economic burden resulting from health issues. Besides, Medicare can reduce the number of days that patients requiring long-term care stay in skilled nursing homes for conditions with few medical health benefits. For instance, Medicare can provide long-term care to people aged 65 years and above for the first 100 days of care in skilled nursing homes for some conditions with few medical health benefits and speech, occupational, and physical therapy. Another alternative for easing the drain on Medicare resources is through lessening the tax slab. Better health care can be delivered with universal health coverage with a lesser tax slab. Additionally, the government can pass a rule that health care services delivered to people above the age of 85 are not charged and minimize recommending surgeries for this group. Lastly, Medicare beneficiaries can be encouraged to obtain supplemental insurance to ease the drain on Medicare resources (Kyle et al., 2019). Fie instance, the client can opt for Managed Care Organizations services.

Question 3

The third question requires discussing the alternatives for easing the drain on Medicaid resources. One of these alternatives is using private health insurance. Notably, people should rely mostly on the private insurance market. Although private insurance costs are relatively high compared to Medicaid services, the accessibility and coverage of private insurance are higher. The majority of health care providers accept commercial insurance compared to Medicaid services. Cost-sharing by the Medicaid beneficiaries is another alternative for easing the drain on Medicaid resources. Every state can set limits for cost-sharing based on their income level, with total out-of-pocket sharing accounting for at most 5% of the income. Medicaid beneficiaries can also use co-pays for long-term care needs rather than for preventive and emergency services to reduce the cost. Beneficiaries can also reduce costs by seeking supplemental insurance from MCO. Furthermore, encouraging Medicaid beneficiaries to start health savings can help ease the drain on Medicaid resources. Here, Medicaid beneficiaries can be sensitized to the increasing cost and limited coverage of Medicaid and encouraged to start health savings. Lastly, to ease the drain on Medicaid resources, Medicaid beneficiaries should be encouraged to choose cost-effective care.

Section B

Comparison of the Entities

Similarities

Medicare, Managed Care Organizations, and Medicaid have several key similarities and differences. In terms of similarities, the ultimate goal of the three entities is to provide quality and managed care services to the enrolled clients and minimize medical costs.

Differences

These differences have been summarized in Table 1 below.

Table SEQ Table * ARABIC 1: Differences Among Medicare, Medicaid, and MCO

Medicare Medicaid Managed Care Organizations

Type of entity Federal program A joint state-federal program A health plan or health care company

Eligibility Eligible to people aged 65 years and people below the age of 65 years with certain diseases and disabilities. Eligible to low-income earners regardless of their age. Applied to both patients and doctors to select a less costly form of care

Gatekeeping No gatekeeping. No gatekeeping. There is gatekeeping where the

Coverage It covers hospital and post-hospital facility fees, outpatient care and prescription drug coverage, lab costs, and doctor fees. It covers basic health care costs such as hospital stays and visit to the doctor and covers 20% of the Medical costs not paid by Medicare. Provides coverage on economic incentives for patients and doctors.

Source: (Sultz & Young, 2017).

Conclusion

Overall, the goal of this essay was to provide similarities and differences of three entities: Medicare, Medicaid, and MCO. The three entities are similar in that their main goal is to provide quality and managed care services to the enrolled clients and minimize medical costs. However, they differ in terms of their management, coverage, eligibility, and inclusion of gatekeeping concept. While MCO is a health plan or health care company, Medicaid is a joint state-federal program, while Medicare is a federal program of medical service providers. Secondly, as evident in the first question, gatekeeping has its benefits and disadvantages. However, gatekeeping is a concept that is only present in Managed Care Organizations, but it is not present in Medicaid and Medicare programs. Furthermore, based on the three questions, it is evident that seeking medical services using Managed Care Organizations is more affordable than using Medicare and Medicaid since, in the second and third questions, Medicare and Medicaid have shown to result in a financial burden to their beneficiaries. Additionally, Medicare is eligible to people aged 65 years and above despite their health status, income level, or medical history, and to people below 65 years with certain diseases and disabilities. Contrary, Medicaid is eligible to low-income earners regardless of their age. MCO is applied to both patients and doctors to select a less costly form of care.

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-e318.

Davis, K., Willink, A., & Schoen, C. (2019). How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden. Issue Brief (Commonwealth Fund).

Engels, A., Reber, K. C., Magaard, J. L., Härter, M., Hawighorst-Knapstein, S., Chaudhuri, A., … & König, H. H. (2020). How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany?. The European Journal of Health Economics, 21(5), 751-761. http://dx.doi.org/10.1136/jech.2005.038240Kyle, M. A., Blendon, R. J., Benson, J. M., Abrams, M. K., & Schneider, E. C. (2019). Financial hardships of Medicare beneficiaries with serious illness. Health Affairs, 38(11), 1801-1806. https://doi.org/10.1377/hlthaff.2019.00362Liang, C., Mei, J., Liang, Y., Hu, R., Li, L., & Kuang, L. (2019). The effects of gatekeeping on the quality of primary care in Guangdong Province, China: a cross-sectional study using primary care assessment tool-adult edition. BMC Family Practice, 20(1), 1-12. https://doi.org/10.1186/s12875-019-0982-zMullner R.M. (2019). Health Services Data: The Centers for Medicare and Medicaid Services (CMS) Claims Records. In: Levy A., Goring S., Gatsonis C., Sobolev B., van Ginneken E., Busse R. (eds) Health Services Evaluation. Health Services Research. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-8715-3_5Sripa, P., Hayhoe, B., Garg, P., Majeed, A., & Greenfield, G. (2019). Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review. British Journal of General Practice, 69(682), e294-e303. https://doi.org/10.3399/bjgp19X702209Sripa, P., Hayhoe, B., Garg, P., Majeed, A., & Greenfield, G. (2019). Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review. British Journal of General Practice, 69(682), e294-e303.

Sultz, H. A., & Young, K. A. (2017). Health care USA: Understanding its organization and delivery (9th ed.). Jones & Bartlett.