Healthcare Organization and Finance

Healthcare Organization and Finance

Scenario

Medicare covers healthcare services such as surgeries, laboratory testing and doctor visits. It also covers supplies such as walkers and wheelchairs. These services and supplies must be considered as indispensable in the treatment of a certain disease or condition (King, 2009). Therefore, the expenses related to the walker that was prescribed to Mrs. Zwick after her discharge would be fully met in this section of the Medicare.

Essentially, part A of Medicare covers a host of services, which include hospital care, skilled nursing facility care, hospice, nursing home care, and home health care services. Concerning Mrs. Zwick case, Part A of Medicare will meet the cost for the 5 days she received at the hospital as well as the 21-day care she received under the care of skilled nursing home. However, it is worth noting that copay applies to most of these services.

Part B of the Medicare covers two types of services. These are the medically necessary services and the preventive services. Medically necessary services are the services or supplies that are required to diagnose or treat a medical condition and that adhere to acceptable set of standards of medical practice. For instance, the IV antibiotics given to Mrs. Zwinc after suffering the urinary infection will be partly covered under this plan. On the other hand, preventive services cover health care services that serve to prevent an illness (such as flu) or detect it well in advance when the treatment can be effective. In general, part B of the Medicare is used to cover things such as clinical research, durable medical equipment, ambulance services, mental health (for inpatient, outpatient, and partial hospitalization), getting a second opinion before taking up a surgery, and limited outpatient prescription drugs (Wakefield, 2008).

Part D of the Medicare relates to Medicare prescription and drug benefit. Its main purpose is to subsidize the costs of prescription drugs for the beneficiaries of Medicare. Under this plan, part of the cost of the drugs prescribed at her discharge will be met by the Medicare. All she needs to do is to inquire from her prescriber if at all she can apply for exceptions from some of the prescribed drugs. Depending on the tier of the drug, either low or high, the prescriber will recommend to Medicare provider on the cost to be covered.

B. Medicare Policy and Reimbursement

The United States Centers for Medicare and Medicaid Services (CMS) prohibits medical facilities from billing beneficiaries of the program for the difference between the lower and higher payment rates. Instead, the hospitals are being encouraged to combat an adverse event as well as improve the quality of care that Medicare beneficiaries receive (Daly, 2010).

CMS identified catheter- associated urinary tract infections as one of the condition that require reimbursement. Under the policy, hospital acquired conditions will be identified basing on the administrative billing data. In order to assist in the process, hospitals are required to incorporate a POA indicator for secondary diagnoses. Use of codes is expected to increase the reliability and validity of the method used in identification of the hospital-acquired infection (Daly, 2010).

1. Ethical implications

Code of ethics for in medical professions stipulates that patients have a right to quality medical care free from any form of exploitation. This implies that the doctors and nurses are required to offer the patient with the necessary information regarding their condition and the billing procedures. An ethical issue arises in the situation of Mrs. Zwick's when she acquires a urinary infection while acquiring care from the medical facility. It is evidently clear that this information is kept away from her. As such, she has to incur the extra cost related to the six antibiotics she received as part of her medication (Harrison & McDonald, 2008).

It is ethically incorrect for the medics to conceal the vital information from her. Besides, in the event the hospital applies for reimbursement, it would have unfairly charged Mrs. Zwick. Therefore, as the CMC policies stipulate, it is the role of all medical institution under Medicare program to provide genuine information for reimbursement (Wakefield, 2008).

Scenario 2

C. Explain how the Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow Mr. Davis to continue his insurance coverage while he is out of work.

Under normal condition, COBRA insurance would cover Mr. Davis for a maximum period of 18 months. However, basing on the permanency of Davis' condition (as determined by SSA under Title II or XVI), this coverage may be extended to further to a possible maximum of 29 months. For the continuation to be legally binding, the insurance company and the employer must receive the SSA Notice of Award later before the initial 18 months elapses. At the end of the prescribed maximum period offered by COBRA, the beneficiary should apply for either Medicaid or Medicare. However, in case Davis is not entitled to Medicare or Medicaid, he is entitled to continue with one of the policies from their insurance provider. However, these policies are limited and more expensive as compared to the group insurance coverage that he had been enjoying (Stevens, 2003).

D. Discuss two challenges that state or local government face in providing care for patients like Mr. Davis who lack insurance coverage and have long-term, chronic illnesses that require ongoing care.

The rising high costs of treating such illnesses: many chronic and terminal diseases require a lot of money in their treatment. Since there are several people who suffer from such illnesses and are uninsured, the local government or state ends up spending so much in their treatment. Studies indicate that the number of Americans lacking health insurance is on a steady rise. In fact, in 2007, United States Census Bureau found out that approximately 45.7 million American (accounting for 15% of total population) were uninsured. This rise is attributed to the increased cost of insurance that discourage employers from offering health insurance coverage for their workers.

The government is also faced with the challenge of convincing insurance companies to insure those people who may be suffering from a terminal or chronic illnesses. This is because most of the insurance companies fear offering a policy on a risk that is certain.

1. Recommend one-step that state or local government could take to address one of the challenges you have discussed.

As a measure to address the challenge of raising costs of treating terminally ill patients such as Mr. Davis, I would expect the state or federal government adopt a system that subsidizes the insurance premiums for the unemployed and uninsured Americans. For example, it is clear that the COBRA premiums increase up to 150% of the extra period covered. This is unfortunate as the likes of Davis can hardly meet the extra costs. As such, the government should increase its subsidies on such individuals to encourage them to enroll for insurance services.