Influence of Federal Government Programs
Created by Congress in 1965, under President Lyndon B. Johnson, Medicare is an insurance program sponsored by the United States government. The purpose of Medicare is to guarantee access to health insurance for US citizens of age 65 and over and to people of any age with disabilities. In 2011, 48.7 million people were covered by Medicare with a total expenditure of $549.1 billion1 from which $182.7 billion was used to cover 15.3 million inpatient admissions; this represents 47.2 percent of total hospital’s admission costs in the US. Medicare falls under the category of a single-payer health care program;2 which means that a single public or semi-public agency organizes the healthcare finances; however, the delivery of care remains under private authority. Given the staggering cost and resources utilized under Medicare, and the continuous efforts of the government to contain hospital costs and maintain the ability to manage their revenue cycle successfully. Medicare’s Impact on Today’s Healthcare Ecosystem
By having multiple options of coverage, affordable premiums and, in some cases nonexistent costs to the members. Furthermore, Medicare is constituted by four parts (A, B, C, D). Part A (Hospital Insurance) covers the hospital’s admissions to inpatient, home-health care agencies, hospices and nursing skilled facilities. No premium cost to members; however, some co-payments and a yearly deductible are required. Part B (Medical Insurance), cover included: primary physician visits and their services, some preventive services and other outpatient care. Part B is optional; nevertheless, a monthly premium as well as an annual deductible is required. Part C refers to two types of healthcare plans (Medicare Advantage and Medigap). Medicare “Advantage” aloud members the freedom to choose parts A and B through an approved private health insurance organization. On the other hand, “Medigap” is a supplement to Medicare, which may help members to cover some co-payments, services and/or deductibles not covered under Medicare benefits. Part D (prescription-drug plan), a complete optional plan that is offered through private health insurance companies. There is a monthly premium, a co-payment and a yearly deductible. It is worth mention that all Medicare benefits are subject to the different types of medical necessity.3 Medicare’s Licensure, Certification, and Accreditation Standard Centers for Medicare & Medicaid Services (CMS) created the Conditions of Participation (CoPs) that healthcare institutions must adhere to if wants to begin and/or continue accepting members of either the Medicaid and/or Medicare. In a nutshell, if a healthcare facility wants to receive reimbursement from Medicare, they must adhere to their standards; moreover, the ramifications of not meeting these standards, for example after a Joint Commission (TJC) survey, could result in immediate facility operations shut down and refuse off all previous and future claims until the standards are met. CMS ensure that the accredited organizations standards either exceed or at least at par with the Medicare standards set in the CoPs. In actuality, a selection of only seven accreditation organizations (AOs) in the nation that are offering the “CMS accreditation programs” for the purposes of certifying that the compliance is met or exceeded of general hospitals, ambulatory healthcare centers, home-health agencies and hospices with the Medicare safety standards.4 CMS in 2012 required for general hospitals and critical access hospitals (CAHs) must meet and sustain the minimum standards in order to participate in the Medicare and Medicaid programs. Major changes were needed to be established in order to comply with the principles of the President’s Executive Order (January 18, 2011), named “Improving Regulation and Regulatory Review.” The president instructed all the executive agencies to lessen the outdated or...
References: 1) How is Medicare funded? (2015, March). Retrieved March 2015, from http://www.medicare.gov/about-us/how-medicare-is-funded/medicare-funding.html
2) Torio, C. M., & Andrews, R. M. (2013, August). National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2011. (HCUP Statistical Brief #160). Retrieved March 2015, from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb160.pdf
3) What Medicare covers. (2015, March 1). Retrieved March 2015, from http://www.medicare.gov/what-medicare-covers/index.html
4) Centers for Medicare & Medicaid Services (CMS). (2008, October 17). Survey & Certification - General Information. Retrieved March 2015, from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter09-08.pdf
5) Centers for Medicare & Medicaid Services (CMS). (2012). Medicare and Medicaid programs; reform of hospital and critial access hospital conditions of participation. Final rule. Federal Register, 77(95), 29034-76.
6) Centers for Medicare & Medicaid Services (CMS). (2013, November 27). Changes for Calendar Year 2014 Physician Quality Programs and the Value Based Payment Modifier. Retrieved March 2015, from https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2013-Fact-sheets-items/2013-11-27.html
7) Centers for Medicare & Medicaid Services (CMS). (2014). Fee Schedules - General Information. Retrieved March 2015, from http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FeeScheduleGenInfo/index.html
8) Budget of the United States Government, Fiscal Year 2010. Washington, DC: Government Printing Office. Retrieved March, 2015, from http://www.gpo.gov/fdsys/pkg/BUDGET-2010-PER/pdf/BUDGET-2010-PER.pdf
9) Japsen, B. (2013, August 23). U.S. Says More Doctors Accept Medicare Patients, Access 'Excellent '. Forbes.com. Retrieved March 2015, from http://www.forbes.com/sites/brucejapsen/2013/08/23/u-s-says-more-doctors-accept-medicare-patients-access-excellent/
10) Burning Glass Technologies. (2012). A Growing Jobs Sector: Health Informatics. Boston: Jobs for the Future. Retrieved March 2015, from http://www.jff.org/sites/default/files/publications/CTW_burning_glass_publication_052912.pdf
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