| Medicare Advantage | Medicaid | Managed Care Organizations | |
| Description | The Medicare Coverage is a health coverage plan for persons aged between 65 and older together and young individuals with disabilities (Lipschutz, Callow, Pollitz, Musumeci & Jacobson, 2015). This health program is governed by the federal rules and it is a voluntary option that covers medicare beneficiaries replacing the traditional Medicare plan, fee-for-service. The Medicare Advantage programs broadly cover services in the Medicare part A, b, and on some occasions part D the benefits of the drug prescription. Therefore, the Medicare Advantage program covers traditional Medicare services together with other benefits. | The Medicaid health plan covers persons with disabilities and low incomes (Lipschutz et al., 2015). The program is financed jointly by the states and federal government, under the state's administration as the federal governments oversee the process. The federal law defines various mandatory benefits to the participating states, which can choose to add more options to the benefits. States can either adopt managed care organizations or managed care delivery organizations such as the managed fee-for-service to provide their Medicaid services (Lipschutz, et al., 2015). | The managed care seems to be gaining acceptance in various states especially due to its integration in the Medicaid programs that have helped to minimize costs as well as help in enhancing the service utilization in the American healthcare system (Kimuyu, 2018). The various types of managed care organizations include the preferred provider organizations (PPO), health maintenance organizations (HMO), and point-of-service (POS) Programs. |
| The benefit design in cost-sharing | They should be equal to the benefits in Part A and B of the traditional Medicare services excluding the hospice benefits (Lipscchutz et al., 2015). These benefits have limitations on the time of coverage and scope in various healthcare settings including a limitation of 100 days in a skilled nursing institution, which affects a plan's ability to change co-insurance, deductibles as well as co-pays although they are capable of loosening their benefits requirements. | The Medicaid under the managed care organizations has out-of-pocket maximum only. | According to Kimuyu (2018), the health maintenance organization encompasses various organized healthcare system. This form of managed care organization offers a large framework of health services to particular populations, which are enrolled in the Medicaid programs (Kimuyu, 2018). Nonetheless, it provides finances to its insurers, thus acting like a health insurer and a management system in the healthcare service delivery. Kimuyu (2018) identifies the HMOs group model as the most common in the US whereby, they contract a multispecialty physician group who attend to their enrollees. In the preferred provider Organizations enrollees in a particular selected network receive healthcare services that are obtained through an agreement between the employer's health benefit and the health insurance carrier (Kimuyu, 2018). In this form of network, the PPO prepares the payment levels together with the reimbursement procedures which are acceptable by the healthcare providers who are participants. The PPOs implement useful utilization management strategies that help utilize health services as well as controlling costs. The point-of-service incorporates other types of plans such as the HMO to the indemnity coverage when covering members outside their networks. (Kimuyu, 2018). In POS, members are not allowed to choose the system of their preference until when they want to receive the service. |
| Maximum out-of-pocket | Medicare's maximum pay-out of the pocket includes 6,700 American dollars for part A and B medical services for individuals enrolled in 2015(Lipschutz et al., 2015). Nonetheless, the program includes a catastrophic cover of around 4,700 American dollars out-of-pocket in 2015. The various separate caps under the Medicare account for 11,400 American dollars pocket, whereby the enrollees might still cater to their prescribed drug costs (Lipschutz et al., 2015). | The Medicaid under managed care organizations tend to have strict limits on the cost-sharing set out-out-pocket (Lipschutz et al., 2015). However, the out-the-pocket generally remains below 5% of the quarterly and monthly income. | |
| Alternatives to ease the drain on resources | The federal government ought to reform the payment process. According to Martinez, King, and Cauchi (2016), the government can offer financial incentives, which will encourage healthcare coordination and collaboration among various providers to minimize expenses on unnecessary services as well as offer rewards to the service providers that quality-oriented. Therefore, the government needs the payment models that are likely to decrease costs while improving care. The payment reforms applicable include accountable care organizations, global payments as well as the bundled payments. The government can also increase the cost-sharing among patients to help reduce unnecessary care and help the patients become more attentive to costs (Martinez, King & Cauchi 2016). The cost-sharing approach increases the patient’s contributions towards their healthcare services in the form of co-payments, higher deductibles, and more pay for the prescription type of medicine. | The traditional fee-for-service mainly emphasizes on paying for volume and individual services instead of focusing on the results (Martinez, King & Cauchi, 2016). Therefore, to minimize the various forms of expenses, a collaboration between the healthcare providers is necessary to develop the most cost-effective type of treatment for their patients. The federal government in the process of reforming payments in Medicare can adopt care coordination, and collaboration among various providers reduce spending (Martinez, King & Cauchi, 2016). The government can also implement the performance-based reimbursements that are tied to efficiency metrics and quality, that encourage coordination through pay while offering incentives for good health results (Martinez, King & Cauchi, 2016). Examination of the current system of delivery and payment system to identify opportunities in the improvement of quality is also necessary. |
References
Kimuyu, P. (2018). The Role of Managed Care Organizations within the Healthcare Industry.
Lipschutz, D., Callow, A., Pollitz, K., Musumeci, M., & Jacobson, G., (2015) Comparison of Consumer Protections in Three Health Insurance Markets: Medicare Advantage, Qualified health plans and Medicaid Managed Care Organizations.Report
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Martinez, J. C., King, M. P., & Cauchi, R. (2016). Improving the health care system: seven state strategies. National Conference of State Legislatures.
