Introduction
Medicare is a national health insurance program that was launched by the United States government in 1966. The program provides medical support to citizens older than 65. Medicare was initially administered by the Social Security Administration, but it is currently under Centers for Medicare and Medicaid Services (CMS). According to the Journal of American Healthcare, Medicare has provided medical insurance covers for 58 million people, of which 49 million are aged above 65 years while 9 million are younger. On average, Medicare takes care of a third of the cost of healthcare for its members. According to the Health Policy Report explanation, Medicare was formed as an interim step towards a broader goal of universal health coverage ( Cotton, Lohman, Brooks, Whiteman, Bao, Greenberg, & Bruce, 2017 ).
This governmental program only covers 80 percent of the patient’s medical costs. Medicare determines the costs allowable for healthcare services provided by the facilities; in return, the caregivers provide write offs on the difference between Medicare and the actual cost of healthcare. The members are liable for the other amounts; they can either pay from their own incomes or join the Medicare health plan. No matter which option they choose, they have to incur out of the pocket expenses. These out of the pocket costs can include deductibles and co-pays. In accordance with the Politics of Medicare handbook (Marmor, 2017), President Johnson flew to Missouri in 1965 to sign the Medicare bill. The author states that Medicare transitioned politically from a legislative act to one of the major government programs within a lifespan of three decades.
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Scope of Operation
Medicare covers the medical costs for several special groups in the community. Firstly, it includes the elderly who are 65 years and above ( Byhoff, Harris, & Ayanian, 2016 ). Recent research has been conducted on Medicare patients’ cost of care in their latter years of life. The findings indicate that 38 percent of the beneficiaries have the chance to experience a nursing home stay in their final years. Although Medicare is not the primary source of cash for this population; it is paramount and plays an essential role in ensuring they live life at best and receive the required medical attention. The research indicates that on average, the last six months before death, Medicare accounts for 70 percent of healthcare costs. The statistical analysis proves that Medicare sorts approximately 61 percent of the diseased costs as 10 percent is sorted by Medicaid ( Byhoff, Harris, & Ayanian, 2016 ). It is general knowledge that American nursing homes for the elderly are usually considered expensive as 18 percent comes from out of pocket spending.
It also provides health insurance for the younger generation of people with disability statuses that are determined by the Social Security Administration. Medicare also facilitates the cost of healthcare for people with end-stage renal disease; this condition was made available under the Medicare program in July 1973. Unlike the other prospective payment systems, Medicare pays for a single product category when it comes to the End Stage Renal Disease Program (ESRD) ( Byhoff, Harris, & Ayanian, 2016 ). Medicare pays one composite rate per dialysis treatment for people with stage five chronic kidneys Disease. The paid rate is meant to cover all the capital and operating costs incurred by healthcare givers and providers in furnishing dialysis equipment in outpatient facilities or in the patient’s home. Medicare is programmed to cover an average of three dialysis sections weekly. Patients who receive home treatments may require more frequent dialysis of more than three days a week if that is the case the liability is on the patients. Medicare will only cover the first three dialysis treatments.
Segments of Medicare
Medicare is made up of four main parts with each part covering specific services. Beneficiaries prefer receiving their part A and B benefits through the traditional fee for service program that is part of the traditional Medicare program. These benefits are offered directly by the federal government; in this case, the government pays for the cost of healthcare received directly without intermediaries. There is a lack of research on the various types of Medicare programs; so much emphasis has been placed on Part D of the Medicare program. Part A deals with inpatient and hospital coverage, B deals with outpatient coverage, Coffers alternatives to Medicare benefits while the important part D provides the cover for a drug prescribed to patients.
Funding and Financial Support
According to the health politics Policy and Law journal (Sullivan, 2013); Medicare’s administrative expenditures are published twice a year by the Centers for Medicare and Medicaid Services (CMS). The first report is addressed to the National Health Expenditure Accounts (NHEA) while the other report goes to the Medicare Board of Trustees. According to the researcher, the two Medicare reports have shown different figures that have spurred up debates about the administrative costs associated with the Medicare program (Sullivan, 2013). The article discussed the statistical methodological controversies related to the two reports in a bid to make it more palatable for the taxpayer. The costs associated with Medicare services are decreased as an act of government’s rule on the insurance premiums and policy conditions. The low-income households and those dealing with chronic illnesses have a tendency of paying larger portions of their salaries to towards healthcare compared to the financially well off individuals. Progressive federal taxes has been strategically managed to handle imbalance in living standards and replace current regressive income related sources of medical financing and reduce out of pocket expenses.
Data published by the Centers for Medical and Medicaid proves that the cost of healthcare is on the rise as the years go by (Friedman, 2013). The increased medical care costs are mostly associated with the increasing rate of chronic diseases, increased cost of pharmaceutical products and the cost of care given to the aging population. The local government spends amicable amounts of money on Medicare and other health services. These expenditures were approximated at $1723 billion in the year 2014. The government covers the costs on private health insurance and for public civil servants as well as the other older adults in the society (Friedman, 2013). The Affordable Care Act ensures that the population has access to medical services despite their financial constraints. This Act has put a heavy strain on the insurance companies and the government itself. According to a research project, the healthcare system incurred a projected amount of $3.13 trillion in the year 2014. Healthcare in the United States is said to be highly regressive. Medicare spending and advisability of value-adjusted payments is dependent on post acute treatment and inpatient hospital services based on geographic variations.
Public Awareness
Very little has been done on the publicity of Medicare. Most of the population has inadequate information on how Medicare works. According to Leslie et al. (2006), ‘As the Medicare program evolves and expands in terms of diversified insurance programs such as the regional preferred provider organizations (PPO); “beneficiaries have an even greater need to understand the program.” Past research reports indicate that most of the beneficiaries have minimal knowledge of Medicare and other health insurance policies. The government is putting in efforts to upgrade the terms of service for the population and adapt to the current technological advancements. Although these efforts are viable and focused on success on the Medicare program, improvement in beneficiary understanding of the program still plays a big role in its success story. A research conducted on the evidence of factors that predict knowledge limitations in the Medicare program concluded that several measures affected beneficiary knowledge.
More past research implies that more product awareness in the part of the beneficiaries is directly proportional to the Center of Medicare Service’s education efforts (Butler, 2018). The Medicare program has participated in a wide range of activities in a bid to improve the spread of health insurance knowledge to the public (Butler, 2018). The National Medicare Education Program (NMEP) has been formed to encourage and assist members of the public in understanding the Medicare program better. The NMEP program has launched public activities inclusive of intensive and progressive evaluation and testing of beneficiaries’ knowledge. The program has ensured information interventions by providing learning materials such as the Medicare & You handbook and information on the Medicare website at www.medicare.gov.
Researches being conducted to examine the product knowledge by the beneficiaries of Medicare and other government health insurance policies are based on surveys and questionnaires. These surveys employ the use of objective measures and encourage openness in the population. In this review, several studies that embrace multiple item indices are used to categorize the various components of Medicare knowledge in the study population (Butler, 2018). The studies that focus on a randomized design have proven more reliable since they are free from cross-sectional limitations. It is recommendable that future studies focus on experimental study designs. Knowledge gained depends on an individual’s preparedness to be get involved in insurance decisions. The beneficiaries who seek information before they get involved in Medicare are more knowledgeable and satisfied with the services offered. Based on Prochaska's’ behavior change model ( Reid, Deb, Howell, Conway, & Shrank, 2016 ). People are categorized in accordance with their readiness levels. The levels can range between the pre-contemplation stages; this is the level where an individual shows indifference or disinterest in the cover to the maintenance in ending, the individuals who have been considering Medicare as an option for more than a year.
Quality Assurance Program
There is a scarcity of research done on the quality and accessibility of Medicare program, the most recent one was done more than ten years ago and was not exclusively focused on Medicare (Gold & Casillas, 2014). The research findings were not exclusively focused on Medicare, and it was more oriented on the quality of healthcare in general. This study found out that care provided by Health maintenance organizations (HMO) was roughly comparable in quality to that offered by the non-Health Maintenance Organizations also known as the traditional indemnity insurance policies. Quality was not standardized as it varied from one health facility to another (Gold & Casillas, 2014). Technological advancements have led to improved services over the years; hence these research findings may not be viable at this particular period.
According to Gold & Casillas (2014), Medicare HMOs offer higher quality outcomes than traditional Medicare with regards to offering preventive services and resource conservation. Although this research uses data that is a little older, it is evident that beneficiaries favor the traditional Medicare over recent Medicare Advantage plan. Traditional Medicare has proven to be of a higher quality and more satisfactory to the beneficiaries. There is a more significant difference between the quality of service between the traditional Medicare system and the recent one. Medicare transitioned from quality assurance to quality improvement from the 1980s to 1990s with a goal to improve the performance by the healthcare providers. As a result, care has been enhanced with time primarily because the government has set measures in place to handle the institutions that do not follow the Affordable Care Act regulations.
Current trends in Medicare
According to research, the current trend in the Medicare Advantage program is the Special Needs Plan (Stemple, Charles, et al., 2008). The Special Needs Plan (SNP) was designed to handle the needs of a particular group of the population with a focus on the most vulnerable individuals in the Medicare System. Unlike the other Medicare programs this program is meant to offer services that are defined by the specific population they serve; it, therefore, does not follow the rules and is not on a contractual basis. According to Stemple et al., the program restricts enrollment to only three target populations which are: the dual eligible, institutional beneficiaries and the chronically disabled. Research indicates that this program is custom made to meet the needs of specific people by modifying care patterns and increased disease management. If well used, this trend could lead to better outcomes and reduced costs.
This research focuses on plan D of the Medicare Program (Stemple, Charles, et al., 2008). Plan D results on high levels of generic drug utilization with the aim of minimizing costs incurred by beneficiaries. The study admits the limited nature of generic drugs and the fact that the plan does not cover brand name gaps. However, the study reveals that with the newly embraced marketing strategy to attract beneficiaries such as direct mail and social media advertising; there is hope for more service consumers of the Special Needs Plan (SNP) product. This new trend is focused on improving the overall wellbeing of the members, increase the satisfaction of the consumers, less costly and provide high-quality service to the beneficiaries.
A recent study on the path forward on Medicare readmissions (Joynt & Jha, 2013) maintains that two-thirds of Americas Medicare oriented health facilities are exposed to 1% penalties on Medicare reimbursements. Joynt & Jha state that “the program could exacerbate disparities” pertaining care and create disincentives in providing care for the seriously sick. With proper governmental regulation and professional competence of caregivers, there is a promising future characterized by low mortality rates of the elderly and a healthier population. The patient protection and Affordable Care Act (ACA) is amove in the right direction for the country, and it has brought a perception of healthcare as a human right that should be received by all individuals.
Conclusion
The literature review focuses on major research findings related to Medicare Programs and the efficiency of the program in the Healthcare system. It is clearly visible that Medicare has brought transformative developments in the health system and led to reduced mortality rates in the elderly and the seriously disabled individuals. Medicare has a promising future considering the forecasting on the governmental efforts being put in place. There is a need for more research on the quality assurance program of the Medicare Advantage and the efficiency of the various categories of Medicare. Most of the researches are focused on plan D category of Medicare and its importance to beneficiaries but not many research papers focus on part A, B, and C of Medicare. Since 1966, the government has been in contract with private insurance companies which operate as the middlemen between the government and the healthcare facilities; thus, there is need to find out if alternative approaches could offer better results.
References
Butler, M. D. (2018). The $74,973 Question: Are Medicare Beneficiaries Informed Users of Private Medical Care Contracts?. Journal of gerontological social work , 1-12.
Byhoff, E., Harris, J. A., & Ayanian, J. Z. (2016). Characteristics of decedents in Medicare Advantage and traditional Medicare. JAMA internal medicine , 176 (7), 1020-1023.
Cotton, B. P., Lohman, M. C., Brooks, J., Whiteman, K., Bao, Y., Greenberg, R. L., & Bruce, M. L. (2017). Prevalence of and factors related to prescription opioids, benzodiazepines, and hypnotics among Medicare home health recipients. Home healthcare now , 35 (6), 304.
Friedman, G. (2013). Funding HR 676: The Expanded and Improved Medicare for All Act How we can afford a national single-payer health plan. Retrieved February , 10 , 2015.
Gold, M., & Casillas, G. (2014). What do we know about health care access and quality in Medicare Advantage versus the traditional Medicare program? (No. e640dda97d0c440bbbe1082ec1a3c5fb). Mathematica Policy Research.
Joynt, K. E., & Jha, A. K. (2013). A path forward on Medicare readmissions. New England Journal of Medicine , 368 (13), 1175-1177.
Marmor, T. R. (2017). The politics of Medicare . London:Routledge.
Reid, R. O., Deb, P., Howell, B. L., Conway, P. H., & Shrank, W. H. (2016). The roles of cost and quality information in Medicare Advantage plan enrollment decisions: an observational study. Journal of general internal medicine , 31 (2), 234-241.
Stemple, C., Cammisa, C. R., Evans, S., Fenter, T. C., Gonzalez, J., Lee, H., & Noga, M. (2008). Current issues and trends in medicare Part D. JMCP , 14 (6 Suppl), 1-28.
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