Healthcare Delivery Systems in the USA: Medicare and Medicaid

see attached file
750– words examining the similarities and differences among health care delivery systems that currently exist in the United States.
Include the following in your assessment:
1. Select two or three health care delivery systems to examine.
2. Provide a description and relevant details of the selected delivery systems.
3. Summarize the mission or philosophy statement for each of the health care delivery systems you selected.
4. Formulate your own mission or philosophy statement, with rationale as to why you chose these elements to include.

Health Care Delivery Systems

Introduction                                                                        

Health care can be differentiated into many classifications. Organizing the United States Health Care Delivery System (Shih, Davis, Schoenbaum, Gauthier, Nuzum, & McCarthy, 2008) has been a fragmented attempt at providing care in the most cost-effective way to the majority of the population. Health care delivery systems often fail to deliver a coordinated transdisciplinary approach to all those who desire care. While it is often a difficult matter to clearly define, there are several ways in which to categorize health care to make it more understandable. Most of this care can be classified into how it is paid for, how it is accessed, where it is provided, and what its purpose is.

Health Care Options

Through the Department of Health and Human Services (HHS), the federal government oversees the Centers for Medicare and Medicaid (CMS), which administers Medicare, the health insurance Marketplace (mandated by the Affordable Care Act of 2010), Medicaid, and the Children's Health Insurance Program (CHIP). The federal government also finances the Federal Employees' Health Benefits Plan and all Veteran Administration Hospitals (Center for Medicare and Medicaid Services, 2008). Financing comes from a fee-for-service program that has a payment schedule for both individuals that pay every time a service is used and federal funds that supplement payments to the providers for care given. In addition, there is a monthly charge for enrollees of the program. Most citizens qualify for Medicare or Medicaid payments when age requirements or disability and income levels are reached, which makes the plan the most widely accessible health care delivery system.

Access to the plan and care provided is a federal program that covers many services from providers that accept Medicare insurance. This may include participating provider options (PPO) that have entered into an agreement with the federal insurance program to charge an established rate to treat members. The federal program is intended to provide health insurance to as many people as possible for an affordable cost from a population-specific criterion. The purpose is primarily to cure and restore health, rather than prevent illness in organized wellness programs. Interdisciplinary collaboration is essential to provide adequate complex care for the patient since the disciplines come from different health care settings.

Health maintenance organizations (HMOs) are private insurance companies that contract with the government to provide care to those of Medicare age at a specific cost per person. HMOs also provide individual "health care services to ... members through networks of doctors, hospitals, and other health care providers" (Texas Department of Insurance, 2008). HMOs may also use the PPO option that contracts with providers to provide a service at a set rate for members. There are usually limitations on provider and service selection, which keeps the costs lower both for the HMO and the member. The payment can be made either by the member or the employer.

Access to the HMO plans is limited to those areas that offer the coverage option, where the care provided is limited to contracted clinics, hospitals, or pharmacies that are designated members of the HMO service areas. The limitation to a controlled network of care is counterbalanced by a lower cost the member has to pay. A way HMOs cut costs is to promote wellness and prevention programs, rather than focus only on curative and restorative health care. Cross-disciplinary work may be established through contracts with specialists, hospitals, nursing homes, and case management to cut costs and determine the best care for the patient.

Philosophy and Mission

Health care systems all have as their goal to provide medical care for the patient. The Medicare federal fee-for-service provides payment to individual providers to care for that patient population. The mission states: "to assist the aged and disabled population with their medical care, Congress enacted legislation to create federal programs that assume partial if not primary responsibility for reasonable and necessary health care expenses" (Center for Medicare and Medicaid Services, 2008). The private fee-for-service system is free of multiple regulations in medical practice and can charge whatever the public is willing to pay.

HMOs were created as a private insurance to provide care with limited access and rules of coverage, but offered a lower cost alternative to health care. The functional goal is to create a patient-centered approach with multiple disciplines involved in the care of the patient. This can be achieved in the restrictive environment of a HMO setting rather than the more independent fee-for-service plan. In order to further get cost under control, the HMOs have developed Best Practice guidelines that identified and mandated usage of those services most efficient to the treatment of the patients (Kuhlmann, 2005). The trend is for allied health professions to use this as a basis for the transdisciplinary team approach.

Health Care Collaboration

Health care professionals are in the perfect place to facilitate greater organization of the health care delivery system. The Commonwealth Fund Commission recommends more education on delivery systems so that development and coordination of efforts can be followed (Shih et al., 2008).

The Interprofessional Alliance Model uses the components of content, process, and outcome to establish a formal basis for problem solving patient care issues in a team concept. Collaboration may aid in treating some of the biggest health care issues in the United States that include:

1.      Heart disease

2.      Malignant neoplasms

3.      Cerebrovascular diseases

4.      Diabetes mellitus

5.      Alzheimer's disease

6.      Kidney disease

7.      Mental Health

8.      Obesity and overweight (especially in children)

Collaboration with health care delivery systems can create new programs for research, treatment, and education to address the health care issues of these and other diseases. Those diseases that capture the public interest usually garner the most research funding, which can lead to treatments and cures.

The national epidemic of diabetes has prompted increased research into treatment options and genetic testing for the disease. An increase in national health care spending on the disease has created more programs to increase education to prevent the progression of the disease and fund research on treatment options. Interprofessional collaboration establishes that the primary provider treats the disease, but the provider may send the patient to a diabetic educator for more training. The educator then sends the patient to a dietician for food plans. The professional diabetes organization may send the patient more information on the disease or lobby for more funding. Society becomes more aware of the disease through news reports and writes congress to increase funding. This is an example of collaboration with an expanded team approach.

Conclusion

Health care delivery systems in the United States continue to struggle with delivering quality care with the rapid rise of costs associated with increases in demand by the public, lack of interdisciplinary approach to care, and lack of organized health care. The fee-for-service government programs guarantee basic coverage to the elderly and disabled. Private insurance plans have a more restrictive policy, but have offered alternatives for care. As in any other industry, those systems that do not meet the needs of the consumers will need to evolve or cease to be viable.

References

Centers for Medicare and Medicaid Services. (2008, May). Medicare part B: Introduction to Medicare billing guide May 2008. Retrieved September 11, 2008, from http://www(dot)medicarenhic(dot)com/providers/pubs/introguide.pdf

Kuhlmann, M. (2005). Transdisciplinary Teams: An evolving approach in   rehabilitation. Retrieved September 9, 2008, from University of Texas Medical Branch, American Congress of Rehabilitation Web site: http://www(dot)utmb(dot)edu/pmch/GSO/Evolving_Approach_to_Rehabilitation.htm

Shih, A., Davis, K., Schoenbaum, S., Gauthier, A., Nuzum, R., & McCarthy, D. (2008, August 7). Organizing the U.S. health care delivery system for high performance. Commonwealth Fund Report, Volume 98. Retrieved September 10, 2008, from http://www(dot)commonwealthfund(dot)org/publications/publications_show.htm?doc_id=698139

Jonas and Kovner's Health Care Delivery in the United States

Read Chapter 2 in Jonas and Kovner's Health Care Delivery in the United States.

http://gcumedia(dot)com/digital-resources/springer-publishing-company/2015/jonas-and-kovners-health-care-delivery-in-the-united-states_ebook_11e.php

Electronic Resource

1. 2014 National Healthcare Disparities Report

Read "2014 National Healthcare Disparities Report" from the Agency for Healthcare Research and Quality website.

http://www(dot)ahrq(dot)gov/sites/default/files/wysiwyg/research/findings/nhqrdr/nhqdr14/2014nhqdr.pdf

2. Health Maintenance Organizations

Read "Health Maintenance Organizations," from the Texas Department of Insurance website.

http://www(dot)tdi(dot)state(dot)tx(dot)us/pubs/consumer/cb069.html

3. Organizing the U.S. Health Care Delivery System for High Performance

Read "Organizing the U.S. Health Care Delivery System for High Performance," from the Commonwealth Fund website.

http://www(dot)commonwealthfund(dot)org/publications/fund-reports/2008/aug/organizing-the-u-s--health-care-delivery-system-for-high-performance

4. Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011

Read "Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, 2011" from the Commonwealth Fund website.

http://www(dot)commonwealthfund(dot)org/publications/fund-reports/2011/oct/why-not-the-best-2011

Website

1. Association of Academic Health Centers

Explore the Association of Academic Health Centers website.

http://www(dot)aahcdc(dot)org/

2. Associations/Organizations

Explore the "Associations/Organizations" page, located on the National Student Nurses Association website.

http://www(dot)nsna(dot)org/careercenter/associations.aspx

3. Center for Infectious Disease Research and Policy

Explore the Center for Infectious Disease Research and Policy website.

http://www(dot)cidrap(dot)umn(dot)edu/

4. Consumers and Patients

Explore the "Consumers and Patients" page, located on the Agency for Healthcare Research and Quality website.

http://www(dot)ahrq(dot)gov/patients-consumers/index.html