Compare and contrast each of the three questions related to Managed Care Organizations, Medicare
Compare and contrast each of the three questions related to Managed Care Organizations, Medicare, and Medicaid with one another and explain how they were similar and different to each other.
Compare and contrast each of the three questions
- Managed care organizations emphasize physicians’ responsibilities to control patient access to expensive hospitalization and specialty care, a principle dubbed “gatekeeping.” Some argue that “gatekeeping” is unethical because it introduces financial factors into treatment decisions. Others say it improves quality by promoting the use of the most appropriate levels of care.
- Medicare is an area that often gets overlooked and is seen as a burden financially. Discuss alternatives to ease the drain on Medicare resources.
- Medicaid is shouldering an ever-increasing burden of cost for long-term care for the elderly, with enormous impacts on state budgets throughout the nation. Discuss alternatives to ease this drain on Medicaid resources.
Develop an APA-formatted essay discussing the three entities.
Describe what they are and how they differ. Include an introduction to let the reader know what will be found in the essay.
Create a table to provide comparison of the three entities. The table can be used as the body of the paper, or it can be added as an addendum after the Reference page. If you opt to add it as an addendum, refer to the table in the narrative in the body of the essay.
As in all essays, include a conclusion to provide a summary of the material. This assignment highlights your ability to do research and display information in a table format. Include citations, as appropriate, for information in the table. Refer to chapter 7 in the APA manual, specifically pages 223 -224 for information on tables using words for displaying information.
Required Source
- Sultz, H. A., & Young, K. A. (2017). Health care USA: Understanding its organization and delivery (9th ed.). Jones & Bartlett. Read Chapter 8.
The following specifications are required for this assignment:
- Length: 750 words
- Structure: Include a title page and reference page in APA style. These do not count towards the minimal word amount for this assignment.
- References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. Include at least two (2) scholarly sources to support your claims.
- Format: Save your assignment as a Microsoft Word document (.doc or .docx).
- File Name: Name your saved file according to your first initial, last name, and the module number (for example, “RHall Module 1.docx”)
Expert Answer and Explanation
Healthcare Finance
In the United States (US), healthcare is paid for or financed in a variety of ways. One of the ways is an out-of-pocket method where individuals pay directly for services they have been offered. The second way is private insurance. Other people have health insurance coverage as a tax-free benefit from their employer (Sultz & Young, 2017). Most working individuals are covered by employer-provided healthcare insurance, a managed care plan, such as a Health Maintenance Organization, or traditional indemnity insurance.
The third method is public insurance and programs. For instance, the government has Military Health Insurance to cover the health of military personnel and their dependents as well as veterans. Other health insurance programs run by the government include Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP) (Sultz & Young, 2017). People often confuse Medicare, Managed Care Organizations (MCOs), and Medicaid. The purpose of this essay is to compare and contrast Medicare, Managed Care Organizations (MCOs), and Medicaid by giving their similarities and differences.
The Three Entities
The first entity is MCO. MCOs are integrated organizations in the healthcare system focused on managed care as a method of reducing care costs while maintaining a high quality of care. The focus of MCOs is to reduce the cost of care while keeping the quality high. There are four types of MCOs (Seiler et al., 2022). The first type is Health Maintenance Organization (HMO). HMO manages care by requiring beneficiaries to see a network of health providers at a much lower cost.
It also needs beneficially to see their primary care provider (PCP) before any provider who is not in the network. The second type is Preferred Provider Organization (PPO). This form of MCO allows one to see any doctor they like, in the network or outside (Opoku et al., 2022). The beneficially may pay less for seeing an in-network provider and higher for the outside network provider.
The third is Point of Service (POS). This program combines HMO and PPO where one can see providers in and outside the network but at slightly higher costs. The last type is Exclusive Provider Organization (EPO) (Opoku et al., 2022). It also combines HMOs and PPOs’ features. Its costs are less than PPO but higher than HMO.
The second entity is the Medicare program. Medical is a federal health insurance program for some young people with disabilities, adults aged 65 years or older, and individuals with End-Stage Renal Disease (Agarwal et al., 2021). Drain in Medicare resources can be eased through the following alternatives. First, reducing unnecessary complications and preventable readmissions.
Complications and readmission increase the cost of care and thus puts more burden on Medicare (Committee for a Responsible Federal Budget, n.d). Second, the drain can be reduced by decreasing the use of high-cost drugs. Lastly, the program should use the value-based model to pay physicians where they are paid based on efficiency, quality, and care coordination.
The third entity is the Medicaid program. Medicaid is a health insurance program that provides health coverage to millions of US citizens, including children, low-income adults, elderly adults and people with disabilities, and pregnant women (Linder et al., 2018). States administer the program based on federal requirements. The program is funded both by the federal government and state governments. Drain in Medicaid resources can be eased through the following alternatives.
First. Physician payment should be modified to decrease unnecessary care. physicians should be paid using the salaried system with a relatively modest bonus for quality (Linder et al., 2018). The second way is to decrease the use of emergency departments (ED) by dual-eligible beneficiaries and children on Medicaid. Linder et al. (2018) reported that treating strep throat in ED costs $328, $122 in a primary care office, and the US $130 at an urgent care center. Based on their findings, many patients as possible eligible for Medicaid should be treated outside ED to ease the drain on Medicaid resources.
Similarities Between Medicare, Managed Care Organizations (MCOs), and Medicaid
The similarity between the three entities is that they all aim to improve access to care by reducing the cost of care. MCOs, Medicare, and Medicaid were developed to make healthcare in the US affordable. MCOs reduce the cost of care by ensuring that healthcare professionals in the networks use more effective treatments at low costs. Seiler et al. (2022) noted that MCOs reduce costs while maintaining the quality of care high. Medicaid and Medicare ensure care accessibility by paying for care services offered to eligible individuals.
Differences
| Managed Care Organizations | Medicare | Medicaid |
| MCOs are integrated organizations in healthcare system (Sultz & Young, 2017). | Medicare is a health insurance program. | Medicaid is a health assistance program |
| Private health institutions provide MCOs | Medicare is a federal program | Medicaid is a federal-state program. |
| Employees of an employer using MCOs and their dependents are eligible for MCOs benefits. | The program is meant for some young people with disabilities, adults aged 65 years or older, and individuals with End-Stage Renal Disease (Sultz & Young, 2017). | Low-income people of every age are eligible. |
| Funded by employers. | Funded by federal government | Funded by both states and federal government. |
Conclusion
The three entities have greatly reduced the cost of care and thus improved access to care in the US. MCOs have reduced the cost of care by ensuring that providers use efficient and cost-effective treatment methods. Medicare and Medicaid have reduced the cost of care by paying for most of the care services offered to its members. However, they are all different. Medicare is funded and run by the federal government. Medicaid is a federal-state program funded by both states and the federal government. MCOs are offered by organizations in the healthcare system and funded by employers.
References
Agarwal, R., Connolly, J., Gupta, S., & Navathe, A. S. (2021). Comparing Medicare advantage and traditional Medicare: A systematic review: A systematic review compares Medicare Advantage and traditional Medicare on key metrics including preventive care visits, hospital admissions, and emergency room visits. Health Affairs, 40(6), 937-944. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.02149
Committee for a Responsible Federal Budget. (n.d). How to reduce Medicare spending without cutting benefits. https://www.crfb.org/blogs/how-reduce-medicare-spending-without-cutting-benefits
Linder, S. H., Aguillard, K., French, K., & Garson, A. (2018). Reducing the cost of Medicaid: A multistate simulation. Health Services Insights, 11, 1178632918813311. https://doi.org/10.1177/1178632918813311
Opoku, S. T., Apenteng, B. A., Kimsey, L., Peden, A., & Owens, C. (2022). COVID-19 and social determinants of health: Medicaid managed care organizations’ experiences with addressing member social needs. Plos One, 17(3), e0264940. https://doi.org/10.1371/journal.pone.0264940
Seiler, N., Horton, K., Pearson, W. S., Cramer, R., Adil, M., Bishop, D., & Heyison, C. (2022). Addressing the STI Epidemic Through the Medicaid Program: A Roadmap for States and Managed Care Organizations. Public Health Reports, 137(1), 5-10. https://doi.org/10.1177/0033354920985476
Sultz, H. A., & Young, K. A. (2017). Health care USA: Understanding its organization and delivery (9th ed.). Jones & Bartlett.
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Who is Eligible for Medicare and Medicaid?
Medicare and Medicaid are two essential healthcare programs in the United States designed to provide assistance to different groups of people. While both programs are funded by the government, they have distinct eligibility criteria and cater to specific populations. In this article, we will explore the eligibility requirements for Medicare and Medicaid to help individuals understand if they qualify for these programs.
Introduction to Medicare and Medicaid
Medicare and Medicaid were established in 1965 as part of the Social Security Act. These programs play a crucial role in ensuring that certain groups of individuals have access to affordable and comprehensive healthcare services.
Medicare primarily serves the elderly population aged 65 and above, along with some individuals with disabilities. On the other hand, Medicaid is a joint federal and state program that provides healthcare coverage to low-income individuals and families, including pregnant women, children, and people with disabilities.
What is Medicare?
Medicare is a federal health insurance program that primarily serves individuals aged 65 and older, regardless of their income level. It also covers some younger individuals with disabilities and those with end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS).
Eligibility Criteria for Medicare
To be eligible for Medicare, individuals must meet the following criteria:
Age: The person should be 65 years or older.
Disability: Individuals under 65 may qualify if they have received Social Security disability benefits for at least 24 months.
End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS): Individuals with ESRD requiring dialysis or a kidney transplant or those with ALS automatically qualify.
What is Medicaid?
Medicaid is a joint federal and state program that offers health coverage to eligible low-income individuals and families. The program is administered by the states, and eligibility criteria and benefits may vary depending on the state of residence.
Eligibility Criteria for Medicaid
The eligibility criteria for Medicaid can vary from state to state, but some common requirements include:
Income: Individuals and families must have income levels below a certain threshold to qualify.
Asset Limits: Some states consider an applicant’s assets in addition to income.
Categorical Requirements: Medicaid is available to certain categories of individuals, such as pregnant women, children, parents, seniors, and people with disabilities.
Citizenship or Residency: Applicants must be U.S. citizens or qualified immigrants with legal residency.
Coverage and Benefits
Medicaid provides a wide range of healthcare services, including hospital stays, doctor visits, lab tests, prescription drugs, mental health services, and preventive care. The specific benefits available may vary based on the state’s Medicaid program.
Key Differences Between Medicare and Medicaid
While both programs aim to provide healthcare coverage, there are significant differences between Medicare and Medicaid:
- Eligibility: Medicare mainly serves seniors and individuals with disabilities, while Medicaid targets low-income individuals and families.
- Funding: Medicare is fully funded by the federal government, while Medicaid is jointly funded by the federal and state governments.
- Cost-sharing: Medicare generally requires cost-sharing in the form of premiums, deductibles, and coinsurance, whereas Medicaid may have minimal or no cost-sharing for eligible individuals.
- Services Covered: The services covered by Medicare and Medicaid differ, with Medicare focusing on medical services and Medicaid offering a broader range of healthcare benefits.
Who is Eligible for Medicare and Medicaid?
Eligibility for Medicare and Medicaid depends on several factors, and it is crucial to understand the requirements to determine if one qualifies for these programs.
Age Requirements
As mentioned earlier, individuals aged 65 and above are eligible for Medicare. However, even if someone is not eligible based on age, they may qualify if they meet the disability criteria.
Disability Requirements
Individuals under 65 may qualify for Medicare if they have been receiving Social Security disability benefits for at least 24 months. This provision ensures that younger individuals with significant health challenges have access to healthcare coverage.
Income and Asset Limits
Medicaid eligibility is primarily based on income and asset limits. Income requirements may vary by state, and some states have expanded Medicaid to cover individuals with slightly higher incomes under the Affordable Care Act (ACA).
Citizenship or Residency Requirements
Both Medicare and Medicaid require applicants to be U.S. citizens or qualified immigrants with legal residency. Proof of citizenship or immigration status is necessary during the application process.
Dual Eligibility for Medicare and Medicaid
Some individuals may qualify for both Medicare and Medicaid, known as “dual-eligible” beneficiaries. These individuals typically have lower incomes and may require more extensive healthcare coverage due to their health conditions.
Dual-eligible individuals may receive additional benefits and cost-sharing assistance to ensure they can access necessary healthcare services without financial burden.
Applying for Medicare and Medicaid
The process of applying for Medicare and Medicaid may vary depending on individual circumstances and the state of residence. For Medicare, individuals may enroll during the Initial Enrollment Period (IEP) around their 65th birthday or during the General Enrollment Period (GEP) if they missed the IEP.
Medicaid applications are typically handled through the state’s Medicaid agency. Interested individuals can apply online, in person, or by mail, providing the necessary documentation to verify eligibility.
How to Choose Between Medicare and Medicaid?
If an individual is eligible for both Medicare and Medicaid, they may have the option to choose between the two programs. The decision depends on various factors, including income, healthcare needs, and personal preferences.
For those who qualify for both programs, known as “dual-eligible” beneficiaries, the state and federal government work together to coordinate benefits to ensure comprehensive healthcare coverage.
Conclusion
Medicare and Medicaid play vital roles in providing healthcare access to different segments of the U.S. population. Medicare primarily serves seniors and individuals with disabilities, while Medicaid caters to low-income individuals and families.
Understanding the eligibility criteria for both programs is crucial for individuals seeking healthcare coverage. Whether one qualifies for Medicare, Medicaid, or both, these programs help ensure that essential healthcare services are accessible to those who need them most.
FAQs
1. Can I have both Medicare and Medicaid at the same time?
Yes, some individuals may be eligible for both Medicare and Medicaid, commonly referred to as “dual-eligible” beneficiaries. If you qualify for both, your healthcare coverage will be coordinated between the two programs to provide comprehensive benefits.
2. Do I need to pay premiums for Medicaid?
Medicaid does not typically require premiums. However, some states may have small monthly fees or copayments for certain services, depending on the individual’s income level.
3. Can undocumented immigrants apply for Medicaid?
No, undocumented immigrants are generally not eligible for Medicaid. To qualify, applicants must be U.S. citizens or qualified immigrants with legal residency.
4. Can I apply for Medicare before turning 65 if I have a disability?
Yes, individuals who have been receiving Social Security disability benefits for at least 24 months are eligible for Medicare, regardless of their age.
5. What healthcare services does Medicare Part D cover?
Medicare Part D provides coverage for prescription drugs. This coverage can help lower the cost of medications prescribed by doctors or healthcare providers. Each Part D plan may have a different list of covered drugs, known as a formulary, and may have various cost-sharing arrangements.
Medicare vs Medicaid Disability
In the United States, both Medicare and Medicaid provide essential healthcare services to eligible individuals, but they serve different populations, including those with disabilities. Let’s explore the differences between Medicare and Medicaid concerning disability coverage.
Medicare:
Medicare is a federal health insurance program primarily designed for:
People aged 65 and older: Individuals who have reached the age of 65 and are eligible for Social Security benefits can enroll in Medicare.
Individuals with disabilities: Under the age of 65, individuals who have been receiving Social Security Disability Insurance (SSDI) benefits for at least 24 months are eligible for Medicare.
Individuals with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS): Regardless of age, individuals with ESRD requiring dialysis or a kidney transplant, or those diagnosed with ALS, are eligible for Medicare.
Medicare provides coverage for hospital stays, medical services, prescription drugs (through Part D plans), and other healthcare needs. It is essential to note that while Medicare offers significant coverage, it may not cover all medical expenses, and beneficiaries may still be responsible for certain out-of-pocket costs.
Medicaid:
Medicaid, on the other hand, is a joint federal and state program that provides healthcare coverage to low-income individuals and families. Eligibility for Medicaid varies from state to state, and it is generally based on:
Income: Individuals and families must have income levels below a certain threshold set by each state.
Asset Limits: Some states consider an applicant’s assets, such as savings and property, in addition to income.
Categorical Requirements: Medicaid is available to specific categories of individuals, including pregnant women, children, parents, seniors, and individuals with disabilities.
Citizenship or Residency: Applicants must be U.S. citizens or qualified immigrants with legal residency.
Medicaid provides comprehensive healthcare coverage, including doctor visits, hospitalization, prescription drugs, and various other medical services. The program aims to ensure that low-income individuals and families, including those with disabilities, have access to necessary healthcare services without facing financial hardships.
Dual Eligibility:
In some cases, individuals may be eligible for both Medicare and Medicaid. These individuals are known as “dual-eligible” beneficiaries. Dual-eligibility provides these individuals with enhanced healthcare coverage, as Medicaid can help cover Medicare’s cost-sharing requirements, such as premiums, deductibles, and copayments. This coordination of benefits ensures that dual-eligible individuals receive more extensive healthcare coverage without incurring significant financial burdens.
In conclusion, both Medicare and Medicaid play crucial roles in providing healthcare coverage to different groups, including individuals with disabilities. Medicare primarily serves seniors and individuals with disabilities, while Medicaid focuses on low-income individuals and families. Dual-eligible individuals have the advantage of accessing more comprehensive healthcare services through the coordination of both programs.
Similarities between Medicare and Medicaid
Medicare and Medicaid are both vital healthcare programs in the United States that aim to provide essential medical services to eligible individuals. While they have distinct purposes and target different populations, there are some similarities between the two programs. Let’s explore the common features shared by Medicare and Medicaid:
Government-Funded Programs: Both Medicare and Medicaid are government-funded healthcare programs in the United States. However, they are financed and administered differently.
Healthcare Coverage: Both programs offer various healthcare services to eligible beneficiaries. These services may include hospital care, doctor visits, laboratory tests, prescription drugs, preventive care, and other essential medical treatments.
Focus on Health Services: The primary goal of both programs is to ensure that eligible individuals have access to necessary medical services. They aim to improve health outcomes and provide financial assistance for healthcare expenses.
Coverage for Certain Populations: Although the eligibility criteria differ, both programs target specific populations to address their healthcare needs effectively. Medicare primarily serves seniors aged 65 and older, and certain individuals with disabilities, while Medicaid focuses on low-income individuals and families, pregnant women, children, and people with disabilities.
Coordination for Dual-Eligible Individuals: Dual-eligible beneficiaries, who qualify for both Medicare and Medicaid, receive coordinated benefits from both programs. This coordination helps provide comprehensive coverage and may reduce the financial burden on these individuals.
State Involvement: While Medicare is a federal program, Medicaid is a joint federal and state program. States play a significant role in administering and managing Medicaid, allowing them some flexibility in determining eligibility criteria and benefits within federal guidelines.
Healthcare Providers: Both Medicare and Medicaid work with a network of healthcare providers, including doctors, hospitals, clinics, and pharmacies. Beneficiaries can choose from a list of participating providers for their medical needs.
Affordable Care Act (ACA) Expansion: The Affordable Care Act (ACA) allowed for the expansion of Medicaid in certain states. This expansion extended Medicaid coverage to more low-income adults, closing the coverage gap for some individuals who did not previously qualify.
In conclusion, Medicare and Medicaid share common goals of providing access to healthcare services to eligible individuals, although they cater to different populations and have varying eligibility criteria. Both programs play crucial roles in ensuring that certain segments of the U.S. population have access to essential medical care, promoting overall well-being and health outcomes.
What is the History of Medicare and Medicaid?
The history of Medicare and Medicaid dates back to the mid-20th century when the United States government recognized the need to address healthcare challenges faced by certain segments of the population. Both programs were established as part of the Social Security Amendments of 1965, signed into law by President Lyndon B. Johnson on July 30, 1965. Let’s explore the history of Medicare and Medicaid in more detail:
1. Medicare:
Medicare was initially proposed as a means to provide health insurance for elderly Americans aged 65 and older. Before Medicare’s enactment, many seniors faced financial difficulties in accessing healthcare, and private insurance coverage for older individuals was often costly and inadequate.
The history of Medicare can be traced back to efforts led by President Harry S. Truman, who proposed a national health insurance program in the 1940s. However, the proposal faced significant opposition from various interest groups, preventing its passage.
It was not until the 1960s that Medicare gained substantial support and momentum. As part of his “Great Society” initiative, President Lyndon B. Johnson made healthcare reform a central priority. He worked with Congress to develop and pass legislation that would create a federal health insurance program for seniors.
On July 30, 1965, President Johnson signed the Social Security Amendments of 1965 into law, which established Medicare. The program’s enactment brought much-needed relief to millions of elderly Americans, providing them with access to affordable healthcare services and coverage for hospital care (Part A) and medical services (Part B).
Over the years, Medicare has undergone several expansions and updates, including the addition of Medicare Part C (Medicare Advantage) and Part D (prescription drug coverage). Today, Medicare continues to play a critical role in providing healthcare coverage to seniors and certain individuals with disabilities.
2. Medicaid:
Medicaid was created to address the healthcare needs of low-income individuals and families, including pregnant women, children, and people with disabilities. Before Medicaid’s establishment, access to healthcare for low-income individuals was limited, and many relied on charity care or went without necessary medical services.
The idea of providing federal assistance for healthcare to the poor can be traced back to the 1930s during the debates over President Franklin D. Roosevelt’s Social Security Act. However, it was not until the 1960s that Medicaid became a reality.
Under the same Social Security Amendments of 1965, Medicaid was created as a joint federal and state program. The federal government provided funding, and states were given the responsibility of administering the program within federal guidelines. This structure allowed states some flexibility in determining eligibility criteria and benefits to suit their populations’ needs.
Medicaid’s original intent was to cover specific categories of low-income individuals, including welfare recipients, children living in poverty, pregnant women, and the elderly who were not eligible for Medicare. Over time, Medicaid has expanded to cover more low-income adults through the Affordable Care Act (ACA) Medicaid expansion, which provided federal funding to states that chose to extend coverage to more individuals with slightly higher income levels.
Today, Medicaid continues to be a crucial safety net program, providing essential healthcare coverage to millions of low-income Americans across the country.
In conclusion, Medicare and Medicaid were established in 1965 as part of the Social Security Amendments to address the healthcare needs of elderly and low-income individuals, respectively. Both programs have evolved over the years and remain fundamental components of the U.S. healthcare system, ensuring that vulnerable populations have access to essential medical services.
