Kot Task 3.4
KOT 734.3.4 Organizational Systems & Quality Leadership
WESTERN GOVERNOR UNIVERSITY
KOT Task 2
April 17, 2014
A1. Medicare Part A
According to (Cherry and Jacob, 2011) Medicare is a federal funded health insurance plan for people over the age of 65 and for those who are younger with certain disabilities. In discussing the details to Mrs. Zwick’s daughter about Medicare coverage information I would explain to them in terms that both mother and daughter can understand. An explanation would begin by letting Mrs. Zwick’s daughter know that Medicare part A is a hospital insurance that helps covers several health care facilities such as hospital stay, skilled …show more content…
nursing facility, hospice services and home health services. Mrs. Zwick was admitted to the hospital as an inpatient for five days for a mild stroke. The inpatient criteria is important information because patients who often go to the hospital are not necessarily admitted but are placed in observation status. The inpatient status must be written by a physician via a doctor’s order.
Since Mrs. Zwick was admitted for the five days she met the requirements for Medicare part A coverage and the criteria for skilled nursing facility. Medicare Part A covered the 5 days of inpatient stay at the hospital. The skilled nursing facility requirements are that the patient have a three midnight hospital stay in order to be considered for admission. Since the requirement was met Mrs. Zwick’s Medicare part A covers her first 20 days of skilled nursing and rehabilitation services at 100% with no cost to the patient. Her services in the skilled facility include a semi private room however as skilled/long term care nurse most nursing homes offer a private room for skilled patients with no added charges. Other services include medications, meals, supplies and rehabilitation services that include PT, OT and ST if needed. Mrs. Zwick’s stay was 40 days so the daughter would need to be aware that after the 20 days the patient is responsible for a copayment that is approximately 20% or about 152.00 per day. (Medicare.Gov)
A2. Medicare Part B
Medicare Part B is the medical insurance that covers different types of services compared to Medicare part A. Medicare part B has a deductible that changes annually. Once the deductible is paid each year, Medicare Part B will pay 80% of the approved Medicare services (Medicare.gov). Medicare part B covers two types of services that include medically necessary services such as services or supplies needed to diagnose/treat a medical condition as long as it meets standards of medical practice. For example if Mrs. Zwick fell at her home and broke a hip her Medicare part B benefits would cover her surgical hip repair as long as it is deemed medically necessary. The other service that Medicare part B covers is preventive services. Elderly immune systems are diminished as they age placing them at risk for flu and pneumonia. Mrs. Zwick’s is 77 years old which places her at risk so she would benefit from her Medicare part B preventive services for flu and pneumonia vaccinations. Equipment that is covered by Medicare part B include wheelchair, walkers, bedside commode and splints. Other services include ambulance services, mental health, and limited outpatient prescription drugs. (Medicare.gov)
A3. Medicare Part D
Medicare Part D is prescription drug benefit plan. The plan will cover Mrs. Zwick’s prescriptions that are not covered by her Medicare part A and B. There are several prescription drug plans and each plan has its own formulary. I would explain to the daughter that the plans are placed in different levels and that each level has a different costs. After reviewing the plans and levels the daughter can decide what plan will best fit Mrs. Zwick’s needs. This plan however does come with an out of pocket expense such as a copayment and monthly premium’s depending on the plan.. “Most formulary plans have between 3 and 5 levels. The lower the level the lower the copay amount. For example, level 1 might include all of the Plan 's preferred generic drugs, and each drug within this level might have a co-pay of $5–10 per prescription.” (Wikipedia, 2014). Mrs. Zwick’s income will be taken into consideration when Medicare part D premiums are being considered.
B.
Reimbursement
Mrs. Zwick’s was admitted to the hospital following a mild stroke however her stay was extended due to a hospital acquired infection. Due to changes that occurred in 2008, Medicare stopped reimbursing hospitals for preventable hospital acquired infections placing health care facilities accountable for the facility acquired infections during a hospital stay. In Mrs. Zwick’s situation the additional care required such as her IV antibiotics will not be covered by her Medicare.
B1. Ethical Implications
Urinary tract infections (UTI’s) are the most common type of nosocomial infections (Holland, 2012) however UTI’s are also one of the infections that is preventable. As a health care provider we are responsible for preventing infections by hand washing and or sanitizing and the other is by following current evidenced based protocols. Due to the facility not following the current evidenced based protocols for catheter care Mrs. Zwick’s had to endure a longer stay at the hospital. The negative implications that may have affected Mrs. Zwick’s could be increased anxiety for having to be hospitalized for an extend stay. Having an IV antibiotics may have caused her to stay in bed longer than needed. Unfortunately Mrs. Zwick’s will be responsible for the cost related to the hospital acquired infection. At 77 years old Mrs. Zwick’s is possibly on a fixed income having to pay the extra expense may lead to possibly her not being able to pay for her medications or not being able to pay for food. It’s important that health care facilities practice their infection control policies and continue to use evidence based protocols overall it will help the hospitals by reducing their infection rates but most of all it will help the
patients.
C. COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families like Mr. Davis who lose their health benefits the option to choose to continue benefits provided by their previously enrolled group health plan for up to eighteen months initially (COBRA, 2014). There are certain scenarios or triggers that allow an eligible event allow Mr. Davis to qualify and some of those circumstances being voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, just to name a few. Though potentially being a great benefit there are some draw backs such as individuals who do qualify for extended coverage may be required to pay premium coverage up to 102 percent of the cost to the plan.
In Mr. Davis’s occurrence since he was hospitalized twice within the past year and with his previous known medical history he may qualify for disability which federal continuation coverage of COBRA can extend that coverage an additional eleven months, bringing a potential health benefit coverage up to the possibility of 29 months.
D. Challenges
There are many challenges that the state or local governments face when providing care for patients with chronic medical conditions and no income to support the member through their illness or disease process. One instance is that there has been times that local entities have no pertinent control or recommendations in regards to administering or qualifying local citizens for treatment of their specific medical conditions. (Swartz, 2009).
Secondly, this process to qualify or screen for potential eligibility is one that is traditionally controlled by the state and administered through state entities. The lack of the state to relinquish control to the local counties causes undue delay in the overall process of (1) qualifying a potential citizen and (2) potentially setting such broad “standardized” qualifying criteria that might not necessarily be relevant from the community stand point for example an area may be more prevalent to cancer or diabetes for another example.
Both instances lead to disparity from the local health official point of view to the state level oversight view. This is a prominent finding in many states overall leading to barriers to care rather than focusing on a program that meets both local and state controlling factors but then becomes a working program for the community.
D1. Recommendations
One recommendation proposed by (Swartz, 2009) is to re-invent or reenergize the local community health center. These centers have been a somewhat unknown cornerstone in the community for forty-nine years. Champions of this idea indicate and can established trend that these centers have the capability and the knowledge base to better care for the health problems identified in the low-income. Champions of this expansion idea have gone as far as to indicate that expanding community health centers would be much more cost efficient than attempting to figure out how to fix health insurance itself.
Another recommendation would be to facilitate a means that would allow local officials to control eligibility screening, and qualifying capability for subsidized health coverage. One such program is recommended by (Carroll and Rodin, 2010). In their research for ways that states could better server the low income with better healthcare for chronic conditions was to expand upon the medical home process most family practices base their practice after. This morphing idea would allow the low income chronic care patient eligibility for care at a designated “health Home” (Carroll, 2010). Under the Patient Protection and Affordable Care Act (ACA) Section 2703 of the ACA already provides enhanced federal funding for two years for "health homes" serving Medicaid beneficiaries with chronic conditions, it is based on these services that care eligibility could be expanded to service those in true need.
E. Relocation
When one ponders healthcare in other countries we often refer to graphic images of some third work emergency room with little to no technology or the staff to treat any patients, and the horrors of being stuck by some dirty needle or other medical piece of equipment. These thoughts are quite differently than the reality of the state of health care in countries such as Great Britain, Japan, Germany, or Switzerland.
For the chronically ill population such as in Mr. Davis’s case he may in fact be better severed for his needs in a different country. Many different countries have very generous benefits for all populations’ regards of where you land in the poverty line. For example the whole of Germany’s population has been required to have healthcare coverage (Thompson, 2013). Coverage benefits range from preventative to surgical. Access for children, the unemployed, or retired is comparable regardless of their life status. Coverage for medications, referrals to specialist and coverage for pre-existing conditions are also covered. German health benefits are very generous. And there 's usually little or no wait to get elective surgery or diagnostic tests.
One might ask how this is possible and if one country can accomplish this than why are not all countries following suit. There are many reasons for this but the most prominent being the control of healthcare costs by regional healthcare organizations which all medical practitioners are required to be part of and the public funding of health insurance through economically predetermined uniform contribution rate as set by the government (Thompson, 2013).
References
Carroll, S. S., Rodin, D. (December 2010) States in Action Archive
Health Homes for the Chronically Ill: An Opportunity for States http://www.commonwealthfund.org/Newsletters/States-in-Action/2011/Jan/December-2010-January-2011/Feature/Feature.aspx
Cherry, B., Jacob, S.R. (2011) Contemporary Nursing: Issues, Trends, & Management, 5th Edition
Consolidated Omnibus Budget Reconciliation Act (COBRA), United States Department of Labor Retrieved on April 16, 2014 available at http://www.dol.gov/dol/topic/health-plans/cobra.htm
Holland, K. (2012, October 5) What Medicare does and does not cover? Retrieved from http://www.healthline.com/health-slideshow/what-medicare-does-doesnt-cover#5
Medicare Part A. Retrieved April 15, 2014 from Medicare.gov available at http://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html Medicare Part D. Retrieved April 15, 2014 from Wikipedia available at http://en.wikipedia.org/wiki/Medicare_Part_D
Swartz, K. (2009) Health care for the poor: For whom, what care, and whose responsibility? Retrieved from http://www.irp.wisc.edu/publications/focus/pdfs/foc262l.pdf
Thomson, S., Osborn, R. (2013, November) The Commonwealth Fund, and Miraya Jun, London
School of Economics and Political Science INTERNATIONAL PROFILES of HealthCare Systems, retrieved on April 14th 2014 available at http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Nov/1717_Thomson_intl_profiles_hlt_care_sys_2013_v2.pdf
WESTERN GOVERNOR UNIVERSITY
KOT Task 2
April 17, 2014
A1. Medicare Part A
According to (Cherry and Jacob, 2011) Medicare is a federal funded health insurance plan for people over the age of 65 and for those who are younger with certain disabilities. In discussing the details to Mrs. Zwick’s daughter about Medicare coverage information I would explain to them in terms that both mother and daughter can understand. An explanation would begin by letting Mrs. Zwick’s daughter know that Medicare part A is a hospital insurance that helps covers several health care facilities such as hospital stay, skilled …show more content…
nursing facility, hospice services and home health services. Mrs. Zwick was admitted to the hospital as an inpatient for five days for a mild stroke. The inpatient criteria is important information because patients who often go to the hospital are not necessarily admitted but are placed in observation status. The inpatient status must be written by a physician via a doctor’s order.
Since Mrs. Zwick was admitted for the five days she met the requirements for Medicare part A coverage and the criteria for skilled nursing facility. Medicare Part A covered the 5 days of inpatient stay at the hospital. The skilled nursing facility requirements are that the patient have a three midnight hospital stay in order to be considered for admission. Since the requirement was met Mrs. Zwick’s Medicare part A covers her first 20 days of skilled nursing and rehabilitation services at 100% with no cost to the patient. Her services in the skilled facility include a semi private room however as skilled/long term care nurse most nursing homes offer a private room for skilled patients with no added charges. Other services include medications, meals, supplies and rehabilitation services that include PT, OT and ST if needed. Mrs. Zwick’s stay was 40 days so the daughter would need to be aware that after the 20 days the patient is responsible for a copayment that is approximately 20% or about 152.00 per day. (Medicare.Gov)
A2. Medicare Part B
Medicare Part B is the medical insurance that covers different types of services compared to Medicare part A. Medicare part B has a deductible that changes annually. Once the deductible is paid each year, Medicare Part B will pay 80% of the approved Medicare services (Medicare.gov). Medicare part B covers two types of services that include medically necessary services such as services or supplies needed to diagnose/treat a medical condition as long as it meets standards of medical practice. For example if Mrs. Zwick fell at her home and broke a hip her Medicare part B benefits would cover her surgical hip repair as long as it is deemed medically necessary. The other service that Medicare part B covers is preventive services. Elderly immune systems are diminished as they age placing them at risk for flu and pneumonia. Mrs. Zwick’s is 77 years old which places her at risk so she would benefit from her Medicare part B preventive services for flu and pneumonia vaccinations. Equipment that is covered by Medicare part B include wheelchair, walkers, bedside commode and splints. Other services include ambulance services, mental health, and limited outpatient prescription drugs. (Medicare.gov)
A3. Medicare Part D
Medicare Part D is prescription drug benefit plan. The plan will cover Mrs. Zwick’s prescriptions that are not covered by her Medicare part A and B. There are several prescription drug plans and each plan has its own formulary. I would explain to the daughter that the plans are placed in different levels and that each level has a different costs. After reviewing the plans and levels the daughter can decide what plan will best fit Mrs. Zwick’s needs. This plan however does come with an out of pocket expense such as a copayment and monthly premium’s depending on the plan.. “Most formulary plans have between 3 and 5 levels. The lower the level the lower the copay amount. For example, level 1 might include all of the Plan 's preferred generic drugs, and each drug within this level might have a co-pay of $5–10 per prescription.” (Wikipedia, 2014). Mrs. Zwick’s income will be taken into consideration when Medicare part D premiums are being considered.
B.
Reimbursement
Mrs. Zwick’s was admitted to the hospital following a mild stroke however her stay was extended due to a hospital acquired infection. Due to changes that occurred in 2008, Medicare stopped reimbursing hospitals for preventable hospital acquired infections placing health care facilities accountable for the facility acquired infections during a hospital stay. In Mrs. Zwick’s situation the additional care required such as her IV antibiotics will not be covered by her Medicare.
B1. Ethical Implications
Urinary tract infections (UTI’s) are the most common type of nosocomial infections (Holland, 2012) however UTI’s are also one of the infections that is preventable. As a health care provider we are responsible for preventing infections by hand washing and or sanitizing and the other is by following current evidenced based protocols. Due to the facility not following the current evidenced based protocols for catheter care Mrs. Zwick’s had to endure a longer stay at the hospital. The negative implications that may have affected Mrs. Zwick’s could be increased anxiety for having to be hospitalized for an extend stay. Having an IV antibiotics may have caused her to stay in bed longer than needed. Unfortunately Mrs. Zwick’s will be responsible for the cost related to the hospital acquired infection. At 77 years old Mrs. Zwick’s is possibly on a fixed income having to pay the extra expense may lead to possibly her not being able to pay for her medications or not being able to pay for food. It’s important that health care facilities practice their infection control policies and continue to use evidence based protocols overall it will help the hospitals by reducing their infection rates but most of all it will help the
patients.
C. COBRA
The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers and their families like Mr. Davis who lose their health benefits the option to choose to continue benefits provided by their previously enrolled group health plan for up to eighteen months initially (COBRA, 2014). There are certain scenarios or triggers that allow an eligible event allow Mr. Davis to qualify and some of those circumstances being voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, just to name a few. Though potentially being a great benefit there are some draw backs such as individuals who do qualify for extended coverage may be required to pay premium coverage up to 102 percent of the cost to the plan.
In Mr. Davis’s occurrence since he was hospitalized twice within the past year and with his previous known medical history he may qualify for disability which federal continuation coverage of COBRA can extend that coverage an additional eleven months, bringing a potential health benefit coverage up to the possibility of 29 months.
D. Challenges
There are many challenges that the state or local governments face when providing care for patients with chronic medical conditions and no income to support the member through their illness or disease process. One instance is that there has been times that local entities have no pertinent control or recommendations in regards to administering or qualifying local citizens for treatment of their specific medical conditions. (Swartz, 2009).
Secondly, this process to qualify or screen for potential eligibility is one that is traditionally controlled by the state and administered through state entities. The lack of the state to relinquish control to the local counties causes undue delay in the overall process of (1) qualifying a potential citizen and (2) potentially setting such broad “standardized” qualifying criteria that might not necessarily be relevant from the community stand point for example an area may be more prevalent to cancer or diabetes for another example.
Both instances lead to disparity from the local health official point of view to the state level oversight view. This is a prominent finding in many states overall leading to barriers to care rather than focusing on a program that meets both local and state controlling factors but then becomes a working program for the community.
D1. Recommendations
One recommendation proposed by (Swartz, 2009) is to re-invent or reenergize the local community health center. These centers have been a somewhat unknown cornerstone in the community for forty-nine years. Champions of this idea indicate and can established trend that these centers have the capability and the knowledge base to better care for the health problems identified in the low-income. Champions of this expansion idea have gone as far as to indicate that expanding community health centers would be much more cost efficient than attempting to figure out how to fix health insurance itself.
Another recommendation would be to facilitate a means that would allow local officials to control eligibility screening, and qualifying capability for subsidized health coverage. One such program is recommended by (Carroll and Rodin, 2010). In their research for ways that states could better server the low income with better healthcare for chronic conditions was to expand upon the medical home process most family practices base their practice after. This morphing idea would allow the low income chronic care patient eligibility for care at a designated “health Home” (Carroll, 2010). Under the Patient Protection and Affordable Care Act (ACA) Section 2703 of the ACA already provides enhanced federal funding for two years for "health homes" serving Medicaid beneficiaries with chronic conditions, it is based on these services that care eligibility could be expanded to service those in true need.
E. Relocation
When one ponders healthcare in other countries we often refer to graphic images of some third work emergency room with little to no technology or the staff to treat any patients, and the horrors of being stuck by some dirty needle or other medical piece of equipment. These thoughts are quite differently than the reality of the state of health care in countries such as Great Britain, Japan, Germany, or Switzerland.
For the chronically ill population such as in Mr. Davis’s case he may in fact be better severed for his needs in a different country. Many different countries have very generous benefits for all populations’ regards of where you land in the poverty line. For example the whole of Germany’s population has been required to have healthcare coverage (Thompson, 2013). Coverage benefits range from preventative to surgical. Access for children, the unemployed, or retired is comparable regardless of their life status. Coverage for medications, referrals to specialist and coverage for pre-existing conditions are also covered. German health benefits are very generous. And there 's usually little or no wait to get elective surgery or diagnostic tests.
One might ask how this is possible and if one country can accomplish this than why are not all countries following suit. There are many reasons for this but the most prominent being the control of healthcare costs by regional healthcare organizations which all medical practitioners are required to be part of and the public funding of health insurance through economically predetermined uniform contribution rate as set by the government (Thompson, 2013).
References
Carroll, S. S., Rodin, D. (December 2010) States in Action Archive
Health Homes for the Chronically Ill: An Opportunity for States http://www.commonwealthfund.org/Newsletters/States-in-Action/2011/Jan/December-2010-January-2011/Feature/Feature.aspx
Cherry, B., Jacob, S.R. (2011) Contemporary Nursing: Issues, Trends, & Management, 5th Edition
Consolidated Omnibus Budget Reconciliation Act (COBRA), United States Department of Labor Retrieved on April 16, 2014 available at http://www.dol.gov/dol/topic/health-plans/cobra.htm
Holland, K. (2012, October 5) What Medicare does and does not cover? Retrieved from http://www.healthline.com/health-slideshow/what-medicare-does-doesnt-cover#5
Medicare Part A. Retrieved April 15, 2014 from Medicare.gov available at http://www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html Medicare Part D. Retrieved April 15, 2014 from Wikipedia available at http://en.wikipedia.org/wiki/Medicare_Part_D
Swartz, K. (2009) Health care for the poor: For whom, what care, and whose responsibility? Retrieved from http://www.irp.wisc.edu/publications/focus/pdfs/foc262l.pdf
Thomson, S., Osborn, R. (2013, November) The Commonwealth Fund, and Miraya Jun, London
School of Economics and Political Science INTERNATIONAL PROFILES of HealthCare Systems, retrieved on April 14th 2014 available at http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/Nov/1717_Thomson_intl_profiles_hlt_care_sys_2013_v2.pdf