HEALTHCARE STRUCTURE, ORGANIZATION AND GOVERNANCE
HEALTHCARE STRUCTURE, ORGANIZATION AND GOVERNANCE
Medicare is the name given to the United States Government - administered health insurance scheme for persons over 65 years of age or who meets certain condition. In 2010, Medicare cost 256.8 billion US dollars: 230.9 billion USD was financed by taxes, the rest by the government. In 2017, Medicare accounted for 13% of the US federal budget.
1.1 Cost and Benefit Analysis
If you are using Part A and Part B benefits paid by the federal government your coverage is called Original or traditional Medicare.
Out of the pocket spending limit
No gym discounts
No covered services
Plans are deductibles
If your benefits are provided by Medicare Advantage or another privately approved Medicare company, then your coverage is called Medicare Advantage. Many Medicare Advantage plans provide additional services and can reduce your medical expenses. If you have Part A and Part B, you can participate in Medicare Advantage health insurance. With this plan, you will not need additional Medi-gap insurance, because Medicare Advantage plans provide the same benefits as Med gap additional insurance. This includes, for example, paying for additional days of hospitalization after you used days covered by Medicare (Berenson, R. A., Sunshine, J. H., Helms, D., & Lawton, E. (2015)..
Medicare Advantage plans are of the following types:
coordinated health care plans
plans using contract medical facilities and doctors
private plans ( fee-for-service )
MA Plan Pros
Cons Plan Cons
“Out-of-pocket maximum is $6700 a year
Still requires you to pay co pays and coinsurance fees
Many plans cost $0 a month
Plans are difficult to compare since no two MA plans are alike
Usually includes drug coverage
Usually no nationwide coverage
Many include hearing and dental
Mainly HMO plans that require referrals to see specialist
Can include gym discounts
Plan can change drug and medical coverage each year
Can switch to another MA plan during open enrollment
Hard to switch to plans like Medigap”
2. Traditional Medicare or Medicare Advantage Plans
Medicare Advantage Plans (Medicare Part C) include all benefits offered under Medicare Parts A and B, plus additional benefits combined under one plan. Reduce Federal payments by lowering Medicare. Members of Medicare Advantage plans must pay a monthly premium, as well as, in many cases, co-payments and a share of the insurance, and can select doctors from the network plan. The costs associated with Medicare Advantage plans are paid in addition to the monthly installments of your Original Medicare program (Afendulis, C. C., Landrum, M. B., & Chernew, 2012).
Medicare Advantage vs. Original Medicare
Medicare Part A and Part B covered services
Prescription drug coverage
Yes, with most plans (not all)
Includes limited prescription drug coverage in certain situations. Doesn’t typically cover prescriptions you take at home.
Your choice of any doctor who takes Medicare assignment
It depends on the plan. Some Medicare Advantage plans require you to use doctors in the plan’s network.
Extra benefits, like routine vision or dental services, routine hearing services, membership in fitness programs, and more.
Yes, with many plans. The extra benefits (if any) may vary from one plan to another.
Covered services when you travel anywhere in the USA
Usually, no. You must live within your plan’s service area, except in emergencies.
Some plans may have deductibles.
Coinsurance or copayments
Generally, yes, for most services
Generally, yes, for most services
It depends on the plan. Some plans have premiums as low as $0.
You still need to pay the Medicare Part B monthly premium as well.
Medicare Part A has a monthly premium, but most people don’t have to pay it.*
Most people pay a Medicare Part B monthly premium.
Annual maximum out-of-pocket spending limit. If you reach this limit, the plan may pay your medical expenses for the rest of the year.
Yes. This amount will vary among plans and might change year to year.
3. The Obama Reform
It is precisely to overcome these drawbacks that a major reform of the American Health Insurance system was adopted in December 2003. It was intended to supplement the Medicare program by partially covering the drug expenditure of the elderly and certain prevention benefits. The reform was to be implemented in three stages:
the first (2004-2006) focused on the extension of medication management for people aged 65 and over,
the second (2005-2007) on changing coverage rates,
the third, starting in 2010, opened the insurance market to competition.
This reform was associated with significant risk-taking (risk of a slippage in spending) due to the arrival in the age groups of over 65 years of the baby-boom generations, the lengthening of the life, the increasing cost of medical techniques and the increase in the volume of drugs consumed. In addition, others feared an increase in inequality related to a possible selection of risks by insurers, the cantonment of Medicare insurance for the poorest, the power conferred on private insurance to ration access to medicines and tax incentives for health savings plans will mainly benefit high-income households. All in all, these reform objectives have failed (McGuire, T. G., Newhouse, J. P., & Sinaiko, 2011).
Senator Barak Obama's election to the presidency of the United States of America on January 20, 2009 was accompanied by a broad reform movement in the health field. The project was voted in the Senate on September 12, 2009. It is considered a historic vote (Gold, 2005).
Excerpt from the article by C. Prieur "The reform of the American health system", review "Practice and organization of care", vol. 42, No. 4/2011, pages 265-274. The reform is in the form of two complementary texts - that is, one rectifies the other - covering hundreds of pages and thousands of articles, because touching from near or far areas very different legal systems: insurance law, regulation of public insurance Medicare and Medicaid , competition law, legislation on small and medium-sized enterprises, general tax legislation, regulation on medical liability. Suffice to say that its implementation, spread over time until 2014 and even 2020, will be gradual and fraught with difficulties especially since the Republicans have announced their intention to oppose the implementation of this law "villainous": an appeal to the Supreme Court from a dozen Republican governors is already 1. In addition, in the area of health, jurisdictions are shared between the federal state and the federated states, some of which run by Republicans will resist the application of a complex
I think Medicare advantage program is better than the tradition program due to the more attractive to a physician and to a hospital. To try to identify what will change in the years to come, we have classified the main measures of these texts dense, depending on the objectives to be achieved, which do not mean that the means used are at the height of each issue.
3.1 Decrease in the number of uninsured
The reform must provide health insurance 32 million Americans who did not; it is not the universal coverage that is hoped for, but there should be no more than 15 million people left without any insurance, and all children will be covered in one way or another. Private insurers will be required to keep children up to 26 years old on the parents' insurance, while some of the uninsured were young people looking for a stable job. Unemployed people will be helped to get insurance just like poor families who cannot access Medicaid. Similarly, all persons will be required to be insured either by their employer or directly; failing this, it will have to pay an annual fine which will gradually increase to reach 2.5% of its revenues in 2016. The "poor" are exempted from this obligation since they are entitled to Medicaid. Companies with more than 50 employees who do not provide coverage to their employees will also be penalized at $ 2,000 per employee not covered. In contrast, small businesses will receive a tax credit. Each state will have to partner with another to organize a regional insurance market where at least two offers will be issued at the lowest price. Insurance companies wishing to participate in these organized markets will have to offer four types of contracts offering a basket of standard services and coverage rates ranging from 60 to 90% of their cost depending on the case. States that do not wish to use organized markets will have to develop a minimum health insurance that they will have to fully administer. In addition, the reform requires insurance companies to publish quality indicators, including administrative costs and profits, so that policyholders know how much of their premiums cover their health care costs and what part enriches insurers.
3.2 Coverage improvements
Similarly, private insurance contracts must include a basket of basic goods and services covering 60% of the care and will have to limit the possible expenses to be borne; preventive acts such as mammography will be supported. All these provisions harden the regulation of the health insurance market; they have been accepted by insurers only because the reform has abandoned the idea of public insurance which, by definition, has not used the "tricks" of private contracts and could have taken away from them an important part of market. But will this new regulation be applied? Opportunities for litigation will not be missed. For people over 65 who are receiving Medicare , the current gaps in drug reimbursement will be reduced ( donut hole in section D). The federal government will invest ten billion dollars in neighborhood clinics to improve local medicine and prevent unnecessary hospitalization of the poorest (community health centers). However, the voluntary interruptions of pregnancies cannot be financed from public funds, a provision on which B. Obama had to commit himself to rally to his cause the elected Democrats anti-abortion.
These different measures are expected to provide greater security for those who already have insurance. Moreover, as mentioned above, in each state, insurers will have to communicate the contract model and the amount of the premiums to a kind of "stock exchange" thus allowing a better competition and reinforcing the weight of the users vis-a-vis the insurers. . The risk pools (collective fund financed by taxes to support heavy risks) should be set up in each state with the partial financial support of the federal state: beautiful land disputes for the application. Finally, Medicare will put in place a kind of long-term care insurance that allows dependent people to stay at home with a daily talk to pay for home care services.
3.3 Rationalization of the sanitary system
The American system works with a lot of waste that a recent survey estimated at over $ 700 billion out of $ 2.5 trillion in health care spending. This general laxity comes from the way the system works: healthcare professionals create the expense that is borne by the insurance companies, which have few means and will to discuss prices and the merits of said expenses and pass them on to the premiums. Hence the considerable amount of health expenditure.
That is why the Obama reform has several hundred pages allowing the creation or the experimentation of all the devices that the Europeans use to regulate their health system: development of the prevention, therapeutic education of the chronically ill, comparative analysis of the effectiveness of treatments and development of standard therapeutic protocols written by the equivalent of our High Authority of Health, created for this purpose. The fight against frauds generated by the fact that public programs are implemented by private insurers, intermediaries between patients and carers, with little regard for the expense presented for reimbursement, will be intensified. Anecdotally, one can cite a measure tending to make mandatory the display of the caloric content in menus of fast food. A new agency, the Center for Medicare and Medicaid Innovation, will have a large budget to initiate experiments: computerization of medical records, multidisciplinary medical houses. These measures are expected to result in savings in the functioning of the health system, but these are not obvious because the means of action of the public programs are hardly touched on the prices of health care providers as well as on the price.
3.4 Increased resources
Apart from the non-insurance penalties imposed on employers and employees, listed above, the reform provides for taxing high-end contracts paid by companies, as well as pharmaceutical companies and medical device manufacturers. Contributions to Medicare will be increased from 1.45 to 2.35% for very high wages; a 3.8% tax is introduced on the capital income of high income earners.
The reform is expected to cost $ 900 billion over ten years; it should not weigh on the budget deficit of the federal state provided that the savings resulting from the rationalization of the health system are at the rendezvous.
4. Capitation Model
In the medical setting, capitation is a payment arrangement for health care between service providers such as physicians or nurse practitioners, or a lump sum payment made at regular intervals to a health care provider by a health care organization. Managed care for a registered patient. The Medicare advantage program is an unusual system in which the funding of private providers is provided by the government. Most hospitals are private, not-for-profit corporations, the majority of physicians work in private practice and those who work in hospitals are not employed by the hospital. It may be more accurate to see the USA health care system as a government-subsidized health insurance system that covers the costs of physicians and private sector institutions. In our opinion, one of the next steps to be taken to improve the capitation is the integration of a computerized clinical record. Subsequently, introduce more capitations so that eventually it is the main method of remuneration of doctors. Finally, one of the last steps would be to create a truly interdisciplinary team to support a registered clientele. The USA government has adopted an incremental strategy by focusing on the voluntary choice of doctors to accredit their practice. The various requirements to become a capitation model encourage medical practices to adopt certain characteristics to improve the performance of the health system. This strategy of gradual change in funding, resources, delivery, and governance seems relevant to bringing about change in the desired direction. USA experiences can provide valuable lessons for the organization of primary care in other international contexts. This is the case in France, where the government proposes to experiment with health homes.
Berenson, R. A., Sunshine, J. H., Helms, D., & Lawton, E. (2015). Why Medicare Advantage plans pay hospitals traditional Medicare prices. Health Affairs, 34(8), 1289-1295.
Afendulis, C. C., Landrum, M. B., & Chernew, M. E. (2012). The impact of the affordable care act on Medicare advantage plan availability and enrollment. Health services research, 47(6), 2339-2352.
McGuire, T. G., Newhouse, J. P., & Sinaiko, A. D. (2011). An economic history of Medicare Part C. The Milbank Quarterly, 89(2), 289-332.
Davis, K., & Rowland, D. (1986). Medicare policy. New Directions for Health and Long-Term Care (Baltimore: Johns University Hopkins Press, 1986).
Gold, M. (2005). Private plans in Medicare: Another look. Health Affairs, 24(5), 1302-1310.
Useful LinksFree Essays About Blog
If you have any queries please write to us
Join our mailing list
© All Rights Reserved 2023