Medicare
Medicare provides medical-related funding for those over 65, young disabled
individuals, and individuals requiring dialysis for end-stage renal disease
(Ghaferi & Dimick, 2018). Benefits of this program include federally
mandated coverage to individuals who qualify and additional optional benefits
such as prescription drug coverage (Nowicki, 2022). A disadvantage of
Medicare is that it does not pay for all of the beneficiary's expenditures.
Additionally, due to the need for funds, the program struggles with the
management of legislation to meet the demands of reimbursements, which
according to the text can lead to the program's bankruptcy in 2026 (Nowicki,
2022). This model utilizes a fee-for-service method that promotes care that is
effective but may not be the best quality of care for the patient.
Medicaid
Medicaid is a federally and state-assisted funding program for individuals or
families of low income. For individuals to qualify for this program, they must
be considered below the 138% of the poverty line. The benefits of this
program include that it is individualized by state and each state is mandated by
law to provide certain mandatory benefits to the individuals (Nowicki, 2022).
These mandatory benefits include in-patient and outpatient services, as well as
laboratory and home health services (Nowicki, 2022). A disadvantage of this
service is the coverage gap that was created with states who did not expand
eligibility. This coverage gap accounts for over 2 million uninsured
individuals who make above the 138% requirement but are still below the
lower limit to buy subsidized health insurance (Nowicki, 2022). Another
disadvantage to Medicaid is that in correlation to medicare, the
reimbursements can not exceed the amounts paid for like services, which
reduces the payments to hospitals provided for their medical services
(Nowicki, 2022)
Health Insurance Portability and Accountability Act (HIPAA)
HIPAA is a federal law created in 1996 to protect patient's health information
from being disclosed without the patients' consent or knowledge (CDC, 2018).
HIPAA provides patients with a Privacy Rule that allows patients to
understand and control how their PHI is used. Additionally, HIPAA has a
security rule that protects a subset of information covered by the Privacy Rule.
Once HIPAA was created, patients gained the ability to see and obtain their
personal health information, which was not permitted prior to the Act. Though
HIPAA does provide individuals with significant protection of their
information, the regulations of this act can be uneasy for healthcare workers.
Often healthcare workers are reluctant to share information about a patient for
fear of breaking HIPAA regulations and facing the consequences such as fines
and imprisonment. Another problem that can arise due to HIPAA involves the
increasing technology being utilized for PHI access. This technology can be
extremely beneficial, but breaches are still possible and PHI can be exposed
further increasing the risk of fines and imprisonment. HIPAA was passed in
the late 90s, when information was primarily paper-based, and its regulations
are not up to date with the current technologies we see and use today in the
healthcare field (Theodos & Sittig, 2020).
References
Ghaferi, A. A., & Dimick, J. B. (2018). Practical guide to surgical data sets:
Medicare claims data. JAMA surgery, 153(7), 677-678.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) | CDC.
(2018, September 14). CDC.Gov.
https://www.cdc.gov/phlp/publications/topic/hipaa.html
Michael Nowicki. (2022). Introduction to the Financial Management of
Healthcare Organizations, Eighth Edition: Vol. Eighth edition. Gateway to
Healthcare Management.
Theodos, K., & Sittig, S. (2020). Health Information Privacy Laws in the
Digital Age: HIPAA Doesn't Apply. Perspectives in health information
management, 18(Winter), 1l.
