Two benefits of Medicare that affect healthcare organizations are:
1. Medicare allows people 65 and older to be covered under Medicare
and enjoy health insurance coverage paid (mostly) by the Federal
government which lessens the financial burden of that age group when
it comes to paying for their healthcare coverage (Nowicki, 2022). This
benefits the insured as well as guaranteeing a portion of the care
provided to the person is covered as many persons over the age of 65
are living on a fixed budget and bills for healthcare provided may be
difficult to afford.
2. In 1972, Medicare coverage was expanded to cover persons younger
than 65 that meet the criteria for a disability (Nowicki, 2022). The
same reason given above applies to this portion of the population.
Two challenges of Medicare related to decision making in healthcare are:
1. Medicare reimburses hospital services based on reasonable cost and
not what the hospitals actually charge for services as hospitals charge
more for their services than cost (Nowicki, 2022). This accounts for a
large portion of hospital reimbursement so care should be as efficient
and effective as possible not to exceed the ‘reasonable cost’ figure.
2. The Centers for Medicare and Medicaid Services (CMS) withholds
2% of reimbursement and only pays and only releases this
reimbursement percentage when performance metrics in these areas
are in (CMS, n.d.). Hospital metrics and measures should be followed
closely to ensure that the organization received the full 2%
reimbursement
Two benefits of Medicaid relate to the healthcare system are:
1. Medicaid, a State-administered program, provides funded health
insurance to those people who cannot afford healthcare expenses
(Nowicki, 2022). This means that the healthcare provider receives
payment for healthcare services that may not otherwise be paid as the
person receiving the care would likely be unable to pay.
2. In 2010, Medicaid was expanded in many states through the
Affordable Care Act (ACA) to allow more persons to be covered by
this program (Nowicki, 2022). This translates into more
reimbursement dollars for healthcare providers and organizations.
Two challenges of Medicaid related to decision making in healthcare are:
1. The ACA assumes that with Medicaid expansion, the number of
persons insured will increase and the amount of uncompensated care
will decrease (Nowicki, 2022). This has taken time to implement and
for organizations to see the benefits of the expansion.
2. Medicaid reimbursements cannot exceed amounts paid by Medicare
for like services (Nowicki, 2022). This means that again, hospitals
will not receive full billed amounts, but a portion thereof.
Two benefits of the Health Information Portability Act (HIPPA) for the
healthcare institution are:
1. HIPPA mandated, the Health and Human Services (HHS) department
published five standards that make up the Administrative
Simplification Program which streamlines the processing of
healthcare claims, reduces paperwork, and saves the healthcare
system billions of dollars while at the same time provides improved
service for insurers, providers, and patients (Nowicki, 2022).
2. HIPAA was designed to provide important protection for around 25
million people in America who are self-employed, move to a different
job, or have a pre-existing medical condition (Nowicki, 2022). This
aids the healthcare institution by ensuring that these people’s
healthcare costs are covered.
Two challenges of HIPPA related to decision making in healthcare are:
1. Because the HIPAA security stand is a set of federal rules to protect
the security of electronic personal health information (PHI), there are
steep fines for HIPAA violations that can have an immense impact on
care providers (Nowicki, 2022).
2. So many providers and healthcare workers have access to electronic
health records (EHR) and PHI that the likelihood of HIPAA breaches
is great. This can occur whether forgetting to exit a screen and leaving
PHI on a computer monitor or a knowing breach by committing
unauthorized access to a person’s PHI. Since taking over
administration and enforcement of the HIPAA in 2009, the Office for
Civil Rights (OCR) investigated 250,375 privacy and security
complaints through November 30, 2020, of which 246,375 have been
resolved (Nowicki, 2022).
References
CMS. (n.d.). The hospital value-based purchasing (VBP) program.
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-
Value-Based-Purchasing
Nowicki, M. (2022). Medicaid. In Nowicki (Ed.), Introduction to the
financial management of healthcare organizations (8th ed. pp. 179-
181). Chicago, IL: Health Administration Press.
Nowicki, M. (2022). Medicare. In Nowicki (Ed.), Introduction to the
Financial Management of Healthcare Organizations (8th ed. pp.
139,157). Chicago, IL: Health Administration Press.
