Question

Discuss health care payment systems. Identify the impact of payments systems on nursing practice.
- Identify an aspect of the health care payment system.
- Provide an overview of the criteria and parameters for implementation.
- Identify the impact on nursing practice.

Answer 1

Discussion on healthcare payment systems:

Healthcare payment systems can be broadly classified as retrospective and prospective. Retrospective payment includes charge based reimbursement, cost-based reimbursement, and percentage of charges. Charge based reimbursements are based on fee for service whereas cost-based reimbursements are based on allowable costs. Prospective payments are negotiated or established prior to provision of service; payments on the basis of diagnostic group or severity index, hospital-acquired conditions are not reimbursed, Medicare is now penalizing readmissions. In essence, healthcare is paid by government programs like Medicare and Medicaid; private health insurance plans, usually employer paid; and the patient’s out-of-pocket payments.

Payment systems affect nursing practice in several ways. States with expanded Medicaid have received waivers allowing them to make certain requirements such as charging co-pays or premiums. Nurses always have been on the patients' side advocating for patients to have access to healthcare. Medicaid expansion is reducing the number of uninsured people and providing more money for hospitals. States with expanded Medicaid reports have decreased amounts spent on charity care and increased Medicaid revenues. Some reports indicate Medicaid expansion means more jobs for healthcare workers, especially for nurses.

The US healthcare system is a complex mixture of public as well as private programs. Most citizens who have healthcare insurance have an employer-sponsored plan. The federal government insures the poor (Medicaid) and elderly (Medicare) as well as veterans and federal employees and Congressmen. There are six government healthcare programs, which serve older persons, disabled, veterans, low-income mothers and children, active-duty military personnel and their dependents, and Native Americans. Medicaid, Medicare, and the State Children’s Health Insurance Program (SCHIP) were devised for groups of people for whom the healthcare sector has failed to work because of their low socioeconomic status and high healthcare requirements. The other three programs, the DOD TRICARE, IHS, and VHA serve particular groups with whom the federal government has some special relationship; the military personnel and their dependents, veterans, and Native Americans.

Many Americans receive payment services through multiple government programs simultaneously. There are low-income Medicare beneficiaries who also qualify for Medicaid, which accounts for 17% of the Medicare population and 19% of the Medicaid population. This dual eligibility group accounts for 28% of Medicare expenditures and 35% of Medicaid expenditures. There are HIS-eligible Native Americans who also qualify for Medicaid if they fulfill income and other requirements, and those aged 65 years and above may qualify for Medicare. In the case of veterans, nearly 45% are 65 years and above and are qualified to receive Medicare also. In addition to these, many eligibles for these programs also have private insurance. Thus patients and practitioners would certainly benefit from consistency in public and private insurance quality enhancement processes