This document provides an overview of Social Security, Medicare, Medicaid, and long-term care insurance as they relate to care of the older adult population. It discusses how Social Security provides retirement income and its sustainability issues. Medicare is described as providing hospital insurance and supplemental medical coverage for elders and some disabled. Medicaid is a joint federal-state program that covers medical costs for low-income individuals. Long-term care insurance can help cover long-term care costs for older adults.
Social security and medicare & medicaid fall 2013 abridgedShepard Joy
This document discusses social security, Medicare, Medicaid, and long-term care insurance programs. It provides an overview of each program, including origins, eligibility requirements, covered services, and current issues. It also examines the impact of an aging population on these programs and retirement.
This document provides an overview of medical technology and its effects. It discusses how technology has improved healthcare but also increased costs. While technology enhances quality of care and life, it has contributed to rising health expenditures. The US promotes innovation but lacks cost controls seen in other countries. Technology assessment evaluates technologies for safety, efficacy and cost-effectiveness to establish appropriate clinical use.
The Affordable Care Act And Its Effect On American Healthcare (3)amande1
The document discusses the impacts of the Affordable Care Act (ACA) on the U.S. healthcare system. It finds that the ACA has significantly expanded health insurance coverage, increased funding for Medicaid and Medicare, and improved access to services. Specifically, it led to more jobs in nursing, longer solvency for Medicare, and millions more being covered by Medicaid. The ACA aims to provide universal and affordable coverage through reforms such as subsidies, mandates, and protections for pre-existing conditions.
The document discusses key concepts in US healthcare including:
1. US healthcare follows a medical model focused on treating illness rather than wellness and prevention.
2. Both social and medical factors influence health outcomes and disparities exist.
3. A holistic approach addressing social determinants through policies, community programs, and individual behaviors is needed to significantly improve population health.
The document provides an overview of the complex U.S. healthcare system, including its decentralized market-based structure compared to other countries' centralized systems. It discusses key players like doctors, hospitals, insurers, and governments. It also covers major public programs like Medicare and Medicaid, as well as private insurance concepts like health plans, coding, and reimbursement structures including capitation and fee-for-service.
The document summarizes the major characteristics of the US healthcare delivery system. It notes that the US system has no central governing agency and little integration between parts of the system. It is technology-driven, focuses on acute care, and is high in costs but unequal in access, resulting in average health outcomes. The US relies more on private sector involvement compared to other developed countries where government plays a larger role.
Us health care system final presentation.Wendi Lee
Wendi Evans is pursuing a degree in health care administration. This presentation will provide an overview of the history and current state of the US healthcare system, including defining key terms, outlining milestones from 1900 to present, comparing the US system to Canada's, and discussing reforms and stakeholders. The summary will discuss the establishment of organized medicine in the US in the 1900s, the passage of Medicare and Medicaid in the 1960s, the implementation of the Affordable Care Act in 2010, and reforms aimed at improving quality and lowering costs.
Social security and medicare & medicaid fall 2013 abridgedShepard Joy
This document discusses social security, Medicare, Medicaid, and long-term care insurance programs. It provides an overview of each program, including origins, eligibility requirements, covered services, and current issues. It also examines the impact of an aging population on these programs and retirement.
This document provides an overview of medical technology and its effects. It discusses how technology has improved healthcare but also increased costs. While technology enhances quality of care and life, it has contributed to rising health expenditures. The US promotes innovation but lacks cost controls seen in other countries. Technology assessment evaluates technologies for safety, efficacy and cost-effectiveness to establish appropriate clinical use.
The Affordable Care Act And Its Effect On American Healthcare (3)amande1
The document discusses the impacts of the Affordable Care Act (ACA) on the U.S. healthcare system. It finds that the ACA has significantly expanded health insurance coverage, increased funding for Medicaid and Medicare, and improved access to services. Specifically, it led to more jobs in nursing, longer solvency for Medicare, and millions more being covered by Medicaid. The ACA aims to provide universal and affordable coverage through reforms such as subsidies, mandates, and protections for pre-existing conditions.
The document discusses key concepts in US healthcare including:
1. US healthcare follows a medical model focused on treating illness rather than wellness and prevention.
2. Both social and medical factors influence health outcomes and disparities exist.
3. A holistic approach addressing social determinants through policies, community programs, and individual behaviors is needed to significantly improve population health.
The document provides an overview of the complex U.S. healthcare system, including its decentralized market-based structure compared to other countries' centralized systems. It discusses key players like doctors, hospitals, insurers, and governments. It also covers major public programs like Medicare and Medicaid, as well as private insurance concepts like health plans, coding, and reimbursement structures including capitation and fee-for-service.
The document summarizes the major characteristics of the US healthcare delivery system. It notes that the US system has no central governing agency and little integration between parts of the system. It is technology-driven, focuses on acute care, and is high in costs but unequal in access, resulting in average health outcomes. The US relies more on private sector involvement compared to other developed countries where government plays a larger role.
Us health care system final presentation.Wendi Lee
Wendi Evans is pursuing a degree in health care administration. This presentation will provide an overview of the history and current state of the US healthcare system, including defining key terms, outlining milestones from 1900 to present, comparing the US system to Canada's, and discussing reforms and stakeholders. The summary will discuss the establishment of organized medicine in the US in the 1900s, the passage of Medicare and Medicaid in the 1960s, the implementation of the Affordable Care Act in 2010, and reforms aimed at improving quality and lowering costs.
Got Healthcare? Affordable Care Act PP (July 2013)Kevin Kane
The Affordable Care Act presentation that Citizen Action of Wisconsin presents with around the state. How the ACA impacts you and how to talk about it.
This document provides an overview of the U.S. healthcare system. It discusses key players like providers, insurers, and patients. It notes that healthcare is a trillion dollar industry, comprising hospitals, medical practices, and insurance companies. The document also outlines government programs like Medicare and Medicaid, different types of health insurance plans, and managed care organizations. Finally, it summarizes some electronic transactions used in healthcare like claims submission and response.
The document summarizes a presentation on comparing the US healthcare system to other countries. It begins with defining terms like OECD, healthcare systems, and analytic methods. It then discusses the evolution of healthcare systems in OECD countries after World War II, with European nations adopting universal coverage through national systems while the US relied on employer subsidies. The presentation outlines different healthcare models - National Health Service, National Health Insurance, and mixed private/public systems - and provides examples from countries like the UK, which has a National Health Service funded mainly through taxes.
The USA healthcare system provides high quality care to patients with adequate insurance. These patients have access to advanced hospitals and highly skilled professionals. However, the system is also very expensive. Many rely on employment-provided insurance, government programs like Medicaid and Medicare, or private insurance. The US leads in medical innovation due to large public and private investments in research and development. But the uninsured can face high medical costs and even debt collection if they suffer from a serious illness or injury. The high cost of care, especially for drugs, is a major concern for patients, particularly the elderly who rely on Medicare.
The document summarizes key aspects of the U.S. healthcare system, including how it is funded, how providers are paid, factors driving rising costs, and challenges around sustainability. It addresses these topics through discussing Medicare/Medicaid payment models, employer-sponsored insurance, measures of quality, and factors influencing costs such as administrative overhead and intensity of services provided. The document uses questions to test the reader's understanding of important healthcare concepts like DRGs, preferred provider organizations, and drivers of "good" practice patterns.
Seminar 9 health care delivery system in united states of americaDr. Ankit Mohapatra
Health care organization
Health financing in US
Payment mechanism
Health expenditure
Human and physical recourses
Public health
Patient pathway into health care
Provision of services
ACA
US vs India Healthcare
Ambulatory Care in the US Healthcare System, Portfolio Option #1Ricci Hayes
This document summarizes ambulatory care in the US healthcare system. It discusses how ambulatory care centers provide non-emergency care on an outpatient basis and have grown significantly since the 1970s. The Affordable Care Act has further increased demand for ambulatory care by focusing on prevention, coordinated care, and efficiency. The document outlines the historical development of ambulatory care, current models, political influences, quality and safety issues, and future challenges around continued growth and ensuring financial viability under new payment systems.
The document analyzes the healthcare industry in the U.S. and ways IT can help small businesses insure employees. It discusses four key factors impacting the industry: the Affordable Care Act, digital/IT infrastructure, advances in omics sciences, and the rising global middle class. The recommendations suggest that IT companies can create customized solutions to help small businesses comply with the ACA's insurance mandate for employees.
This document compares the healthcare systems of Australia and the United States. In the US, 49% of coverage comes from employers, while 16% of Americans are uninsured. Australia provides universal healthcare coverage through Medicare. While both countries face rising costs due to aging populations, Australia spends half the percentage of GDP on healthcare as the US and has no uninsured citizens.
The document discusses the different types of health insurance in the United States. The majority (49%) have private insurance through their employer, while 13% have Medicare, 18% have Medicaid, and 11% are uninsured. Medicare covers those over 65 and is run by the federal government, while Medicaid provides coverage for low-income families and is administered by each state. Private insurance through an employer is most common but may not cover all conditions, and individual plans are increasingly expensive, contributing to the number of uninsured.
This presentation explains what Medicaid program is, who it protects, the creation of the coverage gap and what Medicaid advocacy looks like in the state of Georgia.
The document provides a historical overview of the U.S. healthcare system from preindustrial times to the present. It describes how healthcare progressed from a domestic practice with untrained physicians to the modern medical profession. Key developments included the establishment of medical schools and licensing, the rise of hospitals and health insurance, and the creation of Medicare and Medicaid to expand coverage. The U.S. system remains primarily private but with significant government financing and regulation.
The American healthcare system consists of four main players: patients who receive medical treatment, providers like doctors and nurses who deliver treatment, payers such as private insurance companies and government programs that reimburse for treatment, and public health organizations that monitor and promote population health. Understanding these four players can help simplify the extremely complex and ever-changing U.S. healthcare system.
The document discusses several key issues facing the US healthcare system including rising costs, demographic changes, and quality challenges. It notes that US healthcare costs and spending per capita are the highest in the world. Major drivers of rising costs include high prices, administrative overhead, and high utilization of technology. The Affordable Care Act aims to expand coverage, improve access and quality, and control costs. It establishes insurance exchanges, expands Medicaid, includes an individual mandate, and reforms payments to shift to quality-based systems. Implementation is ongoing from 2010 to 2014 and beyond to transform delivery systems and promote primary care, prevention, and coordinated care models.
The document compares the healthcare systems of Australia and the USA. In Australia, Medicare provides coverage for medical services and public hospitals provide free care. The government contributes 44% of healthcare costs. In the USA, private insurance and government programs like Medicaid and Medicare cover most citizens, though 16% remain uninsured. Both countries face rising healthcare costs due to aging populations. While Australia spends less on healthcare as a percentage of GDP, it provides universal coverage, unlike the partially covered US system.
The document discusses the history of health policy and reform efforts in the United States over several decades. It outlines key programs and legislation from the 1900s onward that attempted to address issues of access, costs, and quality of healthcare. The document argues that meaningful reform is difficult due to the complexity of the healthcare system and the many political and economic interests involved. Future reform efforts will need to focus on reducing costs while improving quality and access.
DataBrief No. 21: Dual Eligibles, Chronic Conditions and Functional ImpairmentThe Scan Foundation
In 2006, 37% of seniors eligible for both Medicare and Medicaid had functional impairment in addition to chronic conditions, compared to only 9% of seniors eligible for Medicare-only. This DataBrief describes how dual eligibles have higher rates of both chronic conditions and functional impairment than Medicare-only beneficiaries.
The document discusses the pros and cons of implementing a universal healthcare system in the United States. It provides background on universal healthcare and what it would entail. While universal healthcare could provide healthcare access to all citizens and reduce costs, there are also concerns that it may stifle medical innovation, lead to increased wait times, and be vulnerable to government mismanagement. The document weighs different perspectives on universal healthcare but does not take a definitive position.
The document discusses health systems in advanced Asian countries and lessons for Thailand. It covers how Japan, Taiwan, and Singapore organize and finance healthcare through social health insurance models. These systems achieve universal coverage and emphasize preventive care. The document suggests Thailand could improve healthcare quality, efficiency and equity by taking a systems approach while strengthening governance.
Social security and medicare & medicaid spring 2013Shepard Joy
This document discusses Social Security, Medicare, Medicaid, and long-term care options for older adults. It provides an overview of each program, including how they are funded, who they cover, and what services they provide. Social Security is discussed as the main federal retirement program that covers most elderly individuals. Medicare and Medicaid are compared, with Medicare as a federal health insurance program for elderly/disabled and Medicaid as a joint federal/state program providing medical coverage for low-income populations. Long-term care insurance is also introduced as a way for individuals to plan for long-term care costs.
This document provides an overview and agenda for a presentation on navigating health reform, the future of healthcare, and telemedicine's expanding role. The presentation covers a quick overview of the Affordable Care Act, what provisions are popular and controversial, costs and workforce issues, the role of states in Medicaid expansion and insurance exchanges, unknown factors, and how telemedicine can help address challenges. The document outlines the speaker's views on various aspects of the healthcare system and reforms.
Got Healthcare? Affordable Care Act PP (July 2013)Kevin Kane
The Affordable Care Act presentation that Citizen Action of Wisconsin presents with around the state. How the ACA impacts you and how to talk about it.
This document provides an overview of the U.S. healthcare system. It discusses key players like providers, insurers, and patients. It notes that healthcare is a trillion dollar industry, comprising hospitals, medical practices, and insurance companies. The document also outlines government programs like Medicare and Medicaid, different types of health insurance plans, and managed care organizations. Finally, it summarizes some electronic transactions used in healthcare like claims submission and response.
The document summarizes a presentation on comparing the US healthcare system to other countries. It begins with defining terms like OECD, healthcare systems, and analytic methods. It then discusses the evolution of healthcare systems in OECD countries after World War II, with European nations adopting universal coverage through national systems while the US relied on employer subsidies. The presentation outlines different healthcare models - National Health Service, National Health Insurance, and mixed private/public systems - and provides examples from countries like the UK, which has a National Health Service funded mainly through taxes.
The USA healthcare system provides high quality care to patients with adequate insurance. These patients have access to advanced hospitals and highly skilled professionals. However, the system is also very expensive. Many rely on employment-provided insurance, government programs like Medicaid and Medicare, or private insurance. The US leads in medical innovation due to large public and private investments in research and development. But the uninsured can face high medical costs and even debt collection if they suffer from a serious illness or injury. The high cost of care, especially for drugs, is a major concern for patients, particularly the elderly who rely on Medicare.
The document summarizes key aspects of the U.S. healthcare system, including how it is funded, how providers are paid, factors driving rising costs, and challenges around sustainability. It addresses these topics through discussing Medicare/Medicaid payment models, employer-sponsored insurance, measures of quality, and factors influencing costs such as administrative overhead and intensity of services provided. The document uses questions to test the reader's understanding of important healthcare concepts like DRGs, preferred provider organizations, and drivers of "good" practice patterns.
Seminar 9 health care delivery system in united states of americaDr. Ankit Mohapatra
Health care organization
Health financing in US
Payment mechanism
Health expenditure
Human and physical recourses
Public health
Patient pathway into health care
Provision of services
ACA
US vs India Healthcare
Ambulatory Care in the US Healthcare System, Portfolio Option #1Ricci Hayes
This document summarizes ambulatory care in the US healthcare system. It discusses how ambulatory care centers provide non-emergency care on an outpatient basis and have grown significantly since the 1970s. The Affordable Care Act has further increased demand for ambulatory care by focusing on prevention, coordinated care, and efficiency. The document outlines the historical development of ambulatory care, current models, political influences, quality and safety issues, and future challenges around continued growth and ensuring financial viability under new payment systems.
The document analyzes the healthcare industry in the U.S. and ways IT can help small businesses insure employees. It discusses four key factors impacting the industry: the Affordable Care Act, digital/IT infrastructure, advances in omics sciences, and the rising global middle class. The recommendations suggest that IT companies can create customized solutions to help small businesses comply with the ACA's insurance mandate for employees.
This document compares the healthcare systems of Australia and the United States. In the US, 49% of coverage comes from employers, while 16% of Americans are uninsured. Australia provides universal healthcare coverage through Medicare. While both countries face rising costs due to aging populations, Australia spends half the percentage of GDP on healthcare as the US and has no uninsured citizens.
The document discusses the different types of health insurance in the United States. The majority (49%) have private insurance through their employer, while 13% have Medicare, 18% have Medicaid, and 11% are uninsured. Medicare covers those over 65 and is run by the federal government, while Medicaid provides coverage for low-income families and is administered by each state. Private insurance through an employer is most common but may not cover all conditions, and individual plans are increasingly expensive, contributing to the number of uninsured.
This presentation explains what Medicaid program is, who it protects, the creation of the coverage gap and what Medicaid advocacy looks like in the state of Georgia.
The document provides a historical overview of the U.S. healthcare system from preindustrial times to the present. It describes how healthcare progressed from a domestic practice with untrained physicians to the modern medical profession. Key developments included the establishment of medical schools and licensing, the rise of hospitals and health insurance, and the creation of Medicare and Medicaid to expand coverage. The U.S. system remains primarily private but with significant government financing and regulation.
The American healthcare system consists of four main players: patients who receive medical treatment, providers like doctors and nurses who deliver treatment, payers such as private insurance companies and government programs that reimburse for treatment, and public health organizations that monitor and promote population health. Understanding these four players can help simplify the extremely complex and ever-changing U.S. healthcare system.
The document discusses several key issues facing the US healthcare system including rising costs, demographic changes, and quality challenges. It notes that US healthcare costs and spending per capita are the highest in the world. Major drivers of rising costs include high prices, administrative overhead, and high utilization of technology. The Affordable Care Act aims to expand coverage, improve access and quality, and control costs. It establishes insurance exchanges, expands Medicaid, includes an individual mandate, and reforms payments to shift to quality-based systems. Implementation is ongoing from 2010 to 2014 and beyond to transform delivery systems and promote primary care, prevention, and coordinated care models.
The document compares the healthcare systems of Australia and the USA. In Australia, Medicare provides coverage for medical services and public hospitals provide free care. The government contributes 44% of healthcare costs. In the USA, private insurance and government programs like Medicaid and Medicare cover most citizens, though 16% remain uninsured. Both countries face rising healthcare costs due to aging populations. While Australia spends less on healthcare as a percentage of GDP, it provides universal coverage, unlike the partially covered US system.
The document discusses the history of health policy and reform efforts in the United States over several decades. It outlines key programs and legislation from the 1900s onward that attempted to address issues of access, costs, and quality of healthcare. The document argues that meaningful reform is difficult due to the complexity of the healthcare system and the many political and economic interests involved. Future reform efforts will need to focus on reducing costs while improving quality and access.
DataBrief No. 21: Dual Eligibles, Chronic Conditions and Functional ImpairmentThe Scan Foundation
In 2006, 37% of seniors eligible for both Medicare and Medicaid had functional impairment in addition to chronic conditions, compared to only 9% of seniors eligible for Medicare-only. This DataBrief describes how dual eligibles have higher rates of both chronic conditions and functional impairment than Medicare-only beneficiaries.
The document discusses the pros and cons of implementing a universal healthcare system in the United States. It provides background on universal healthcare and what it would entail. While universal healthcare could provide healthcare access to all citizens and reduce costs, there are also concerns that it may stifle medical innovation, lead to increased wait times, and be vulnerable to government mismanagement. The document weighs different perspectives on universal healthcare but does not take a definitive position.
The document discusses health systems in advanced Asian countries and lessons for Thailand. It covers how Japan, Taiwan, and Singapore organize and finance healthcare through social health insurance models. These systems achieve universal coverage and emphasize preventive care. The document suggests Thailand could improve healthcare quality, efficiency and equity by taking a systems approach while strengthening governance.
Social security and medicare & medicaid spring 2013Shepard Joy
This document discusses Social Security, Medicare, Medicaid, and long-term care options for older adults. It provides an overview of each program, including how they are funded, who they cover, and what services they provide. Social Security is discussed as the main federal retirement program that covers most elderly individuals. Medicare and Medicaid are compared, with Medicare as a federal health insurance program for elderly/disabled and Medicaid as a joint federal/state program providing medical coverage for low-income populations. Long-term care insurance is also introduced as a way for individuals to plan for long-term care costs.
This document provides an overview and agenda for a presentation on navigating health reform, the future of healthcare, and telemedicine's expanding role. The presentation covers a quick overview of the Affordable Care Act, what provisions are popular and controversial, costs and workforce issues, the role of states in Medicaid expansion and insurance exchanges, unknown factors, and how telemedicine can help address challenges. The document outlines the speaker's views on various aspects of the healthcare system and reforms.
A health insurance roadmap takes a look at some simple solutions to the complex issues facing health insurance, medicare, medicaid, long term care insurance, and the high cost of health expenses in retirement.
This will work because so much of this is already in place and a lot of the rest would be quick and easy to implement. As in all areas, knowledge is power. Consumers can take control of your insurance portfolio by becoming educated about insurance. Better education and understanding will lead to positive results for consumers and for the insurance industry.
Navigating Oceans of Data - Being Part of and Competing in the ACO & Bundled ...jfsheridan
Bundled Payment BPCI and Accountable Care Organizations are changing the paradigm for payment and delivery of post acute care. This change creates episode of care programs. The presentation reviews how New Jersey is affected by BPCI and ACOs.
Better health outcomes at less cost - future nhs stage, 4pm, 2 september 2015NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
Florida Blue Health Care Policy Overview: Agent CEU CourseFlorida Blue
The document provides an overview of health care policy in the United States, covering the history and development of the system, current issues around costs, access, and quality, and various proposals for reform. It discusses how the system has transformed over time, with growing roles for the government, employers, and health insurers. It outlines key stakeholders and examines trends in health care expenditures, costs drivers, and international comparisons. The summary also looks at challenges around access and quality, opportunities for improvement, and various proposals to expand coverage while improving efficiency and outcomes.
The clinical case study of a patient with advanced COPD who has multiple comorbid conditions and develops sepsis provideD the backdrop for two potential clinical pathways—sepsis and post-sepsis syndrome.
The Canada Health Act established conditions for publicly funded universal healthcare across Canada, requiring that provinces receive federal funding only if they comply with provisions like public administration, comprehensiveness, universality, portability, and accessibility. This legislation aimed to protect Canadians' physical and mental well-being by facilitating reasonable access to health services without financial barriers. The Act and related reforms sought to establish a nationwide system of universal public healthcare coverage in Canada.
This document provides a historical overview of healthcare policy and programs in the United States from the 1930s to present day. It discusses the establishment of key programs like Social Security in 1935, Medicare and Medicaid in 1965, the Children's Health Insurance Program (CHIP) in 1997, and the Affordable Care Act in 2010. The document also outlines the goals and funding mechanisms of these major policies, and describes optional and mandatory benefits covered by programs like Medicaid. It analyzes factors that necessitated healthcare reform over time and how policies have attempted to address issues like the growing uninsured population.
mHealth Israel_US Telehealth + Reimbursement Post CoVID_King & SpaldingLevi Shapiro
The document discusses telehealth, telemedicine, and reimbursement in the US pre- and post-pandemic. It notes that historically Medicare limited telemedicine but expanded coverage significantly during the pandemic. It explores ongoing debates around permanent expansions, differences between telehealth and telemedicine, employer adoption challenges, and compliance issues. Deployment structures like contracting through wellness programs are examined. Reimbursement changes during the pandemic and proposals for the future are summarized, including defining "reasonable and necessary" coverage and considering commercial insurance coverage.
Running Head MEDICARE POLICY Of 2019 MEDICARE POLIC.docxglendar3
Running Head: MEDICARE POLICY Of 2019
MEDICARE POLICY
Medicare Policy of 2019
Maria Williams
Southern New Hampshire University
06/07/2020
Introduction
Description of the Medicare Policy of 2019
Patient Safety and Quality Improvement Act (PSQIA) is one of the most important health care policies in the United States. The Act was passed in 2005 to protect health care professionals and workers who report unsafe conditions in hospitals. The policy was formulated to encourage the reporting of adverse events and malpractices that occur in health care centers. Such events may include medical errors and accidents. The law seeks to protect the identity of professionals who report such incidences while maintaining the patients’ confidentiality. To protect patient privacy, the law imposes fines for confidentiality breaches (Nash, 2011). The policy also bestows the Agency for Healthcare Research and Quality (AHRQ) with the responsibility to publish a list of patient safety organizations that record and assess patient safety data. The Office of Civil Rights also enforces the policy among national health care facilities. The primary goal of this policy is to encourage health professionals to improve the safety and quality of health care and to understand the underlying causes of hazards in the delivery of healthcare (Nash, 2011). The policy also seeks to encourage the sharing of such results in all states within a protected legal framework, thereby minimizing any risks that are associated with patient care. In so doing, the policy hopes to reduce potential risks that patients are exposed to.
Rationale and Professional Relevance
Maintaining patient safety and quality of care are some of the most important goals of healthcare professionals. The policy goes a long way in encouraging all health care professionals to observe safety and quality standards. The Institute of Medicine regards patient safety as indistinguishable from delivery of quality care (Mitchell, 2008). Health professionals should observe patient safety practices such as use of stimulators, bar coding, computerized order entry, and crew resource management to avoid errors and improve health care processes (Mitchell, 2008). In order to comply with the legislation, nurses and other professionals should focus their attention on defining and measuring quality long before national and state level stress on quality improvements. Nurses have the responsibility in patient safety to avoid medication errors and prevent patient falls.
Stakeholder Analysis
The success of a policy depends on stakeholder participation and compliance. The key stakeholders of the policy can be broadly categorized as internal or external stakeholders. Within a health care institution, internal stakeholders include health professionals such as nurses, physicians, pharmacists, and clinical officers. External stakeholders, on the other hand, include patients, community members, government re.
Running Head MEDICARE POLICY Of 2019 MEDICARE POLIC.docxtodd581
Running Head: MEDICARE POLICY Of 2019
MEDICARE POLICY
Medicare Policy of 2019
Maria Williams
Southern New Hampshire University
06/07/2020
Introduction
Description of the Medicare Policy of 2019
Patient Safety and Quality Improvement Act (PSQIA) is one of the most important health care policies in the United States. The Act was passed in 2005 to protect health care professionals and workers who report unsafe conditions in hospitals. The policy was formulated to encourage the reporting of adverse events and malpractices that occur in health care centers. Such events may include medical errors and accidents. The law seeks to protect the identity of professionals who report such incidences while maintaining the patients’ confidentiality. To protect patient privacy, the law imposes fines for confidentiality breaches (Nash, 2011). The policy also bestows the Agency for Healthcare Research and Quality (AHRQ) with the responsibility to publish a list of patient safety organizations that record and assess patient safety data. The Office of Civil Rights also enforces the policy among national health care facilities. The primary goal of this policy is to encourage health professionals to improve the safety and quality of health care and to understand the underlying causes of hazards in the delivery of healthcare (Nash, 2011). The policy also seeks to encourage the sharing of such results in all states within a protected legal framework, thereby minimizing any risks that are associated with patient care. In so doing, the policy hopes to reduce potential risks that patients are exposed to.
Rationale and Professional Relevance
Maintaining patient safety and quality of care are some of the most important goals of healthcare professionals. The policy goes a long way in encouraging all health care professionals to observe safety and quality standards. The Institute of Medicine regards patient safety as indistinguishable from delivery of quality care (Mitchell, 2008). Health professionals should observe patient safety practices such as use of stimulators, bar coding, computerized order entry, and crew resource management to avoid errors and improve health care processes (Mitchell, 2008). In order to comply with the legislation, nurses and other professionals should focus their attention on defining and measuring quality long before national and state level stress on quality improvements. Nurses have the responsibility in patient safety to avoid medication errors and prevent patient falls.
Stakeholder Analysis
The success of a policy depends on stakeholder participation and compliance. The key stakeholders of the policy can be broadly categorized as internal or external stakeholders. Within a health care institution, internal stakeholders include health professionals such as nurses, physicians, pharmacists, and clinical officers. External stakeholders, on the other hand, include patients, community members, government re.
Medicare claims data contains valuable information that can be used for healthcare innovation and cost savings. The data includes procedures, diagnoses, and costs for over 38 million Medicare beneficiaries. When organized and analyzed, insights from the claims data can help reduce costs, improve quality of care, and validate new healthcare programs. However, working with Medicare data also has pitfalls like dealing with duplicate claims and ensuring privacy. Overall, harnessing Medicare claims data offers opportunities to innovate the healthcare system through observational studies, risk adjustment, and evaluation of new initiatives and treatments.
The document discusses key issues related to health reform implementation for safety net health systems. It provides an overview of the National Association of Public Hospitals and Health Systems (NAPH), which advocates for safety net hospitals. The document outlines provisions of the Affordable Care Act related to coverage expansion, exchanges, provider payments, and innovation opportunities. It identifies challenges and questions for safety net health systems to consider regarding health reform implementation.
The document discusses rising health care costs in the United States from 1969 to 2004, factors contributing to increased costs such as an aging population and technology, and responses to rising costs including managed care and malpractice reform. It also covers health care financing through programs like Medicare, Medicaid and private insurance, as well as the growing number of uninsured Americans.
The Heartaches Associated with Billing for Cardiac DevicesPYA, P.C.
PYA Principal Denise Hall-Gaulin and Consulting Manager Joanna Malcolm presented a free webinar for the Georgia chapter of the Healthcare Financial Management Association, on Tuesday, December 6, 2016.
The presentation was geared toward C-suite hospital leaders, compliance officers, in-house counsel, operational leaders, and patient accounting leadership, and covered:
The criteria for implantable cardioverter defibrillators (ICDs), pacemakers, and other devices
The documentation requirements for payment
The prerequisites for a clean audit
The document provides an overview of the key issues in the U.S. healthcare system and proposals for reform. It discusses problems like rising costs, uninsured populations, and disparities in quality. The reform proposals aim to expand coverage, reduce costs, and improve quality through mechanisms like insurance exchanges, individual and employer mandates, expanded Medicaid, and payment reforms. Stakeholders like insurers, providers, consumers would all be impacted by the reforms through changes to financing, coverage, and care delivery.
Similar to Social security and medicare & medicaid spring 2014 abridged (20)
Hematology oncology-nurs 3340 fall 2017Shepard Joy
This document outlines learning outcomes and content related to alterations in hematologic function and childhood malignancies. It begins by describing the functions of red blood cells, white blood cells, and platelets. It then discusses differences in pediatric hematopoiesis compared to adults. Specific topics covered include anemia, sickle cell disease, hemophilia, and childhood cancers. Nursing care is discussed for conditions such as vaso-occlusive crises, bleeding episodes, and cancer diagnosis and treatment.
Endocrine metabolic nurs 3340 fall 2017Shepard Joy
The document provides information on caring for children with endocrine or metabolic conditions. It begins with an anatomy and physiology review of the endocrine system and key differences in children. Several pathophysiological conditions are then described, including:
- Growth hormone deficiency causing short stature
- Precocious puberty from premature hormone secretion
- Hypothyroidism impairing growth and development
- Congenital adrenal hyperplasia resulting in virilization of female genitalia if untreated
The summary highlights some of the major conditions discussed and learning objectives covered in the document.
Pediatric musculoskeletal nurs 3340 fall 2017Shepard Joy
This document provides an overview of alterations in the musculoskeletal system in children. It describes common pediatric variations, including softer bones that heal faster in children. Nursing care is outlined for structural deformities of the foot, hip, and spine. Common infectious musculoskeletal disorders are also discussed. The document reviews nursing assessments of the musculoskeletal system in children and common nursing diagnoses. Casting procedures and care are explained for conditions like fractures, clubfoot, and hip spica casts.
Infectious disease in children nurs 3340 fall 2017Shepard Joy
This document discusses infectious diseases in children and the immune system. It describes how the immune system works and why children are more vulnerable to infectious diseases than adults. The document outlines the different types of immune protection and explains the process of infection and disease transmission. It provides information on common childhood illnesses and the medical and nursing management of infectious diseases.
Pediatric neurologic nurs 3340 fall 2017Shepard Joy
This document provides an overview of the anatomy and physiology of the neurologic system in children and alterations that can occur. It describes the key parts of the brain involved in thinking. Differences between the pediatric and adult nervous systems are outlined, including a more rapid brain development in children. Guidelines for assessing the neurologic system in infants and children are provided, including developmental milestones, tests of coordination and balance. Diagnostic tools like CT, MRI and EEG are mentioned. Common conditions that can cause alterations in neurologic function are described such as seizures, increased intracranial pressure, and traumatic brain injury. Nursing care considerations are highlighted.
Here are the key postoperative nursing interventions for an infant with esophageal atresia/TEF:
- Maintain airway patency
- Keep NPO and administer IV fluids and electrolytes for hydration and nutrition
- Elevate head of bed to 45 degrees to prevent aspiration
- Suction as needed to keep airway clear
- Administer prophylactic antibiotics to prevent infection
The goals are to prevent aspiration, maintain hydration and nutrition until oral feeds can resume, and prevent complications like infection. Close monitoring of the airway and GI output is also important.
This document discusses strategies for caring for hospitalized children of different ages. It contrasts how infants, toddlers, preschoolers, school-age children, and adolescents understand and respond to illness and hospitalization according to their developmental level. It outlines common stressors for children and recommends nursing interventions to minimize stress, such as encouraging parental presence, preparing children for procedures, providing age-appropriate activities and information, and allowing choices when possible. The use of play and pet therapy to help children cope is also described.
Alterations in genitourinary function in children fall 2017Shepard Joy
This document provides an overview of the anatomy, physiology, development, and common issues related to the pediatric genitourinary system. It begins with learning outcomes and then reviews anatomy and physiology of the urinary system and kidneys. It describes differences in fluid balance, renal function, bladder capacity, and reproductive system development in children compared to adults. The document outlines topics to include in a health history and physical assessment for the genitourinary system. It lists common nursing diagnoses and diagnostic tests used to evaluate the system.
Respiratory lecture nurs 3340 fall 2017Shepard Joy
The document describes the anatomy and physiology of the pediatric respiratory system, key differences compared to adults, respiratory assessment in children, common acute respiratory conditions like otitis media, tonsillitis, and croup, signs of respiratory distress and failure, and nursing considerations for treatment and management of respiratory issues in children.
Alterations in cardiovascular function in children fall 2017Shepard Joy
This document discusses alterations in cardiovascular function in children. It begins with learning outcomes related to anatomy and physiology of the cardiovascular system, pathophysiology of congenital heart defects, and nursing care of infants and children with heart defects. It then covers topics such as overview of the cardiovascular system, fetal circulation, transition to postnatal circulation, pediatric cardiac assessment, diagnostics, and types of heart disease in children. Nursing care is discussed for conditions such as congestive heart failure and for procedures like cardiac catheterization.
This document provides information on caring for preterm infants in the neonatal intensive care unit (NICU). It describes the characteristics of preterm neonates, including underdeveloped organs and difficulties with respiration, thermoregulation, and nutrition. The document outlines various respiratory conditions preterm infants may experience and discusses nursing interventions to maintain airway, breathing, and oxygenation. These include positioning, suctioning, oxygen therapy via various devices, surfactant administration, and other treatments. The goal is to support the preterm infant's immature systems and promote development until they can transition to extrauterine life.
Health promotion of the infant & toddler fall 2017Shepard Joy
This document provides information on health promotion for infants and toddlers. It outlines several objectives related to child development, nutrition, health concerns, communication, and anticipatory guidance. Nursing diagnoses that may be relevant for this age group are also listed. The document then reviews normal infant development by age group and describes common infant reflexes. It provides information on assessing growth, body systems, motor skills, language, vision, hearing, psychosocial development, sleep, and crib safety for infants.
Growth & development nurs 3340 fall 2017 updateShepard Joy
Growth and development is a continuous process from conception through adulthood. The document discusses several key principles of growth and development including different rates of growth, developmental theories including psychosexual theory and psychosocial theory, stages of development from infancy through adolescence, and factors that influence individual growth and development. It also provides nursing diagnoses and interventions related to children's growth, development, and family dynamics.
Introduction to pediatric nursing nurs 3340 fall 2017Shepard Joy
This document provides an introduction to pediatric nursing. It discusses key differences between caring for children versus adults, including differences in physical assessment techniques according to age and development. The roles of nurses in caring for children are to provide direct care, patient education, advocacy, and case management. The primary goals of pediatric care are health promotion and health maintenance for children and their families.
Health promotion of the infant & toddlerShepard Joy
This document provides information on health promotion for infants and toddlers. It covers several key areas:
1) Developmental milestones, the importance of play, nutrition needs, common health concerns, communication skills, and anticipatory guidance.
2) Common nursing diagnoses for infants and toddlers related to knowledge, parenting skills, immunization status, family coping, and various risks.
3) A review of normal developmental age groups from neonate to preschooler, focusing on growth, motor skills, cognition, language, and psychosocial development.
Pediatric musculoskeletal nurs 3340 spring 2017Shepard Joy
This document discusses alterations in musculoskeletal function in children. It begins with objectives related to describing pediatric variations in the musculoskeletal system and planning nursing care for related disorders. It then provides an overview of the musculoskeletal system, including bones, cartilage, joints, and muscles. Specific pediatric musculoskeletal disorders discussed include metatarsus adductus, clubfoot, genu varum/valgum, and developmental dysplasia of the hip. Treatment options like casting, bracing, and surgery are described. The document emphasizes nursing assessments and interventions for related nursing diagnoses.
Pediatric neurologic nurs 3340 spring 2017Shepard Joy
This document provides an overview of the anatomy and physiology of the neurologic system in children and alterations that can occur. It describes key differences in the developing pediatric neurologic system compared to adults, including an immature but rapidly developing brain. Assessment of the neurologic system in children is described, including developmental milestones, reflexes, and diagnostic testing. Specific conditions discussed include increased intracranial pressure, seizures, epilepsy, and altered levels of consciousness. Nursing care focuses on monitoring, safety, and supporting normal growth and development.
This document discusses alterations in gastrointestinal functioning in children. It outlines 7 learning objectives related to anatomy and physiology of the developing GI system, pathophysiology of GI disorders, signs and symptoms, care for cleft lip/palate, nursing management of surgical vs. non-surgical GI conditions, infections of the GI tract, and developmentally appropriate nursing care. Key concepts covered include the immature GI system of infants, common congenital defects and disorders, diagnostic tests and treatments.
This document discusses alterations in hematologic function and childhood malignancies. It covers the following key points:
1. It describes the functions of red blood cells, white blood cells, and platelets and how they differ in children compared to adults.
2. It discusses common pediatric hematologic disorders like sickle cell disease and hemophilia, outlining their pathophysiology, clinical manifestations, diagnosis, and treatment.
3. It provides an overview of childhood cancers, including incidence, causes, signs, diagnostic tests, treatment goals like chemotherapy and bone marrow transplant, and the most common types.
Alterations in genitourinary function in childrenShepard Joy
The document provides an overview of alterations in genitourinary function in children, including anatomy, development, common conditions like urinary tract infections, diagnostic tests, and treatment modalities. It reviews the differences between pediatric and adult genitourinary systems as well as important nursing considerations for assessing, diagnosing, and managing genitourinary issues in children.
An astonishing, first-of-its-kind, report by the NYT assessing damage in Ukraine. Even if the war ends tomorrow, in many places there will be nothing to go back to.
Acolyte Episodes review (TV series) The Acolyte. Learn about the influence of the program on the Star Wars world, as well as new characters and story twists.
Essential Tools for Modern PR Business .pptxPragencyuk
Discover the essential tools and strategies for modern PR business success. Learn how to craft compelling news releases, leverage press release sites and news wires, stay updated with PR news, and integrate effective PR practices to enhance your brand's visibility and credibility. Elevate your PR efforts with our comprehensive guide.
04062024_First India Newspaper Jaipur.pdfFIRST INDIA
Find Latest India News and Breaking News these days from India on Politics, Business, Entertainment, Technology, Sports, Lifestyle and Coronavirus News in India and the world over that you can't miss. For real time update Visit our social media handle. Read First India NewsPaper in your morning replace. Visit First India.
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Here is Gabe Whitley's response to my defamation lawsuit for him calling me a rapist and perjurer in court documents.
You have to read it to believe it, but after you read it, you won't believe it. And I included eight examples of defamatory statements/
El Puerto de Algeciras continúa un año más como el más eficiente del continente europeo y vuelve a situarse en el “top ten” mundial, según el informe The Container Port Performance Index 2023 (CPPI), elaborado por el Banco Mundial y la consultora S&P Global.
El informe CPPI utiliza dos enfoques metodológicos diferentes para calcular la clasificación del índice: uno administrativo o técnico y otro estadístico, basado en análisis factorial (FA). Según los autores, esta dualidad pretende asegurar una clasificación que refleje con precisión el rendimiento real del puerto, a la vez que sea estadísticamente sólida. En esta edición del informe CPPI 2023, se han empleado los mismos enfoques metodológicos y se ha aplicado un método de agregación de clasificaciones para combinar los resultados de ambos enfoques y obtener una clasificación agregada.
Social security and medicare & medicaid spring 2014 abridged
1. Social Security and
Medicare & Medicaid
NURS 4100 Care of
the Older Adult
Spring 2014
Joy A. Shepard, PhD(c), MSN,
RN, CNE
1
2. Objectives
Analyze
the benefits of Social Security
Discuss the phenomenon of
retirement as it relates to an aging
society
Compare and contrast the Medicare
and Medicaid programs
List the benefits and barriers to longterm care insurance
2
8. Social Security
Social
Security Act of 1935
Federal public retirement pension
system
Full retirement age steadily rising (since
1980s)
Major source income
Has decreased poverty rates
Major recipients female elderly
8
9. Social Security
Qualifications
Financially
sustainable?
No means test
Procrastination – bad policy
What suggestions do YOU have to
save Social Security?
Text of the 1935 Social Security Act
9
10.
11.
12. Review Question
Which
of the following factors would not
threaten the solvency of Social
Security?
A.
Baby Boomers taking early retirement.
B. Means testing being implemented for
Social Security.
C. Another recession or depression.
D. Aging of the population.
12
14. Retirement
Phenomenon
of retirement – How
will it be redefined by the Boomers?
Decades of retirement - feasible?
Social Security sufficient?
Are Boomers prepared?
“Third Age” career strategies
14
17. Medicare
Title
XVIII of the Social Security Act (1965)
Covers elderly and some disabled
–
–
Part A – Hospital insurance
Part B
Supplemental
medical insurance (physician
care)
Preventive services
Limited
means test
Covers ~ 45% of elders’ medical care bills
17
18. Medicare Preventive Services
18
Prevention is any activity that reduces the burden of
mortality or morbidity from disease. Services performed
in a clinical setting that are designed to prevent disease,
injury, or disability, prolong life, and promote health are
known as preventive health services.
Examples: Screening, testing, counseling, immunization,
preventive medication, and preventive treatment.
Help people avoid disease or injury (primary), delay the
onset of disease (primary), detect disease in its earliest
and most treatable state (secondary), or alter and
change the course of chronic conditions by restoring
function and reducing complications (tertiary).
Result: Longer, healthier, and more productive lives.
19. Medicare Preventive
Services (Part B):
One-time “Welcome to Medicare” preventive visi
vis
Abdominal aortic aneurysm screening
Alcohol misuse screenings and counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Colorectal cancer screenings
Depression screenings
Diabetes screenings
19
20. Medicare Preventive
Services Cont’d…
Diabetes self-management training
Glaucoma tests
HIV screenings
Mammograms (screening)
Nutrition therapy services
Obesity screenings and counseling
Pap tests and pelvic exams (screening)
Prostate cancer screenings
Sexually transmitted infections screening and cou
20
29. Medicare no longer covers the cost of
10 hospital-acquired conditions
29
Foreign object
retained after surgery
Air embolism
Blood incompatibility
Stage III & IV pressure
ulcers
Falls & trauma
Poor glycemic control
Catheter-assoc UTI
Vascular catheterassociated infection
Certain surgical site
infections (CABG,
bariatric, orthopedic)
DVT or PE following
TKR, hip replacement
For more information, please see http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage
http://www.cms.hhs.gov/apps/media/press/factsheet.asp?
Counter=3227&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&p
30. Review Question
30
Medicare recently issued a new ruling. It will
cease paying for 10 preventable hospitalacquired conditions. Which of the following
conditions are included in the new ruling?
– A. Hematoma after venipuncture
– B. Skin tear after being turned and
repositioned
– C. Cellulitis after IV infusion
– D. Pneumonia after aspirating on meal tray
31. Medicaid
Title
XIX Social Security Act (1965)
Covers “medically indigent”
Funded partly by federal and partly by
state governments
Run by states under federal guidelines
North Carolina statistics
31
North Carolina Medicaid State Plan
North Carolina Division of Medical Assistance
32. Latest Data: NC Medicaid
Enrollments & Payments
FMAP: Federal Share of Medicaid Costs
32
Rising Enrollments
Federal Share/ State
Share: 65.5%/ 34.5%
34. Affordable Care Act of 2010 Expands
Medicaid Eligibility in 2014
The Affordable Care Act of 2010, signed by
President Obama on March 23, 2010, creates a
national Medicaid minimum eligibility level of 133%
of the federal poverty level ($29,700 for a family of
four in 2011) for nearly all Americans under age 65.
This Medicaid eligibility expansion goes into effect
on January 1, 2014 but states can choose to
expand coverage with Federal support anytime
before this date-see related Federal Policy
Guidance and states that have expanded Medicaid
prior to 2014.
States can also choose to opt out of the expansion.
See eligibility provisions in the Affordable Care Act.
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Eligibility.html
34
43. Review Question
_________
is a $498 billion public
health insurance program for lowincome individuals and the largest longterm care program for the disabled and
elderly.
A. Medicaid
B. Medicare
43
44. Review Question
Which of the following applies to Medicare and which applies to Medicaid?
44
A. Federally administered, nationwide healthcare coverage program for elderly/ disabled
B. Entitlement program—all individuals have a legal right to apply for the program; if they
meet the eligibility criteria, they are entitled to receive coverage
C. Uniform: one set of requirements applies to all participating providers/ beneficiaries
D. Joint federal/ state partnership: healthcare coverage for low-income individuals
E. Differences among state programs: covered populations, benefits, cost sharing,
delivery systems and reimbursement to providers
F. Means-tested program that provides benefits to certain categories of people who meet
rigorous income and asset rules
G. States may cover other individuals under “waiver” programs
H. Every state has a limit on what things (“assets”) a recipient may own and keep
45. Ethical Issue: Transfer of Assets
& “Spend Down”
Is transferring assets
to qualify for
Medicaid ethical?
Right to leave assets
to children?
Should wealthy be
subsidized?
Punished for being
frugal?
45
47. Long-Term Care Insurance
Plan
ahead for LTC costs
Mainly people over age 55
4-10% older population
covered
Provides 7% of total funding
for LTC
47
Editor's Notes
Fertility rate below replacement rate
Increased life expectancy due to improvements in public health
Demographic pyramid is going to square, then inverting. It is losing its base of support.
The wide-based demographic triangle is going to square and eventually will invert. In 1935, more than 16 workers
supported each retiree. Presently there are 3.3. By the year 2030, the ratio will dip to a thoroughly unworkable 2.1 to one. Instead of having a wide base of young working people to support and pay for the elders' benefits, there will be an inverted triangle with a top-heavy elderly population.
Is the continuation of entitlement programs fiscally sustainable as the Boomers age?
The age structure of the overall population is projected to change greatly over the next four decades (Figure 1). Much of this change is driven by the aging baby boomers and trends in immigration. Figure 1 illustrates the importance of the baby boom generation in shaping the overall population. In 2010, the baby boom generation will be 46 to 64 years old.4 The echo of the baby boom is also evident in the 2010 population pyramid for the age groups near 20.5 By 2030, all of the baby boomers will have moved into the ranks of the older population. This will result in a shift in the age structure, from 13 percent of the population aged 65 and older in 2010 to 19 percent in 2030.In 2010, 60 percent of the U.S. population will be aged 20–64. By 2030, as the baby boomers age, the proportion in these working ages will drop to 55 percent.
Green color – 2010
Dark purple – 2030
Light purple – 2050
The aging Baby Boomers are going to dramatically affect society for many decades to come.
Dependency ratio – number of people per 100 who are too old or too young to be working and must DEPEND on productive wage earners.
This is a measure of burden placed on working age population age 20-64 to support older people and children over the next 4 decades.
Indicator of potential burden on those in the working population. Greater number = greater burden.
Smaller portion working
Larger portion of population depending on government services (or family/ personal savings) to get by.
2010 – 67 per 100
2030 – for every 100 people age 20 to 64, there will be 83 people who are probably too old or too young to be working.
More retirees + fewer workers = trouble for the system. Dependency ratio and stress on Social Security system increases dramatically when cohorts of retiring workers are replaced by smaller cohorts of active workers.
Social Security Act of 1935 – old-age pension. Franklin D. Roosevelt’s “New Deal.” Defines age of retirement.
Social Security is most important because it provides a foundation for retirement income. Social Security is the public retirement pension system and social insurance system administered by the federal government, the largest domestic government program today. Social Security covers almost all US workers except for some state and local government employees. The biggest controversies over Social Security revolve around this core retirement program, which is essentially a tax on wages during working years followed by a wage subsidy during retirement years.
Strengthened with addition of survivors’ and dependents’ benefits (1939), disability insurance (1956), Medicare (1965), and automatic adjustment of benefits for inflation and supplement income (1972). The Social Security Act provided a safety net of income in return for a lifetime of employment; it never was intended to be the sole source of retirement income. It also provided a standard age by which retirement could be defined. Participation in the Social Security system is mandatory through payroll taxes called “contributions.”
Social Security was never meant to entirely fund seniors' expenses. It was never intended to be the sole income source for people in retirement. As such, it provides only a bare subsistence. Social Security retirement benefits average $1,229 monthly for a single person ($14,748 annually) and $1,994 monthly for a retired couple.
Social Security constituted 90% or more of the income received by 36% of beneficiaries in 2010. (23% of married couples and 46% of non-married beneficiaries).
Social Security replaces about 40% of an average wage earner’s income after retiring, and most financial advisors say retirees will need 70% or more of pre-retirement earnings to live comfortably. To have a comfortable retirement, Americans need much more than just Social Security. They also need income from private pensions, savings, investments, or continued part-time employment. For nearly 40% of older adults, Social Security provides the main source of their income.
The large majority of beneficiaries have other income from a pension, savings, or continued part-time employment. The major sources of income as reported by older persons in 2010 were Social Security (reported by 86% of older persons), income from assets (reported by 52%), private pensions (reported by 27%), government employee pensions (reported by 15%), and earnings (reported by 26%).
Social Security has decreased poverty rates of the elderly, particularly for female elderly. Half of the older women in the US would live in poverty without their SS income. Approximately 75% of the poor elderly are women who depend on SS as the major source of income. Women represent 60% of all SS recipients at age 65; at age 85, women represent 71% of all SS recipients.
The median income of older persons in 2011 was $27,707 for males and $15, 362 for females. Households containing families headed by persons 65+ reported a median income in 2011 of $48,538. Almost 3.6 million elderly persons (8.7%) were below the poverty level in 2011.
Social Security is funded through the Federal Insurance Contributions Act tax (FICA), a payroll tax. Employers and employees are responsible for making equal FICA contributions. During 2012], Social Security taxes were levied on the first $110,100 of income for employment; amounts earned above that are not taxed. Covered workers are eligible for retirement and disability benefits. If a covered worker dies, his or her spouse and children may receive survivors' benefits. Social Security accounts are not the property of their beneficiary and are used solely to determine benefit levels. Social Security funds are not invested on behalf of beneficiaries. Instead, current receipts are used to pay current benefits (the system known as “pay-as-you-go"), as is typical of some insurance and defined-benefit plans.
Both minimum retirement age and work credits are needed to qualify for Social Security retirement benefits. A person may start receiving benefits as early as age 62 (early retirement) or as late as 70. Since 2003, the full Social Security retirement age has been slowly rising to accommodate demographic trends and increased life expectancies. For those individuals born before 1938, the full retirement age is 65 years. A person born in 1955 will reach full retirement age at 66 years and 2 months; an individual born in 1960 or later will not reach full retirement age until 67 years. Social Security benefits are based on the worker’s average of the highest years of earnings, adjusted for inflation. For each $1,130 that is earned, a person receives one Social Security “credit,” up to four per year. Most people need 40 credits (10 years of work) to be eligible for retirement benefits.
Social Security was designed with the typical family of the 1930s in mind and was only meant to be a supplement to other forms of retirement income. In fact, when Social Security was created in 1935, only 5% of the population reached age 65. By1940, the life expectancy at birth had climbed slightly to 61.4 years for men, 65.7 years for women. The planners assumed the fund would remain solvent because the life expectancies of the era would prevent most people from living long enough to collect benefits.
The rising life expectancy we see today is both a blessing and a challenge. Now, those who survive to age 65 can expect to live 17 (men) to 19 (women) years longer. Federal spending for Medicare, Medicaid, and Social Security are expected to surge, nearly doubling by 2035, as people live longer and spend more time in retirement. Further, advances in medical technology and prescription drugs will likely keep pushing the costs of health care. This is problem with most entitlement programs – they end up costing far more than originally envisioned, often by a factor 10, 20, 30, or even 40.
Demographic pyramid – going to square and then to inversion. In 1935, more than 16 workers supported each retiree. Presently, there are 2.87 workers per beneficiary. By the year 2030, the ratio will dip to a thoroughly unworkable 2.1 to one. Instead of having a wide base of young working people to support and pay for the elders’ benefits, there will be an inverted triangle with a top-heavy elderly population. Is the continuation of Social Security income fiscally sustainable as the Boomers age?
As the Boomers eventually retire, the number of beneficiaries will surge. The Congressional Budget Office estimates that the annual cost of Social Security will increase by 75% in the next decade, reaching a projected $1.3 billion in 2021.
No means test is required to receive benefits; rather, it is an earnings-related program. Benefits are financed by payroll taxes paid by employees and employers on income up to a certain level. The richest retiree will receive benefits alongside the poorest retiree.
Some analysts advocate means testing retirement benefits—reducing or eliminating benefits to retirees who have substantial private pensions, savings, and other sources of retirement income. Critics of means testing point out that this approach would alter the very nature of the system from one in which all benefit to a system targeted at low-income workers. Such a change could also reduce the political viability of the system by reducing the constituency with a stake in the program. Administrative costs as well as incentives for people to “game” the system would also increase. *Distinction here between a SOCIAL program which helps all equally or in proportion to their taxation and a POVERTY program which disproportionately helps the poor.
What ideas do YOU have to save Social Security?
“B”
Phenomenon of retirement – How will it be redefined by the Boomers?
Demographic pyramid – going to square and then to inversion. Not enough young working people to support the burgeoning elderly population through decades of retirement.
The workforce as a whole is aging, and life expectancy has increased dramatically. It may not be sustainable for society in the near future to support large numbers of elders during decades of retirement. Many Boomers are not prepared in terms of "nest egg" savings and pensions to adequately cover their living expenses during retirement years. Social Security was originally meant to only supplement retirement income and is not sufficient for funding anything other than a "bare-bones" existence. Not surprisingly, up to 80% of Boomers plan to continue to work in some capacity after the traditional retirement age of 65. Work life extension is one solution and barriers to continued employment of seniors are being removed. Mandatory retirement was abolished in 1986 and, in 2000, the earnings penalty was removed from Social Security. Productive aging is defined by Caro, Bass, and Chen (2010) as "any activity by an older individual that produces goods or services, or develops the capacity to produce them, whether they are to be paid for or not" (p. 410). The notion of productive aging directly challenges the pervasive societal stereotypes of elders as being frail and dependent, rigid, or unable to learn new things. Obstacles to productive aging include institutional ageism, labor market conditions, cultural lag, unattractive volunteer/ employment assignments, and lack of interest by older people in community service and post-retirement employment opportunities.According to Bower and Sadler (2009), ways to plan for "Third Age" career strategies include: preparing a life portfolio, taking an honest inventory of one's strengths and weaknesses, evaluating one's needs, preparing oneself for the future, building networks, being flexible, and developing a support system.
The Medicare program was created in 1965 as Title XVIII of the Social Security Act. Its primary purpose was to provide health care coverage for the elderly, who were defined at that time as anyone 65 years of age or older. In 1972 provisions were added to the act to include people who were permanently disabled and those with kidney disease. Before Medicare, as many as half of people over age 65 were without health insurance, whereas today almost all people are covered. Much has changed in the Medicare population in more than three decades. Since 1965, life expectancy has risen from 70 to 77, and the 65+ population grew from 9% to 13% of the total US population. Medicare has had a major impact on the health of the elderly population: Since 1965, half as many Americans die of heart attacks and a third as many die of strokes, and this is a tremendous accomplishment.
Medicare is the chief federal government program that pays for health care for 39.6 million Americans over age 65 and another 7.9 million disabled people of all ages. Medicare has serious limitations: It doesn’t pay for the first day of hospitalization; it doesn’t cover hearing aids, eyeglasses, or dental care. It also excludes long-term care coverage, except for limited periods after hospital discharge.
The two main elements of the program are Part A, which provides hospital insurance, and Part B, which provides supplementary medical insurance that covers physician care, along with limited home and outpatient services. Part B is purchased by beneficiaries with payment of a small premium. That separation pretty well defines the major thrust of the program. It is oriented to the acute care, medical model. There is no Part C covering long-term care. Although some limited forms of long-term care coverage have been added over the years, this was not the original intent of the Medicare program.
Medicare has expanded coverage of preventive services to encourage older people to stay healthy. Medicare pays for a “Welcome to Medicare” preventive exam and a preventive visit each year after that. This is given within the first 12 months of enrollment in Part B. It covers a medical and social health history with attention to modifiable risk factors for disease, education and counseling about preventive services, and referrals for care if needed. Services covered during this examination include measurement of height and weight and blood pressure, vision screening, an ECG, routine immunizations as needed, education and counseling on how to stay well, and a list of recommended screening tests and a timetable for when they should be obtained. The following screeening tests are recommended by Medicare: Screenings for breast, cervical, vaginal, colorectal, and prostate cancer; bone mass screening (once every 2 yrs for those at risk); fasting blood glucsoe screening (q6mos for those at risk); diabetes monitoring; flu, pneumonia & hepatitis B vaccinations; nutriton assessment; glaucoma screening; and smoking cessation counseling.
Medicare is an entitlement program (like Social Security), meaning that anyone belonging to a particular population group is entitled to coverage. It is available primarily on the basis of age. here historically has been no requirement that recipients demonstrate financial need (as there is with Medicaid) (“means testing”). The wealthiest retiree has enjoyed the same rights to Medicare coverage as the poorest. This has become a major issue in recent years as the program struggles to provide coverage for a population that has grown many times faster than was predicted. In fact, the funding source for the program, the Medicare Trust Fund, is currently in considerable jeopardy.
Like Social Security, Medicare is funded from payroll taxes, with additional funding from general revenues and premiums from beneficiaries. Unlike SS, whose problems lie many decades into the future, Medicare faces short-term financing problems. Overall, Medicare spending has risen much faster than the cost of living, and thus it presents government policymakers with a serious problem of cost control.
The Trust Fund-Part A is headed for insolvency by the year 2024 (depending on your source) unless actions are taken to change either its funding source or the way in which those funds are spent. The Part B (Supplementary Medical Insurance Trust Fund) is projected to last longer because beneficiary premiums cover about 25% of it.
Based on US Census Bureau middle-range population forecasts, it is estimated that the Medicare costs for the oldest-old (85+) could increase sixfold by the year 2040. In light of these troubling forecasts and trends, there is serious discussion about the rationing of health care for the elderly in the future.
When the 2003 Medicare prescription drug bill was passed there was a little noticed provision tacked on that added a "means" test to the bill. Means testing—reducing, eliminating, or charging more for benefits to seniors who have substantial private pensions, savings, and other sources of retirement income.
Medicare means testing was implemented for the first time on January 1, 2007. The Part B premium is "means tested," meaning the government determines the Medicare Part B premium based on a person’s income. Seniors with incomes of $80,000 per year or higher will pay more for services than lower-income seniors. It also introduced a scale of premiums which goes up as income rises. Starting in 2007 the premium for Medicare Part B increases substantially for high income individuals. This has affect about 2 million people. The increase is in the form of a premium surcharge that is to be paid in addition to the normal Part B premium. This surtax is owed even if the individual Medicare recipient has not sign up for prescription drug coverage.
Means testing radically changes the nature of Medicare. The program was designed as universal social insurance with everyone paying a uniform premium and receiving a standard package of benefits. Supporters of means testing argue that it's needed to cut Medicare costs and make the program more sustainable. Government estimates, however, indicate that higher premiums for some will not save Medicare. In 1965, when it was first enacted, Medicare spent a little more than $3 billion. Today, it spends more than $200 billion each year. Last year, Medicare paid out $516 billion in benefits. Program income was $486 billion. Nearly two thirds of that total goes to hospitals, where acute and often high-technology care are provided. If health care rationing on the grounds of age were ever to be introduced, it would probably take place in the Medicare program and would show up in the large sector of Medicare concentrated in hospitals.
Although Medicare expenditures have climbed dramatically, Medicare still covers only about half of the out-of-pocket expenses of older people; roughly the same percentage as when the Medicare program was first enacted in 1965. Part of the reason is that Medicare B reimburses 80% of physicians’ “reasonable charges.” In fact, the amount reimbursed may or may not reflect actual charges in a specific geographic area. Because of what limits on what Medicare will pay, around 30% of Medicare beneficiaries also have private Medigap insurance policies to cover the remainder of their medical bills.
One of the identified weaknesses of Medicare has been its lack of emphasis on preventive care. To address this service gap, the new healthcare reform law expanded coverage of preventive services to help older people stay healthy and experience optimal functionality and quality of life. As of January 1, 2011, many preventive services are now covered under Medicare. Some preventive services are provided at no cost to the beneficiary while others require a co-insurance payment.
Medicare covers all the cost for a one-time comprehensive “Welcome to Medicare Preventive Visit,” if given within the first 12 months of enrollment in Part B. There is no co-payment or deductible for this visit. This one-time preventive visit covers a detailed medical and social history, family history, identification of modifiable risk factors for disease, review of medications, depression screen, functional ability and safety screen, a focused physical exam, counseling about preventive care services, discussion of advance directives, and referral for further tests if needed. Services covered during this examination include measurement of blood pressure, weight, and height, vision screening, an electrocardiogram, routine immunizations, wellness education and counseling, and a list and timetable of recommended screening tests. Those beneficiaries who have been enrolled in Part B longer than 12 months are eligible for an annual “wellness” visit. There is no cost for the yearly “wellness” visit. If additional tests or services are needed during the visit, however, then the beneficiary must pay co-insurance or deductibles for the extra costs.
Despite the changes in Medicare to promote access to preventive services, many older adults currently do not receive vaccinations, screenings, and other preventive services that national experts recommend. A contributing factor is that many older adults are still unaware of these services. Nurses are in a pivotal position to educate and encourage older adults to take advantage of these preventive health services and to make healthy lifestyle changes.
Medicare Part C, formerly known as "Medicare+Choice," is now known as "Medicare Advantage". MA was brought into existence by Part C of Medicare. It involves privatized corporate sponsored health insurance rather than traditional government sponsored, single payer health insurance which is what Medicare is. This section of Medicare allows private companies such as UnitedHealth, Blue Cross Blue Shield, Humana, Kaiser, and Coventry Health Care to arrange care for Medicare beneficiaries enrolled in the plan. To join a Medicare Advantage Plan, one must have Medicare Part A and Part B before being able to get Part C. In addition, the enrollee might have to pay a monthly premium to the Medicare Advantage Plan for the extra benefits that they offer. Medicare now serves 47.5 million elderly and disabled people.
About 25 percent of beneficiaries have chosen to enroll in Part C “Medicare Advantage” private health plans that contract with Medicare to provide Part A and Part B health services. Many of these plans offer extra benefits like vision and dental care. But independent studies have found that the private plans cost the government more per person than traditional Medicare.
Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.
Medicare Prescription Drug Plan (Part D):
The Medicare Prescription Drug, Improvement and Modernization Act of 2003 added Part D. Medicare Part D pays for outpatient prescription drugs. See handout for details of deductibles, copayments, and the “donut hole.”
“A”
Original Medicare covers many health care services and supplies, but there are many costs (“gaps”) it doesn’t cover.
A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan doesn’t cover (such as copayments, coinsurance, and deductibles).
In 2006, 18% of Medicare beneficiaries were covered by a Medigap policy.
A person must be enrolled in part A and B of Medicare before they can enroll in a Medigap plan. During the open enrollment period which begins within 6 months of turning 65 or enrolling in Medicare Part B at 65 or older, a person may obtain a Medigap plan on a guaranteed issue basis (i.e. no medical screening required). Outside of open enrollment, the issuing insurance company may require medical screening and may obtain an attending physician's statement if necessary. Medigap insurance is not compatible with other forms of private Medicare coverage, such as a Medicare Advantage plan.
If a senior is in the Original Medicare Plan and has a Medigap policy, then Medicare and the Medigap policy will pay both their shares of covered health care costs. Medicare pays first; then the Medigap policy pays its share.
If a person is enrolled in a Medicare Advantage Plan, then the person doesn’t need and can’t use a Medigap policy.
Medigap offerings have been standardized by the Centers for Medicare and Medicaid Services (CMS) into twelve different plans, labeled A through L, sold and administered by private companies. Each Medigap plan offers a different combination of benefits. The coverage provided is roughly proportional to the premium paid.
Medicare covers: “Skilled nursing care” in nursing facilities or units in hospitals. Skilled nursing (SNFs) may be free-standing or they can be units in hospitals or nursing facilities. Skilled nursing care is health care given when skilled nursing or rehabilitation staff are needed to manage, observe, and evaluate the patient’s care. Examples of skilled care include changing sterile dressings and physical therapy. Other “unskilled” care in nursing facilities is not covered at all by Medicare. Skilled services must be certified as necessary by a physician, be related to a hospital admission (occur within 30 days of a hospital stay of at least 3 days for the same condition), and be needed on a daily period, with the patient paying a portion of the cost from day 21 through 100.
Medicare coverage of skilled nursing services is limited to 100 days per benefit period. A benefit period is defined as beginning when the Medicare beneficiary first enters the hospital until there has been a 60-day break in hospital or SNF services.
Subacute care is not a separate category under Medicare. It is generally provided in Medicare-certified SNFs or units and is reimbursed through the SNF mechanism.
Medicare has embraced home health care services. To receive that reimbursement, these services must be provided by agencies certified by the Medicare program. Medicare covers hospice care for people who are certified to be terminally ill, with 6 months or less to live. The care must be palliative rather than curative, and as with other types of Medicare coverage, must be delivered by a provider organization that is certified by that program.
Medicare does not regularly provide coverage in settings such as assisted living or adult day care.
“Never events” – in 2007 accounted for $22 billion in expenses:
Wrong site surgeries
Transfusion with the wrong blood
Pressure ulcers (stage III and IV)
Falls or trauma
Iatrogenic/ nosocomial infections involving surgeries or catheters
The 10 categories of HACs include:
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Stage III and IV Pressure Ulcers
Falls and Trauma
Fractures
Dislocations
Intracranial Injuries
Crushing Injuries
Burns
Electric Shock
Manifestations of Poor Glycemic Control
Diabetic Ketoacidosis
Nonketotic Hyperosmolar Coma
Hypoglycemic Coma
Secondary Diabetes with Ketoacidosis
Secondary Diabetes with Hyperosmolarity
Catheter-Associated Urinary Tract Infection (UTI)
Vascular Catheter-Associated Infection
Surgical Site Infection Following:
Coronary Artery Bypass Graft (CABG) - Mediastinitis
Bariatric Surgery
Laparoscopic Gastric Bypass
Gastroenterostomy
Laparoscopic Gastric Restrictive Surgery
Orthopedic Procedures
Spine
Neck
Shoulder
Elbow
Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
Total Knee Replacement
Hip Replacement
“C”
Medicaid – At the same time that the Medicare program was developed to provide health care for the elderly, Congress also created Medicaid as a program to provide health care for the poor. Enacted as Title XIX of the Social Security Act, Medicaid is different from Medicare in several very specific ways.
Medicaid serves the "medically indigent," those have no other coverage, and cannot afford to pay for their own care.
Medicaid is managed by state governments under federal guidelines.
First, it has no age limitations but covers people of all ages. Second, it does have income restrictions, covering only those who are “medically indigent” and who cannot pay for their own health care insurance. Third, Medicare is funded and operated by the federal government, but Medicaid is jointly funded by the federal and state governments and is run by the states under federal guidelines. Finally, whereas Medicare coverage is limited in terms of the types of services covered and the length of time they are covered, Medicaid essentially covers most services needed by its beneficiaries.
Recently, some clinics and physicians are refusing to accept Medicare assignments; some will not treat Medicaid recipients; and some limit the number (ratio) of Medicaid patients they will service. The problematic financial situation has numerous causes: high cost of well developed and technologically advanced treatments; high costs of malpractice insurance, aggressive lawyers, and large settlements; large gaps between the wealthy and the poor; expensive and extensive research necessary for development of new treatments; and others. Add to all those variables the extensive and mind-boggling demands within the insurance agencies themselves.
Medicare and Medicaid are not always necessarily separate programs. In some instances, Medicare recipients with low incomes may also be eligible to receive aid from Medicaid. If someone is covered by both, first Medicare will pay, then Medicaid.
For those who are fully covered by Medicaid, the Medicare health care coverage is supplemented by services provided under their respective State's Medicaid program. Some such services include:
Nursing facility care beyond the 100-day limit provided by Medicare.
Prescription drugs.
Eyeglasses.
Hearing aids.
Medicaid is the primary public medical assistance provider in the state of North Carolina. In 2009, the N.C. Medicaid program served about 21% of the total state population, or 1 out of 5 every resident in the state. An estimated 10% and 16% of the total recipients were seniors and residents with disability, respectively. These groups account for 65% of total Medicaid expenditures, amounting to about $5.6 billion combined. Medicaid enrollees have increased dramatically during the recession, from an 18.8% baseline during 2006 (relatively prosperous year) to 21% during 2009.
Eligibility: Income 100-200% of the federal poverty level (depending on Medicaid program). Less than $40,000 annually for a family of four.
The Affordable Care Act of 2010, signed by President Obama on March 23, 2010, creates a national Medicaid minimum eligibility level of 133% of the federal poverty level ($29,700 for a family of four in 2011) for nearly all Americans under age 65. This Medicaid eligibility expansion goes into effect on January 1, 2014. One of the most controversial parts of the U.S. Supreme Court ruling on the Affordable Care Act allows states to opt out of expanding Medicaid coverage in 2014. In North Carolina, where roughly one in five residents is uninsured, the expansion would initially add roughly 525,000 residents to the program. The number grows to 560,000 by 2019 with about 75 percent of those currently not insured. Who determines whether NC opts-out of the Medicaid expansion? Governor McCrory will.
In the year 2009 (the latest year for which data are available), 71.81% of NC Medicaid expenditures were paid by the federal government, and 28.19% of the expenses were paid by the State of North Carolina. Total expenditure to the State: $3,069,599,500. Last year, the state ran into a $200 million shortfall with Medicaid expenditures. Total overall expenditures in 2009: $10,888,466,523.00
Major reimburser of long-term care. Costs for LTC consumer 1/3 of Medicaid funds. 60% of Medicaid funds spent for LTC involves costs for nursing homes (20% of total Medicaid funds at this time). The elderly and disabled account for 2/3’s of Medicaid expenditures. Nearly 40% of all Medicaid benefits go to the elderly, chiefly for nursing home care. 50% of Medicaid dollars spent for elderly = cost of nursing homes.
The FMAP varies from state to state and is determined annually by a statutory formula designed to account for income variation across the states.
Total NC Medicaid paid in 2009: $10,888,466,523.00
Federal portion paid: $7,818,867,023.00 (71.81%)
State portion paid: $3,069,599,500.00 (28.19%)
Enrollment in 2006: 1,667,247
Enrollment in 2009: 1,974,287
2nd largest expenditure in the state. Second only to K-12 public education.
In most states, Medicaid coverage is extensive, particularly in long-term care. This makes it a major source of funding for long-term care consumers and providers. Medicaid also serves as a backup to Medicare, paying for services for low-income elders beyond those covered by Medicare. Because Medicaid is a welfare-type program, it is not intended as a reimbursement source for anyone with other resources.
This means that consumers must not be eligible for other forms of health insurance, public or private. They must also use up all of their available resources before becoming eligible for Medicaid. Medicaid coverage for long-term care services ranges from none at all for some providers to being the primary funding source for others. Medicaid accounts for over 40% of all funding for most nursing facilities. Medicaid is also a provider of reimbursement for assisted living facilities and programs. The coverage is far from universal, varying from state to state, but it is growing.
Medicaid is the second largest source of funding for home health care agencies, although it falls far behind Medicare.
Other forms of long-term care, such as subacute care, hospice, and adult day care, are generally not covered by Medicaid, but may be covered as a supplement to Medicare or under some of the waiver innovations.
Medicaid is the largest health insurance program in the U.S., covering over 62 million Americans (full time coverage – 70 million for at least one month), including millions of the poorest individuals and families in the nation. It also serves as a key source of health care financing and is the dominant source of the country’s long-term care financing. The Affordable Care Act (ACA) expands Medicaid significantly beginning in 2014 and the expanded program is to serve as the foundation of the broader framework created by the ACA to cover millions of previously uninsured low-income adults and children.
Medicaid funding is the dominant source of financing for safety-net providers that serve low-income and uninsured people (Figure 3). In 2010, Medicaid payments on behalf of enrollees accounted for more than one-third (35%) of safety-net hospitals’ total net revenues.2 In addition, supplemental Medicaid payments known as “DSH” payments financed 24% of the costs of uncompensated care provided by these hospitals, and other supplemental Medicaid funding financed another 11%. Community health centers, which provide care in many underserved areas, also rely heavily on Medicaid patient revenues, which accounted for 38% of their total operating revenues in 2011.
Medicaid is the main source of coverage and financing for long-term services and supports (LTSS). Nearly 10 million Americans, about half of them elderly and about half of them children and working-age adults with disabilities, need LTSS.4 LTSS are largely not covered by either Medicare or private insurance, but Medicaid covers nursing home and other institutional care as well as a broad range of home- and community-based LTSS that support independent living. Medicaid finances 40% of all long-term care spending, and more than 6 of every 10 nursing home residents are covered by Medicaid. Over half of Medicaid long-term care spending is for institutional care, but a steadily growing share – 45% in 2011, up from 20% in 2000 – is going to home and community-based care.
While Medicaid already plays an integral role in our health care system, the Patient Protection and Affordable Care Act* (Affordable Care Act, or ACA), signed by President Obama on March 23, 2010, ushers in a significant new chapter in the program’s evolution. Under the ACA, Medicaid eligibility will expand in 2014 to reach millions more poor Americans – mostly, uninsured adults.
Roughly two‐thirds of Medicaid spending is attributable to seniors and people with disabilities. “Dual eligible” beneficiaries, who are enrolled in both Medicare and Medicaid, account for nearly 40% of all Medicaid spending. Through the economic downturn, the main driver of Medicaid spending was enrollment growth. Medicaid spending per person has been rising more slowly than medical care inflation and private insurance premiums.
The 5% of Medicaid beneficiaries with the highest costs account for over half of all Medicaid spending. As is true for all payers, spending in Medicaid is highly skewed. That is, a very small group of high-cost enrollees accounts for a large share of total spending. In FY 2009, the 5% of beneficiaries with the highest health and long-term care costs accounted for 54% of all Medicaid spending (Figure 13).The disabled individuals among these high-cost beneficiaries alone accounted for 30% of total Medicaid expenditures.
Approximately 40% of older adults will spend some time in a nursing home during the last years of their lives.
Another side product of the quandary caused by conflicting societal obligations is an ethical issue that has been gaining considerable attention. Related to financing, and therefore to access, it is the issue of “spending down” one’s resources to qualify for Medicaid coverage. This has produced one of the most urgent and pervasive ethical debates associated with long-term care.
Many of those who do not qualify for Medicaid still do not have enough assets to pay for long-term car themselves. They face a cruel choice: struggle to provide home-based care or do what is necessary to obtain Medicaid. To qualify for Medicaid, it is necessary to “spend down” lifetime accumulated assets to become impoverished and therefore eligible for assistance. Under regulations of the Medicaid law, spouses of those thus impoverished may obtain some protection, but children and grandchildren lose their share of accumulated life savings. One major problem with Medicaid financing of long-term care is that it introduces inequities across families, age groups, and social classes. For example, should people who become poor in old age be treated the same as those with a lifetime of poverty? Should families that contribute their own labor for caregiving have that contribution taken into account?
In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in "countable" assets.
The spouse of a nursing home resident--called the "community spouse" -- is limited to one half of the couple's joint assets up to $109,560 (in 2009) in "countable" assets. This figure changes each year to reflect inflation. In addition, the community spouse may keep the first $21,912 (in 2009), even if that is more than half of the couple's assets. This figure is higher in some states, even up to the full maximum of $109,560 (in 2009).
Most people who enter nursing homes as private-pay residents spend their assets by the end of 1 year and require government support for their care; one-third of the Medicaid budget is spent on long-term care. As the percentage of the advanced-age population grows, society will face an increasing demand for the provision of and payment for services to this group. In this era of budget deficits, shrinking revenue, and increased competition for funding of other special interests, questions may arise about the ongoing ability of the government to provide a wide range of services for older adults.
To what extent does the government owe each of us coverage for our care, regardless of our ability to pay for it? Consumers faced with spending down ask why, after they have been paying their taxes all these years, have to lose all that they have saved just to be eligible for long-term care? After all, is it not the same care that is covered for those who were not so farsighted and prudent? Should coverage not be an entitlement as so many other government benefits? People feel that the savings that they put away over many years were meant to be passed on to children and grandchildren. They believe it is unfair to take all of that way from them, in effect penalizing them for being frugal, and point to others who either spent all they had frivolously or never bothered to provide for themselves in the first place. Where is the incentive to save if it is to be taken away by the government?
Countering arguments, primarily coming from government entities that are hard-pressed to finance Medicaid programs, center on the unfairness of providing coverage to those who have their own resources.
Which is more or less ethical – to take away an individual’s savings or to force government to pay for someone who has those savings? The issues also affects the children and grandchildren of the individual consumers of long-term care. If asset transference is not allowed, they may not receive the inheritance that they, and their parents, had anticipated. On the other hand, if today’s elderly are allowed to collect Medicaid while transferring their assets to their children and grandchildren, these later generations may not have a public system on which to fall back.
According to public pinion surveys, 82% of the general public recognize that they cannot afford to pay the cost of long-term care either at home or in a nursing home. They also know that they cannot rely on the family alone; 86% want the government to help pay for long-term care instead of leaving it entirely up to the family. But despite such clear public sentiment, a universal public insurance program for long-term care is still not available in the US. On the contrary, Medicaid has become the public program of last resort to pay nursing home costs. In fact, it is the fastest-growing component of state budgets, and it is increasingly becoming an old-age program. Nearly 40% of all Medicaid benefits go to the elderly, chiefly for nursing home care.
The U.S. Department of Health and Human Services estimates that 70 percent of persons aged 65 and older will need some sort of institutional or community long-term care services before they die. Forty percent will require care in a nursing home. An estimated 9 million people over the age of 65 require ongoing help with health and personal care.
The longer people live, the more likely the need for long-term care services. Older adults aged 75 to 84 make up 60 percent of the long-term care population. And, one in five seniors aged 85 and above is institutionalized in a nursing home - quite a shocking statistic. With an average stay of 19 months and an average cost of $70,000 per year, the high cost of a nursing home stay is a serious threat to the economic well-being and assets of most middle-income older Americans. Even though it could take years if not decades for the need for long-term care services to materialize, everyone should have a fiscal plan in place for this contingency.
One practical consideration is long-term care (LTC) insurance, which is a type of insurance coverage that is available for people who need long-term care services. Once certain criteria are met, LTC insurance generally covers services needed for an extended period of time in settings outside of the acute-care hospital. Services include custodial care, medical care, diagnostic testing, rehabilitation, hospice, respite care, help with household chores, and/or caregiver training. The settings include the personal residence of the policyholder, assisted living facilities, nursing homes, and adult day care.
Most long-term care is not medical care, but rather assistance with personal tasks of everyday life (activities of daily living) or tasks required to live independently in a community setting (instrumental activities of daily living), which is known as custodial care. Traditional health insurance or Medicare covers part of the cost for hospital stays, prescription drugs, and provider visits, but usually does not help with the cost of custodial long-term care services. Some older people mistakenly believe that Medicare will cover such expenses. In fact, Medicare covers very little of the actual cost for long-term care; coverage is under restricted circumstances for short periods of time.
Long-term care insurance is bought mainly by people over age 55. The average age for new applicants is 57, and half the current policyholders are in their 60s. Once a person purchases a LTC policy, the policy cannot be changed and is usually guaranteed renewable for life. The insurance company cannot cancel the policy for any reason other than non-payment or depletion of benefits. This type of insurance can be purchased at any time. The age when a policy is first purchased is important because premiums are based on the age and health status at purchase and afterwards remain stable for the life of the policy. The best time to purchase LTC insurance is between the ages of 45 and 55, because it is reasonably affordable. After the age of 55, premium costs start to accelerate rapidly. The annual premium for LTC insurance more than doubles from age 50 to age 60 and more than triples from age 55 to age 65. The same policy that goes for $400 a year at age 50 would cost up to $1100 a year at age 65. Regardless of age, people with certain chronic or disabling conditions may not qualify for LTC insurance at all.
Long-term care insurance is vastly underutilized and therefore plays a relatively minor role in financing long-term care. Even though more than 100 insurance companies now offer these policies, and more than 2.5 million policies are now in force, LTC insurance provides only 7 percent of total funding for long-term care in the United States, while out-of-pocket expenditures cover nearly 25%. Currently, about 4 to10% of noninstitutionalized Americans over the age of 55 have private insurance protection for LTC expenses. One barrier to LTC insurance is the cost. For the elderly, premiums are high when compared to income. Ideally, healthy middle-age adults should buy LTC insurance while the rates are still relatively low, as a hedge against future needs, but this is not happening to a large degree. Many people are in a state of denial about their possible future LTC care needs.
In considering a LTC policy, it is important to understand what services the policy covers and how it covers these services. Before signing on the dotted line, read the policy carefully to scrutinize restrictions, exclusions, and limitations. Make sure that you, as the future beneficiary, understand every part of the policy. Investigate the policy coverage in terms of deductible, coverage, dependency requirements, preadmission hospitalization requirements, benefit periods, and lifetime benefit ceilings.
Policies vary greatly according to policy restrictions. Some policies require a deductible, which is stated in terms of nursing home days. Also, most LTC policies provide a fixed daily fee, or specific dollar amount for each day you spend in a nursing home or for each home-care visit, rather than the actual cost. Because of deductibles and fixed daily fees, out-of-pocket expenses could be considerable, despite having LTC insurance. Additionally, some policies require a certain amount of disability before benefits will be paid (such as functional dependency in three activities of daily living). A comprehensive policy is probably the best option if you anticipate eventually needing several layers of long-term care services. In the home setting, comprehensive polices generally cover these services: skilled nursing care; occupational, speech, physical, and rehabilitation therapy; and, help with personal care. Many comprehensive policies also offer homemaker services, such as light housekeeping, laundry, and meal preparation.
Another alarming fact is North Carolina's low savings rate of about 4%. Currently, many residents rely on publicly-funded LTC programs. Medicaid is the primary public medical assistance provider in the state of North Carolina.