Health Delivery and Organization in United States
Government Regulation
The primary federal government agency that participates in the regulation of healthcare is the United States Department of Health and Human Services (HHS). There are numerous agencies that are regulated by the HHS. The Centers for Medicare and Medicaid (CMS) regulate subsidized healthcare. Research and matters involving public well-being is controlled by the Centers for Disease Control and Prevention. Research for health and biomedical topics is carried out by the National Institutes of Health. The Health Resources and Services Administration promotes access of health care for populations who are uninsured, isolated, or medically vulnerable. Guidelines for clinical practice in reference to technology, outcomes, disparities, and safety is over seen by the Agency for Healthcare Research and Quality. Health of citizens is ensured by the Food and Drug Administration by governing food, tobacco, drugs, medical devices, and vaccines. The Affordable Care Act of 2010 created a branch of the CMS called the Center for Medicare and Medicaid Innovation to decrease spending and increase quality of healthcare and Patient-Centered Outcomes Research Institute to compare outcomes and conduct research on illness and injury (The Commonwealth Fund, 2016).
A counselor for policymakers and private entities is The National Academy of Medicine (formerly the Institute of Medicine). The National Academy of Medicine is an independent nonprofit organization that works outside of government. Stakeholders such as the American Medical Association comment on and lobby for policies affecting the health system. The Joint Commission is an independent, nonprofit accrediting association of healthcare facilities. The prime authorizer of private health insurance and the health insurance marketplace is The National Committee for Quality Assurance. Certifications for medical doctors in given by The American Board of Medical Specialties and the American Board of Internal Medicine provide certification to physicians who meet specified standards of quality (The Commonwealth Fund, 2016).
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| (The Commonwealth Fund, 2016) |
Role of Advanced Nursing Roles in Delivering Healthcare
Advanced practice registered nurses (APRN) are registered nurses who are educationally prepare with a Masters or Doctorates degree in nursing. They have become a major role in providing health care across outpatient, inpatient, and specialty health services across the United Stated. Their scope includes more responsibilities that a registered nurse. Activities they are certified to do include assessment of patient, diagnosing patients, patient management, ordering of tests, preforming invasive procedures, and prescribing medications. There are many specialties of the APRN role such as Family Nurse Practitioner, Pediatric Nurse Practitioner, Nurse Midwife, Adult Gerontology Nurse Practitioner, Acute Care Nurse Practitioner, Nurse Anesthetist, and Clinical Nurse Specialist. APNs usually work with a group that includes physicians but they may practice independently with a physician over seeing their practice depending on which state the are licensed to work in. Prior to being licensed for practice each APN much take a certification exam that is specific to their specialty (National Council of State Boards of Nursing [NCSBN], 2018).
Role of Healthcare Professional in Delivering Healthcare and Funding
Medicare and Medicaid make up public healthcare. Forty nine percent of total funds for healthcare in 2014 was spent on public healthcare. Medicare is paid for by payroll taxes, premiums, and federal general revenues. Medicaid is paid for with taxes and executed within each states. Medicaid functions un federal guidance. The federal government doubles state funds for Medicaid. The rates for reimbursement is established by each state’s per-capita income. The growth of Medicaid from regulations that were implemented with the Affordable Health Care Act made Medicaid completely funded by the government through 2017. If you have insurance, tax credits are given annually (The Commonwealth Fund, 2016).
Private insurance is paid for by employers and consumers. Taxes are not required to be paid on private insurance policies and has decreased the governments taxable income by two hundred and sixty billion dollars annually. The companies of private insurance may be for profit or non for profit. Regulations are upheld at state and federal levels. Thirty nine percent of the net healthcare costs in 2014 were spent of private health insurance. It is common for consumers to obtain public and private insurance such as those with Medicare benefits. When a Medicare recipient elects to purchase additional private insurance it is Medigap which extends the covered services and decreases the out of pocket costs for medical services. Higher rates are paid to providers from private insurance companies when compared to public policies (The Commonwealth Fund, 2016).
A third of all physicians are primary care physicians and work in group or individual practices. Large practices employee other staff such as nurses and assistants who are paid salary. The choice of which physician is up to the consumer as long as the provider accepts their type of insurance. Some policies require a referral for specialists from their primary care physicians. Physicians are paid by private insurances through an agreed upon cost, set fees by public insurance, and receive bonuses from both types of insurance depending on their quality and performances. A copayment is usually due to the physician from the patient in addition to the amount paid by the insurance and may be due at the time of service or the patient will receive a bill (The Commonwealth Fund, 2016).
Private and public hospitals have specialists working there. When the consumer has a health maintenance organization policy they must obtain a referral from their primary care provider to see a specialists from a predetermined list. Due to Medicaid having paying low rates to specialists, many refuse to see these patients resulting in difficulty for them to obtain an appointment. Payment to specialists is the same as with primary care providers. There is decreased after hour care availability except for in emergency departments of hospitals. Forty percent of primary care physicians have contracts for after hour employment at facilities such as urgent care centers. Urgent care centers may be owned by hospitals or physicians. Insurance companies also have support for after-hours issues via a physician telephone service (The Commonwealth Fund, 2016).
Seventy percent of hospitals are nonprofit. For profit and public hospitals each make up fifteen percent of hospital types. All are paid in different methods. They can be paid by each service or case or bundled payments. In bundled payments, if the patient is readmitted then the hospitals can be responsible for the cost of caring for the patient and will not get reimbursed by the insurance. Medicare makes payments to hospital based on diagnosis related groups. Hospital physicians are usually paid via a salary or per service provided (The Commonwealth Fund, 2016).
Trends
During 2015, private voluntary health insurance was held by sixty seven percent of U.S. citizens, fifty five percent had insurance through their employer, fifteen percent had direct coverage, sixteen percent had Medicare coverage, twenty percent had Medicaid, and five percent had coverage through the military. Twenty seven million U.S citizens were uninsured as of 2016. The trend of being uninsured decreased by half a percent since the previous year. The decrease is attributed to the Affordable Healthcare Act of 2010 and the opening of the market place in 2014. The cumulative insurance coverage among all ethnicities increased from 2014 to 2015. By 2018, the number of uninsured residents is predicted to decrease by twenty four million. New government administration is currently working on repealing the Affordable Healthcare act so the future of insurance coverage is unknown. Ten million citizens qualified for insurance coverage through public programs of Medicare and Medicaid during 2015. During the same year eight million children of low income families obtained insurance coverage through Children’s Health Insurance Program (CHIP) (The Commonwealth Fund, 2016). Migrants who are not legally registered in the United Stated are ineligible for public insurance resulting in approximately two thirds of this population being without insurance. Hospitals are required to stabilize all patients who present with an emergency. Depending upon the state that the illegal migrant is in, they may be eligible for emergency public insurance through Medicaid (The Commonwealth Fund, 2016).
Health Policy
To ensure that all United States citizens are able to have cost effective and exceptional health insurance, The Affordable Care Act (ACA) was established in 2010. The act implemented “shared responsibility” for insurance costs between the government, employers, and citizens. There is a federal insurance program for citizen who are sixty five years of age or older as well as qualifying citizens with disabilities. The program is Medicare and is controlled by The Centers for Medicare and Medicaid Services (CMS). The Centers for Medicare and Medicaid Services (CMS) also controls the Medicaid and the Children’s Health Insurance Program (CHIP). These programs are a combination of federal and state subsidies for qualifying low income citizens (The Commonwealth Fund, 2016).
State government associations control private insurance entities. State and federal marketplaces for health insurance were incorporated into the Affordable Care Act in 2014. The marketplace allowed for citizens to have access to insurance coverage through private companies along with financial assistance for qualifying citizens based on their income. During the development of the marketplace, state administrators were able to choose if they would like to be included in a federal subsidized expansion of Medicaid eligibility (The Commonwealth Fund, 2016).
Access and Current Issues
Insurance coverage is legally required to be provided coverage if their company has fifty or more employees. The marketplace associated with the Affordable Care Act makes services available for ambulatory patients, emergencies, hospital, maternity, new born, mental health, substance use disorders, prescription medications, rehab services after illness, lab testing, disease prevention, wellness appointments, and management of chronic disease. Pediatric services are included as well. Public health coverage for pediatrics generally include vision and dental services opposed to public plans for adults which do not. Vision and dental plans are listed on the marketplace and are separate policies than health policies. The state chooses which plans are right for the population and specific services that are covered may vary (The Commonwealth Fund, 2016).
The in network providers of private insurers is often small and payment is not provided to providers who are not within the network. Separate policies for dental, vision, and long term care are available at an additional premium fee. Preventative care is included with private insurance and does not require a copayment if the provider is in network. Hospitalization, provider costs, and preventative care are paid for through Medicare with small copayments required. An additional plan covers prescription drug costs with Medicare. Medicare consumers may choose which ever provider they like because they reimburse with a fee for service payment plan. The government pay a private insurance company for coverage if the consumer chooses to hold a Medicare Advantage plan (The Commonwealth Fund, 2016).
Copayments are usually required for physician visits, hospital services, and prescription drugs. The copayment amount is different with every private insurance policy. If a plan has a deductible of $1,250 for individuals or $2,500 for a family, a health savings account which is tax free can be used to pay for services. An annual amount is predetermined for the individual to be put into their health savings account that may be used to pay for healthcare services throughout that calendar year. The Affordable Care Act shares the cost of insurance when enrolled through the marketplace based upon the citizens income. Incomes between one hundred to two hundred fifty percent of federal poverty level or an annual income of $20,090 for a family of five qualify for the cost of insurance to be shared. Fifty seven percent of citizen who enrolled in the marketplace received assistance to pay for their insurance premiums. Citizens with up to one hundred thirty eight percent of poverty level are likely to qualify for Medicaid. There are programs for uninsured and low income citizens to receive care at public hospitals, health departments, and free clinics. Private providers are also required to give a percentage of charity or free of charge care to citizens who cannot afford it. Coverage with health insurance is variable with a wide range of public and private services but large amounts of the population remain uninsured (The Commonwealth Fund, 2016).
References
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