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KOT Task #2: Medicare Essay

Though Medicare plans are typically for persons over the age of 65 years old, they do not come without costs to the patient. If the patient has enough work credits, Medicare Part A is automatically available to the patient once he or she reaches age 65. Medicare Parts B and D, however, require the patient to navigate through an application process and the patient may incur penalty fees if he or she does not sign up for the plans during the allotted time frame once they have reached the age of 65. For Medicare parts B and D, the patient is responsible for paying the designated premiums. The Medicare Part B premium ranges from $96.40-110.50 monthly and the Part D plan ranges from $28.60-$38 monthly. There is also additional Medicare plans available for the patient to purchase through insurers such as Blue Cross and Blue Shield or Etna, however there are additional premiums in varying amounts (Medicare.gov, 2012).

In most cases, Medicare Part A will cover inpatient hospital stays, rehabilitation centers, and long-term care facility stays. For Mrs. Zwick, Medicare Part A would apply to the rehab and inpatient hospitalizations. Medicare Part A will cover Mrs. Zwick’s five day hospital stay and the first 20 days of her stay at the rehabilitation facility. Each day following the first 20 days of rehab, a fee of $144.50 per day will accumulate at the rehabilitation facility for a total of $2890.00 which the facilities will be responsible for due to the patient acquiring a preventable infection during her stay (Medicare.gov, 2012). Medicare Part B is similar to medical insurance; covering medically necessary services such as MD visits and services, outpatient care, durable medical equipment, home health services, and sometimes preventative care services.

In Mrs. Zwick’s case, Medicare Part B would cover the prescribed walker or other assistive devices if needed. However, based on Medicare Part B plan coverage, Mrs. Zwick will be responsible for a deductible of 20% of the cost of the walker (Medicare.gov, 2012). Medicare Part D is an elective prescription drug coverage plan available to Medicare recipients.

There are various prescription drug plans offering medication coverage based on the plan’s preferred drug list. Though Mrs. Zwick’s plan coverage was not specified in the case study, she may be responsible for a co-payment for prescription drugs. If Mrs. Zwick does in fact have a co-payment, it would be a set amount; for example $10 per prescription or less if she receives generic drugs. Or, depending on if Mrs. Zwick has entered a coverage gap or “donut hole”, she will then be responsible for 50% of the costs of her prescription medications (Medicare.gov, 2012).

Though Mrs. Zwick does have Medicare coverage, the plan may not pay for Mrs. Zwick’s extended stay or additional care required related to a hospital-acquired condition. In recent years, Medicare began refusing to pay for preventable, hospital acquired infections; making hospitals and other facilities accept responsibility for preventable infections acquired during the patient’s stay. However, in Mrs. Zwick’s instance, there may be some debate as to which facility will be held accountable for the preventable urinary tract infection (UTI).

Though the case study reads that Mrs. Zwick was diagnosed with a hospital-acquired UTI, it also states that she was diagnosed 10 days into her stay at the rehabilitation facility and that there were complaints that Mrs. Zwick was not receiving proper catheter care. If the rehab facility was not following the current evidence-based protocol related to the patient’s catheter care, there is a strong possibility Mrs.Zwick did not acquire the urinary tract infection until after she was transferred to the rehab facility. Therefore, the hospital would not be responsible for the costs of care related to the UTI. However, Medicare would still not cover the costs and the nursing facility would then be held accountable for the extra costs incurred during the patient’s extended stay.

Consolidated Omnibus Budget Reconciliation Act, also known as COBRA, is a plan available to persons who have a loss of employment and health coverage. The COBRA plan will allow Mr. Davis to continue his health coverage beginning the original date his coverage was ceased and is usually available for approximately 18 months. However, the Cobra plan is not free of charge to the unemployed patient. The plan typically offers identical plan coverage to the patient; however the plan is more costly than the original premium the patient was used to paying. The cost of the COBRA plan is usually the amount of the previous premium in addition to the amount the employer contributed plus a 2% administration fee. The premium amount the patient would be responsible for would be quite a bit more costly, yet still less expensive than an individual rate. In order to for the patient to be covered by the COBRA plan, he would have to submit all the proper paperwork within the allotted time frame and pay the monthly premiums without monthly payment reminders (FAQs for Employees About COBRA Continuation Health Coverage).

Though COBRA is a way for Mr. Davis to continue his health insurance coverage once he became unemployed, it is not likely to be affordable. This then becomes a challenge that state or local governments are faced with. Two challenges state or local government may be faced with in providing care for patients like Mr. Davis with pre-existing conditions and lack of insurance coverage are increased costs and decreased health maintenance of the patients. Patients with long-term, chronic illnesses like Mr. Davis’s, care can be very costly, especially when the patient is unable to maintain routine medical care or visits and medications. Without routine medical care and maintenance medications, patients like Mr. Davis tend to have more frequent emergency room visits and hospitalizations; increasing costs for state and local government as well as tax payers.

Though Mr. Davis is able to receive care during an emergency room visit, the providers are not fully aware of his health history and are only able to provide a temporary fix of his symptoms and not address his health care needs. One possible solution for the state and/or local government to consider would be to offer state funding for patients with chronic illnesses to be covered by a state funded insurance plan based on the patient’s income. This would allow for Mr. Davis to be seen for routine care, in an attempt to keep him healthy and reduce emergency room visits and hospitalizations. Another possible solution would be for local and state governments to fund healthcare facilities and/or clinics designated to care for patients with chronic health conditions; providing public health nurses who are available to visit the patients in the home in order to educate him or her on disease and disease processes.

Though Mr. Davis is frustrated with the healthcare delivery in the United States and may think he would be better served in another country, he may be gravely disappointed by in their healthcare delivery systems even more. Countries such as Great Britain, Japan, Germany, and Switzerland offer public health insurance, however coverage does not come without strain. The universal health care coverage plans not only causes great deficit to the economy, but they also come with premiums, delays in care, and often times no choice of providers. Specialty appointments are nearly impossible to obtain, and in many cases terminally ill patients die prior to receiving the needed care. The plans cover the person and his or her dependents (plans including dependents have higher premiums), but the insured is still responsible for a portion of the services or bill; this applies to the elderly as well. The universal health care plans not only affect the insured, but the healthcare providers as well.

In many cases, the healthcare workers are paid lower wages and work less hours in order to help offset some of the costs. The universal health plan in Great Britain offers residents no choices in regards to providers or facilities in which care is received and it is required for the patient to wait 122 days just to receive a routine appointment regardless of their condition (Healthcare Economist, 2008). Japan’s National Health Insurance covers those individuals and their dependents that are not eligible for employer-based insurance. However, the focus of coverage is on the older population; benefiting the retired community. If the insured is not of retirement age, the costs of premiums are higher (Fukawa).

In Germany, less than 1% of the population is not covered by the Public Health Insurance. Germany’s healthcare plan offers the insured free choice of outpatient care physicians and hospitals if referred with the focus of care being on chronic care (Busse). Germany offers coverage for the following services: preventative care, inpatient and outpatient care, physician services, mental health care, dental care, prescription drug coverage, medical aids, rehabilitation services, and sick leave compensation (Busse).

In Switzerland, there is no choice of providers or facilities in which the patient receives care due to private sector. This means patients like Mr. Davis would incur increased premiums and resulting in limited access to routine care and extended services (Clarke, 2011). Based on the different types of coverage available to patients offered under universal healthcare plans, Mr. Davis would be better served and cared for with the German Healthcare System due to the type of disease he has and his particular health care needs.

References
Busse, R., MD, MPH. The German Health Care System. Berlin University of Technology & Charite’. Clarke, E. 2011. “Healthcare Systems: Switzerland”. CIVITAS Institute for the Study of Civil Society. Retrieved May 5, 2012 from www.civitas.org.uk/nhs/switzerland.pdf[->0] FAQs for Employees About COBRA Continuation Health Coverage. Retrieved May 5, 2012 from http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html Fukawa, T. Public Health Insurance in Japan.

Healthcare Economist, 2008. Health Care Around the World: Great Britain. Retrieved fromhttp://healthcare-economist.com/2008/04/23/health-care-around-the-world-great-britain/ Medicare.gov, 2011. Retrieved May 5, 2012 from http://www.medicare.gov/navigation/medicare-basics/medicare-benefits

[->0] – http://www.civitas.org.uk/nhs/switzerland.pdf


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