The Role of Funding in Achieving Excellent Healthcare Services

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Creating a hospital system that can instill the best quality of care for the patients is dependent upon the type of funding that will be received. Funding comes from donors and other single parties but majority of the time it comes from the insurance companies. There are thousands of health insurance companies available. A state insurance, like Molina healthcare, allows the low-income families and people with disabilities to receive care at a lower cost. A federal insurance that people receive once they turn 65 years of age is Medicare.

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Medicare is made up of Part A for hospital coverage and Part B for medical coverage. Additional Medicare coverage that is optional includes Part C for Medicare Advantage and Part D for prescription drugs. Third party payors, which are mostly private insurances include United Health Care, Aetna, Blue Cross Blue Shield, and Humana. Each insurance company has its own coverage, costs, and benefits. Hence, financial problems are occurring among patients due to the increased cost of sharing in insurance plans like higher deductibles and copayments (Bain et al.

, 2016).

There are different types of Molina healthcare. There is Medicaid, Molina Medicare, Integrated Medicaid/Medicare, and the Molina Marketplace. Molina Medicaid provides healthcare to a wide variety of people who qualify for government funded insurance programs. Molina Medicare offers advantage plans to those who have Medicare and/or Medicaid coverage. These plans are comprehensive and have access to quality health care facilities and professionals at little to no cost. Integrated Medicaid/Medicare is a member-centered care plan for those who qualify.

It is aimed to meet the unique needs of the clients. Lastly, the Molina Marketplace offer plans that eliminate financial limitations for quality care and allow Medicaid members the freedom to stay with their providers until they are fully transitioned to the marketplace. This is known as exchange in other states.

Molina Healthcare offers several benefits for their clients. Some of these benefits include non-emergency medical transportation, non-medical transportation, preventive and comprehensive dental services, vision, women’s health care services, and over-the-counter (OTC) benefits (Molina Healthcare, 2018). These advantages of Molina help the underprivileged populations receive the care they need by aiding in transportation to their appointments and providing basic and preventative health services with no copay. Molina is an example of managed health care, which by nature, aims to lower healthcare costs (Nickitas, Middaugh, & Aries, 2016). Although they offer several benefits, managed care does not focus on ensuring quality care. The main goal is to lower costs for their clients which is demonstrated by little to no out-of-pocket copays.

The four parts to Medicare coverage include: Part A, B, C, and D. Part A covers inpatient care in a hospital, skilled nursing facility care, hospice care, and home health care (McNamara & Wright, 2018). There are two sections of Part A Medicare: premium-free Part A and Part A premiums. In the premium- free Part A, you do not pay a monthly premium if Medicare taxes were paid during the time you were working. In Part A premiums, it is possible to pay up to $422 monthly according to 2018 plans (The official U.S. government site for Medicare, n.d.). If Part A is chosen, one must also have Medicare Part B as well.

Part B covers medically necessary services and preventive services such as doctor’s office visit, physical therapy, and occupational therapy (McNamara & Wright, 2018). Similarly, there are two sections to Part B which include: Part B premiums and Part B deductible and coinsurance. The premium is a monthly payment that is automatically deducted from the benefit payment if benefits are also received from social security, railroad retirement board, or office of personnel management. If additional benefits are not received, there will be a bill. The amount paid each month depends on the yearly income. For instance, the monthly cost for 2018 is determined from 2016 income. The Part B deductible is $183 per year. Once the deductible is paid, a 20% copayment is charged for doctor services, outpatient therapy, and durable medical equipment (McNamara & Wright, 2018).

Part C is known as a Medicare advantage plan offered through private insurance companies. Advantage plans include HMO and PPO (What is Medicare Part C?, 2018). On the other hand, Part D, offers coverage for prescription drugs. In regard to long-term care services, Medicare does not cover the costs unless certain conditions are met. Help will be provided if the inpatient stay is at least three days in the hospital, admission to a nursing facility is within 30 days of discharge, and skilled care is needed (Medicare, 2018). If care is still needed after 100 days at a skilled nursing facility, Medicare will not pay for it. A benefit of Medicare is that it accepts a wide range of providers. However, a drawback is that there is no vision, dental or hearing benefits (The advantages and disadvantages of Medicare, 2017). Medicare Parts A and B are more prevalent whereas, C and D are optional.

Third party payers are private insurance companies that are not run by the government. Private insurance is comprised of various entities that include public and private health insurance alongside managed care preferred provider networks (Nickitas, Middaugh, & Aries, 2016). When filtering through private insurance companies our group chose to assess the following: Aetna, United Healthcare, Humana, and Blue Cross Blue Shield. The benefit of each private insurance party was that each has an affiliation with Medicare. Finally, private insurance companies allow for individuals to create a program that fits their personal needs whether it be cost or medical opportunities. Additionally, within certain programs individuals can choose to pay for a deductible which is a fixed rate in which the individual pays for health care coverage, once it is surpassed the insurance company then covers the remaining value (Healthcare.gov, 2018). The fixed rate is paid at the beginning of the new year and ranges depending on the what medical coverage the insurance companies offer.

The first two organizations that were eliminated were United Healthcare and Humana based on cost, coverage for the patient, and overall compensation of medical care. United Healthcare is a in-network insurance company that meets the criteria of the Affordable Care Act (United Healthcare, 2018). It functions under PPO, otherwise known as Preferred Provider Organization. A PPO allows individual parties to access various types of medical services such as choosing your own doctor, going to different hospitals, and opportunity for extensive medical coverage. Furthermore, United Healthcare has routes of plans such as short term, dental, and supplemental (United Healthcare, 2018). The second organization that was omitted was Humana. Humana functions on HMO, also known as Health Maintenance Organization. HMO’s are built upon specific referrals to health care providers, admission to certain hospitals, and limited medical coverage. The main benefit of HMO is that it is at a reasonable amount per month for an individual party. Additionally, Humana has a focus with integrating Medicare into their coverage by creating plans that are tailored to an individual’s needs (Humana, 2018).

The last two parties that were assessed included Aetna and Blue Cross Blue Shield (BCBS). Between both insurance companies, reasonable monthly rates are offered alongside coverage for single parties, families, small and large businesses. Aetna and BCBS offer HMO and PPO hybrids which allows for more diverse coverage for all. Alongside the hybrid coverage, both companies allow for nationwide coverage but with a catch (Health Research Funding, 2018). BCBS has coverage across the United States but is comprised of smaller entities that do not all mirror each other, meaning that an individual may have coverage under BCBS in Illinois, but their coverage will not be the same say if they traveled to another state (Blue Cross Blue Shield Association, 2018).

While on the other hand, Aetna has nationwide coverage that is constant and equal coverage throughout each state (Aetna, 2018). Constant and equal coverage will allow for the individual party payer to have more flexibility with making medical decisions. Overall though, Aetna when rated for health satisfaction ranked number one (Consumer Reports, 2013). The downside to Aetna is that it is not compatible with Medicare where BCBS offers plans that help to formulate Medicare into its coverage (Health Research Funding, 2018). Furthermore, for a corporate perspective, it allows us to accept more patients and receive a constant income.

We chose each plan on the primary basis of instilling good effective care while sustaining a valuable income for the hospital. Each insurance plan helps patients to receive the ultimate coverage for their condition whether it be in an inpatient or outpatient setting. Molina was chosen because it is the front runner for state insurance. It is a government funded insurance and offers comprehensive coverage and transition between states. In addition to choosing Molina, Medicare was also added to the list of insurances because it is a nationwide health insurance. There is one downfall to Medicare that we cannot control which is the lack of coverage for hearing, vision, and dental. On the other hand, Medicare is beneficial because there are numerous parts in which an individual party can choose from. Furthermore, Medicare can be added to a third-party insurance to create overall medical coverage.

When choosing from third party payers, it was between United Healthcare, Humana, Blue Cross Blue Shield, and Aetna. United Healthcare and Humana did offer either a PPO or HMO in conjecture with federal and state insurance. We did not feel that having to choose between a PPO or an HMO package showed enough coverage for the patient nor would it benefit the hospital. BCBS and Aetna were the only two out of the four third party payers that offered hybrid.While these insurance companies offer quality coverage, we chose Aetna because of its nationwide coverage alongside its combination of covering HMO and PPO. The nationwide coverage and hybrid package allows patients to have more flexibility with their care while also allowing medical professionals the ability to have privileges at various places that are supported by this type of insurance.

We were choosing on the basis of core values of nursing, beneficence, and utilitarianism, which are defined as doing the most good for the most amount of people. Clients do not necessarily have a preference whether their insurance is public or private as long as the costs are covered (Sommers, Gawande, & Baicker). The chosen insurances will allow our hospital to help diversify our patient population. The mix of patients will benefit the medical personal staff, especially the nurses who are on the floors and interacting with patients the most. Diverse patient population leads to exposure to varying types of disorders and illness because they do not present the same in every patient. Furthermore, with this level of exposure it will allow our nurses to be at the forefront of medicine and further understand how important insurance coverage is with treating patients which in turn will lead to a increase in quality care. Moving forward with healthcare, we think it would be beneficial to have the insurance policies developed by doctors, nurses, and other medical personnel to make sure that both sides of the policies are accounted for and mutually benefit. Nurses are in a unique position to provide insight and educate policymakers as well as their patients on the importance of knowledge when it comes to healthcare coverage (Gardner, 2013).