Medicare: The Federal Health Insurance Program

Medicare is a federal health insurance program mostly focused on adult patients over the age of 65, patients with kidney failure, and certain groups of disabled patients of no specific age. From the early stages of its work, Medicare has set the standards that allow healthcare facilities to participate in the program. This fact, as well as the fact that Medicare has increased the use of health information technology and clinical quality measures (CQMs), makes it a major influencer in shaping the U.S. healthcare system.

Medicare has a significant impact on licensure, certification, and accreditation standards nowadays. With more than 60 million beneficiaries, it is administered by the Centers of Medicare and Medicaid Services (CMS). CMS sets specific guidelines for health agencies and providers, facilitating the process of them becoming licensed, certified, or accredited. It requires hospitals and physicians alike to have state licensure and an NPI-number to be able to work in their states. Accreditation standards are significantly influenced by the program as well. To assess if a healthcare organization is able to provide beneficiaries with high-quality services, it should undergo an accreditation process. This survey is called “deeming” and can be conducted by a state agency, such as CMS or a national accrediting organization (AO), such as the Joint Commission (Lam et al., 2018). However, before giving a deemed status, the AO has to apply for CMS approval. This shows a significant role that Medicare plays in setting standards for these types of recognitions.

Another factor influenced by the Medicare program is quality reporting systems. To provide patients with the most qualified help, the program applies clinical quality measures (CQMs) – tools that facilitate tracking the quality of care. These measures assess health outcomes, patient safety, clinical processes, efficient use of medical resources, and other factors (“Electronic clinical quality measures basics,” 2020). The results then allow CMS to ensure that all individuals get first-rate treatment from eligible professionals and hospitals.

From the standpoint of reimbursement for healthcare services, Medicare guarantees financial support based on two critical factors – the type of program (Part A, B, or C) and the acceptance of an assignment by a provider. Payments from patients are needed if specific services are outside the Part A or Part B spectrum (Sherrell, 2020). Healthcare providers file reimbursement claims themselves, and in case of disagreement with a particular assignment, patients may be required to pay the full cost, which proves providers’ critical role (Sherrell, 2020). The application deadline is one year, and during this period, reimbursement is to be provided. Part C of the program also allows for financial assistance when a certain amount is paid monthly, but there is no requirement to file a claim. Overall, patient access to care has improved with Medicare, largely driven by the reimbursement regimen. According to Lam et al. (2018), in certain regions, for instance, in rural areas, providers often experience a burden caused by a large flow of patients who have received convenient insurance conditions. Reimbursement payments under the program help hospitals financially, thereby allowing more patients to rely on qualified care.

The use of health information technology within Medicare is a common practice. Orzol et al. (2018) consider the role of endocrinologists in healthcare and note that “population health management software can help providers identify patients with poorly controlled diabetes who would benefit from additional services” (p. 299). In this case, Medicare is a program that promotes the use of technological advancements as convenient tools that allow endocrinologists to perform comprehensive screening and diagnose correctly, thereby using program resources wisely. Therefore, innovation encourages following the goals of Medicare to uphold the quality of medical assistance and promote comprehensive care for the population.

In conclusion, one can state that Medicare has indeed proven to be a great achievement of the U.S. healthcare system. It has improved different health and medical care sectors tremendously and continues to aim for further advances in assistance to the population. Through the use of its standards, quality reporting systems, and health information technology, Medicare succeeds in making healthcare services available to every citizen.

References

Electronic clinical quality measures basics. (2020). CMS.

Lam, M. B., Figueroa, J. F., Feyman, Y., Reimold, K. E., Orav, E. J., & Jha, A. K. (2018). Association between patient outcomes and accreditation in US hospitals: Observational study. BMJ, 363, 1-10.

Orzol, S., Keith, R., Hossain, M., Barna, M., Peterson, G. G., Day, T., Gilman, B., Blue, L., Kranker, K., Stewart, K. A., Hoag, S., & Moreno, L. (2018). The impact of a health information technology – Focused patient-centered medical neighbourhood program among Medicare beneficiaries in primary care practices. Medical Care, 56(4), 299-307.

Sherrell, Z. (2020). How do Medicare reimbursements work? Medical News Today.

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