SAT Task#3: Healthcare Financing Essay

SAT Task#3: Healthcare Financing Essay

SAT Task#3: Healthcare Financing Essay

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Healthcare Financing SAT Task 3
Organizational Systems and Quality Leadership SAT Task3 Performance Assessment covering he…View more

University
Western Governors University
Course
Organizational Systems and Quality Leadership (NURS 4210)
Academic year
2021/2022

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1 Running Head: HEALTHCARE FINANCING

Healthcare Financing College of Health Professions, Western Governors University August 1, 2021

Health Insurance

The United States has a diverse array of health insurance coverage options. Most Americans receive health care coverage through private insurance companies through employer sponsored plans. There are also several different federal and state funded programs available to specific populations. Health care coverage in the United States can be either for-profit or not- for-profit. Two thirds of Americans receive health care coverage through private insurance group plans offered as an employment benefit (Tikkanen et. al., 2020). Businesses with more than employees are required to provide employer sponsored health insurance to staff. Payments to these group insurance policies are from both the employer and the employee. Services covered by employer sponsored private insurance plans are different for each organization. All Japanese citizens and resident non-citizens living in the country for greater than 3 months are required by law to enroll in a health insurance plan. Most Japanese individuals are enrolled in the statutory health insurance system (SHIS) while a small portion are enrolled in the Public Social Assistance Program which is for low-income individuals. The SHIS is further broken down into two types of insurance plans which are employment based and resident-based plans. The government regulates all aspects of the SHIS by setting and enforcing regulations, standards and costs therefore coverage is equal with each plan. Care, coverage, and costs are the same regardless of which insurance plan the insured carries. Individuals do not have the ability to choose which plan they carry, rather coverage is determined by factors such as age, employment status and income. Health Care for Seniors

Medicare is a federally funded program that provides health care coverage for adults at age 65 and older as well as people of all ages with certain disabilities or end stage renal disease. Most inpatient care services in the United States are paid for by Medicare. Medicare is divided into four parts offering different types of coverage. Medicare Part A is hospital insurance that covers for inpatient stays in acute and subacute settings. Medicare Part A also offers limited coverage of hospice and home health care. Medicare Part B is medical insurance that pays for outpatient services, home health care, physician visits, preventative care and durable medical equipment. Medicare Part C is also known as Medicare Advantage. This program is private insurance coverage that is approved by Medicare to provide coverage for Part A and B services as well as some prescription drugs. Medicare Part D is private insurance approved by Medicare to provide outpatient prescription drugs (The Medicare Learning Network, 2018). Japanese seniors must enroll in a residence-based health care plan known as the Health Insurance for the Elderly. This is funded through subsidies within SHIS. In 2000 Japan implemented universal health coverage for long term care as a method to combat the costs of the growing elderly population. Long term care insurance coverage is available for all citizens aged 65 and older as well as those over the age of 40 with certain health conditions. The long- term care insurance provides care to elderly regardless of ability of pay or availability of family to provide care in the home. Services covered include home health, nursing home care, respite care, home modifications, medical equipment and assistive devices (Iwaguami et al., 2019). Japanese long term care coverage is funded by taxes and individual mandatory contributions. Co-insurance payments are range from 10-20% of care costs based on income. For low-income

individuals the fee for room and board and other services are waived (The Commonwealth Fund, 2020). Health Care for Low Income and Unemployed Health care options are available to those who are unemployed through government funded programs. Coverage options are based upon household income. Options available include Medicaid, CHIP and Marketplace insurance plans (Department of Health and Human Services, n.). The Affordable Care Act made funding available to federally approved health care facilities that provide care to individuals regardless of their ability to pay. Additionally, there are laws that require emergency services to be provided to individuals despite inability to pay for services, national origin, race or insurance status (Tikkanen et., 2020). Medicaid is a federal and state funded program that offers health care coverage for people with low-income, pregnant women and children. Medicaid is the nation’s primary payor for mental health care, childbirth and long-term care. Eligibility and coverage vary from state to state however all programs must met certain federal guidelines. Medicaid programs are required to provide coverage for physician visits, inpatient and outpatient care services, psychiatric services, medications, prenatal care and childbirth and preventative care and screenings (The Medicare Learning Network 2018). Individuals that do are not offered health insurance through their employer and do not meet criteria for receiving Medicaid may purchase health insurance through the Marketplace. The Health Insurance Marketplace is a state or federal service that helps individuals, families and small businesses find affordable health insurance plans. Some individuals may qualify for

tax credits to assist with the cost of health insurance plans (Department of Health and Human Services, n.). In Japan people with low income enroll in SHIS and receive benefits such as reduced coinsurance and reduced mandatory contributions. Some health care providers are approved to provide care to low-income individuals at a reduced rate. For individuals with no income the Public Social Assistance Program is available for health care coverage. Individuals that are enrolled in the Public Social Assistance Program are not required to pay for services. Health Care for Children The Children’s Health Insurance Program (CHIP) is funded by state and federal governments and provides health care coverage for children whose families are low-income but do not meet criteria for Medicaid coverage. CHIP programs must cover physician visits, emergency care, dental and vision services, immunizations, medications, acute care and medications (Department of Health and Human Services, n.). Japanese children are covered as dependents under the health care plan of their parents. Typical co-insurance for Japanese citizens under SHIS plans is 30% of the cost of care. There are no co-insurance costs for children ages 6 and younger. Families that are covered under SHIS do not need to make mandatory contributions when taking family medical leave after the birth of a child (The Commonwealth Fund, 2020). Prescription Drug Coverage Per capita spending on prescription drugs is significantly higher in the United States than in any other country. The Commonwealth Fund (2017) indicates that the main factors impacting the prescription drug spending in each country population, number of drugs used, drug use per

person, types of drugs used and drug price. Insurance providers help pay for the cost of prescription medications. Private and government funded insurance plans use Pharmacy Benefit Managers (PBMs) to help reduce the cost of medications. The PBM’s encourage the use of generic medications and negotiate the cost of medications with drug companies. Insurance plans and PBM’s work with expert panels of health care providers called Pharmacy and Therapeutics Committees (P&T) to develop formularies (Pharmaceutical Care Management Association, 2021). The cost of formulary medications are significantly less expensive to consumers. Consumers are often able to access non-formulary medications through a prior authorization process. With a prior authorization a physician outlines the need for non-formulary medication in writing or verbally. These are subject to approval by the insurance provider. Japanese drug prices are determined and routinely reviewed by the national government. A systematic approach is used to calculate the cost of new medications based on factors such as cost of production and availability of similar medications on the market. Medications are covered by insurance plans with co-insurance of 30%. Children, the elderly and those with no income pay lower coinsurance rates (Yamate, n.). Specialty Care The ability of an individual in the United States to see a specialist is dependent on the type of insurance they carry. There are several different options to choose from when purchasing insurance coverage. A Health Maintenance Organization (HMO) is an insurance plan that offers a selected network of providers that insured can choose from. Care from providers outside of the offered network will not be covered by insurance. To see a specialist the insured

individual’s primary care provider must complete a referral prior to the visit. Preferred Provider Organizations (PPO) have selected in-network providers however individuals are able to use providers out-of-network at a higher cost. A claims process must be completed in order to receive assistance with paying for out-of-network care. A referral is not required to see a specialist with a PPO. With an Exclusive Provider Organization (EPO) there is more freedom to choose providers however insurance will not pay for any out of network providers. A referral is not required to see a specialist. A Point of Service (POS) is a combination of benefits from a HMO and PPO. With a POS plan a referral is necessary to see a specialist. The insured individual may see in-network or out-of-network providers (Goodell, 2020). In Japan care from a specialist is available at the same cost as a primary care physician. There is no referral process required to see a specialist. There are no restrictions to care, or specialty services based on type of insurance since coverage is universal across all different plans. Co-insurance is 30% of the cost of service as with all other services in the Japanese healthcare system. Preexisting Conditions The Patient Protections and Affordable Care Act (PPACA) allows Americans with preexisting health conditions access to care. Under the PPACA, insurance providers are not allowed to deny coverage or charge individuals higher rates based on their health status prior to enrollment. There are, however, a select few private plans that have been grandfathered to allow exclusions to preexisting conditions (Department of Health and Human Services, 2017). There are no exclusions for care of preexisting conditions in Japanese healthcare. The healthcare system places a large focus on preventative health care which helps reduce the

amount of money spent managing chronic conditions. The Japanese national health insurance is required to pay for the care of all conditions and illnesses. Financial Implications The United States has a very large and growing population that uninsured. The cost of healthcare in America is so high that even many individuals that have health insurance are unable to afford the cost of care. Access to quality care is out of reach to many with lower income, particularly those of color. There is no regulation to the cost of care and prices of services and medications are determined by private for-profit companies. Preventative health care is not readily available to a large population of individuals and therefore preventable and chronic conditions can be very expensive to manage. Many individuals go without needed care because they are unable to afford the cost. The Japanese healthcare system is one of the best in the world. All Japanese people are required to have the same level of healthcare coverage regardless of ability to pay. The focus on preventative health services as well as the wide accessibility of care helps reduce preventable disease and manage chronic health conditions in a more affordable manor. Cost of care is regulated by the government and kept at a reasonable price that is attainable to all citizens.

References

Department for Health and Human Services. (n.). unemployed. HealthCare. healthcare/unemployed/coverage/. Health care coverage options for

Department of Health and Human Services. (2017, August 4). existing condition? HHS. hhs/answers/affordable-care-act/can-I-get- Can i get coverage if i have a pre- coverage-if-I-have-a-pre-existing-condition/index. Department of Health and Human Services. (n.). HEALTHCARE GLOSSARY. HealthCare. Health insurance marketplace® – healthcare/glossary/health-insurance-marketplace-glossary/. Department for Health and Human Services. (n.). eligibility requirements. HealthCare. healthcare/medicaid- Children’s health insurance Program (chip) chip/childrens-health-insurance-program/. Goddell, S. (Ed.). (2020, June 15). SERVICE, POS. WebMD. webmd/health-insurance/types-of-health- Types of health insurance PLANS: HMO, PPO, HSA, fee for insurance-plans. Iwagami M, Tamiya N. Future. JMA J. 2019;2(1):67-69 The Long-Term Care Insurance System in Japan: Past, Present, and

Pharmaceutical Care Management Association. (2021, July 16). pcmanet/policy-issues/formulary-design/. Formulary design. PCMA.

Sarnak, D. O., Squires, D., & Bishop, S. (2017, October 5). the U. an outlier? Prescription Drug Spending: Why Is the U. an Outlier? Prescription drug Spending Why is commonwealthfund/publications/issue-briefs/2017/oct/paying-prescription-drugs-around-world-why-us-outlier.

The Medicare Learning Network. (2018, July). Medicare and Medicaid Basics. cms/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ProgramBasics. Tikkanen, R., Osborn, R., Mossialos, E., & Djordjevic, A., Wharton, G. A. (2020, June 5). International Healthcare Systems Profiles Japan. Home. commonwealthfund/international-health-policy-center/countries/japan#reducing-disparities.

Tikkanen, R., Osborn, R., Mossialos, E., Djordjevic, A., & Wharton, G. A. (2020, June 5). International Healthcare Systems Profiles United States. The Commonwealth Fund. commonwealthfund/international-health-policy-center/countries/unistates. ted-

Yamate, M. (n.). Update of Drug Pricing System in Japan pmda.go/files/000221888.pdf.
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4
HEALTHCARE FINANCING
individuals the fee for room and board and other services are waived (The Commonwealth
Fund, 2020).
Health Care for Low Income and Unemployed
Health care options are available to those who are unemployed through government funded programs. Coverage options are based upon household income. Options available include Medicaid, CHIP and Marketplace insurance plans (Department of Health and Human
Services, n.d.). The Affordable Care Act made funding available to federally approved health
care facilities that provide care to individuals regardless of their ability to pay. Additionally, there
are laws that require emergency services to be provided to individuals despite inability to pay
for services, national origin, race or insurance status (Tikkanen et.al., 2020).
Medicaid is a federal and state funded program that offers health care coverage for
people with low-income, pregnant women and children. Medicaid is the nation’s primary payor
for mental health care, childbirth and long-term care. Eligibility and coverage vary from state to
state however all programs must met certain federal guidelines. Medicaid programs are
required to provide coverage for physician visits, inpatient and outpatient care services,
psychiatric services, medications, prenatal care and childbirth and preventative care and
screenings (The Medicare Learning Network 2018).
Individuals that do are not offered health insurance through their employer and do not
meet criteria for receiving Medicaid may purchase health insurance through the Marketplace.
The Health Insurance Marketplace is a state or federal service that helps individuals, families
and small businesses find affordable health insurance plans. Some individuals may qualify for
5
HEALTHCARE FINANCING
tax credits to assist with the cost of health insurance plans (Department of Health and Human
Services, n.d.).
In Japan people with low income enroll in SHIS and receive benefits such as reduced
coinsurance and reduced mandatory contributions. Some health care providers are approved to
provide care to low-income individuals at a reduced rate. For individuals with no income the
Public Social Assistance Program is available for health care coverage. Individuals that are
enrolled in the Public Social Assistance Program are not required to pay for services.
Health Care for Children
The Children’s Health Insurance Program (CHIP) is funded by state and federal
governments and provides health care coverage for children whose families are low-income but
do not meet criteria for Medicaid coverage. CHIP programs must cover physician visits,
emergency care, dental and vision services, immunizations, medications, acute care and
medications (Department of Health and Human Services, n.d.).
Japanese children are covered as dependents under the health care plan of their
parents. Typical co-insurance for Japanese citizens under SHIS plans is 30% of the cost of care.
There are no co-insurance costs for children ages 6 and younger. Families that are covered
under SHIS do not need to make mandatory contributions when taking family medical leave
after the birth of a child (The Commonwealth Fund, 2020).
Prescription Drug Coverage
Per capita spending on prescription drugs is significantly higher in the United States than
in any other country. The Commonwealth Fund (2017) indicates that the main factors impacting
the prescription drug spending in each country population, number of drugs used, drug use per

SAT Task#3: Healthcare Financing Essay