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History and Standards of Medicare and Medicaid

Introduction

Medicare is a publicly funded healthcare program that ensures special groups, including the elderly and the physically challenged members of society receive medication. Individuals aged above sixty-five years are entitled to free healthcare services while those with disabilities are also allowed to access free medical services. Other groups included in the program are people with end-stage renal diseases, as well as those living with Amyotrophic lateral sclerosis. Medicare insurance program is divided into several programs, with the first Part (Hospital Insurance), also referred to as Part A, being paid through the owner’s savings. This means that an individual would need to contribute his or her savings while still working for the government or any private organization for a specified period before being incorporated into the program. For individuals beyond the age of sixty-five years, they have an option of paying a lump sum in case they never contributed anything at their youthful age. Others might have worked for a period ranging from five to ten years implying that they will pay little in case they want to be involved in the program.

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Conversely, any individual who might have worked for over ten years in government will not have to pay the premiums on a monthly basis. If an individual develops any kind of mental complication, he or she will be offered specialized care under the program, even though such services would be on a short-term basis. These special cares include blood transfusion, ambulance rescue services, and home-based care services. Any legal citizen is entitled to the first plan without necessarily paying for the monthly premium. The second plan referred to as Part B Supplementary Medical Insurance, is optional and all individuals enrolled in the first plan have a choice of signing up for the second program at an additional cost. The second part offers mainly outpatient medical services, such as doctor services and surgical center procedures. On the other, Medicaid is paid to supplement government-funded health programs. Official governmental data shows that Medicare supports the health of over fifty million Americans.

Medicaid is specifically designed for poor families with low income and inadequate resources to afford private insurance programs. It differs from Medicare because it offers services to people of all ages. Any person qualifies to be enrolled in the program provided he or she has a low income that does not cater for healthcare. The state and federal governments jointly fund the program, but each state is given the mandate of identifying those in need and enrolling them in the program. All legal citizens and permanent residents can apply for the program, including poor adults, young children, and individuals living with disabilities. In fact, it is clear that an individual does not qualify to be enrolled in the program through poverty alone because other factors are also taken into consideration. A bill is underway to ensure that funding for Medicaid services is expanded to allow many people to enjoy free healthcare in the country. The law requires that any American citizen considered poor be funded. The Supreme Court ruled that funding for the Medicaid program would have to be increased, irrespective of whether states append their signatures.

History of the Two Programs

Medicare was established in 1965 under Johnson’s regime. Social Security Act was amended to include the insurance program that would cater for the health needs of individuals beyond the age of sixty-five, as well others with special needs. The program does not discriminate based on income and medical history because it offers specialized health to people from all regions of the country. Before the program, old people had to pay additional charges because they are always at risk. Several changes have been made to the program that has existed for over forty years. Recently, the program covers the needs of people with speech problems, physically challenged, and those in need of chiropractic therapy. In the early 1980s, the program made it mandatory for the government to increase funding for health maintenance organizations, irrespective of whether they are public or private. In the subsequent years, a bill was introduced in congress that consequently gave young people with disabilities an opportunity to receive funding through the program. Under the leadership of Bush in 2003, a bill was introduced that demanded the supply of drugs under the program. Medicare insurance program has facilitated the development of science and medical research since it allows funding to institutions specializing in medical studies (Hogan, Lunney, Gabel, & Lynn, 2001). In 1982, a new program titled hospice benefits was introduced to help the elderly cope with the health challenges that come with old age. The program was made permanent in 1984, something that cushioned the old from health risks.

Medicaid enjoys a long history beginning in 1980 when states received waivers from the central government to introduce Medicaid programs in their respective health programs. The program helps the poor and helpless in society to enroll for health services in private institutions while the government pays the bill. Just like Medicare, Medicaid was formed in 1965 through the amendment of the Social Security Act. It was formed specifically to empower states to support healthcare programs for poor people. Initially, only the blind, elderly, physically challenged, and pregnant women were entitled to the benefits of the program, but several changes have ensured that all groups are involved. In fact, the country depends on Medicaid to offer healthcare services to the majority because other programs, such as Medicare simply focus on special groups. Based on this, it is the role of each state to come up with standards that would ensure that only people in need receive this sort of funding. For instance, state officials are expected to set eligibility standards, the type of services offered, as well as the rate of payment. Since each state has its own selection criteria, it does not mean that once an individual is eligible in one state, he or she will definitely be served in the next state. A government agency that oversees the implementation and the running of the program was set up to ensure smooth service delivery. Since the program differs in several ways from the Medicare program, it has special programs for schools, which are referred to as the Fee for Service, which caters to the costs of healthcare for special children. The law requires that each child be offered free appropriate public education. Based on this, the law demands that the Medicaid program pays the medical expenses for each child.

Administration and Financing

The two programs are managed by the same governmental agency referred to as the Centers for Medicare and Medicaid, which is a special section within the Department of Health and Human Services. The agency is charged with the responsibility of ensuring that reforms are introduced in the healthcare system and all necessary bills are presented to the relevant authorities for discussion and approval. The major objective is to give each American an opportunity to access quality healthcare since the services offered by private institutions are high and are sometimes unreliable. All projects funded through CMS are subjected to scrutiny to prevent any misappropriation of funds. The agency is in partnership with other privately owned healthcare organizations in the country, which offer services on behalf of the government. For instance, the intermediaries are supposed to offer call center services, payment processing, enrolment of eligible candidates, and finally conducting auditing to determine any case of fraud. Medicaid has a different system of operation because it is co-funded by the states and the federal government. Additionally, each state has a unique program, even though all of them are required to comply with the law in order to receive any form of assistance from the federal government. Funding is provided to states based on the matching formula whereby the per capita of each state is determined before applying the formula. The richer states receive not more than fifty percent of the requested funds while the poorer ones might receive full funding

Several state authorities are concerned with the Medicaid funding program because it always consumes more resources, yet the federal government does not provide adequate cash. In fact, it has turned out to be a major political issue during campaigns because any local leader has to give a clear program on how he or she would spend funds on the program. Each state spends at least sixteen percent of the funds on the program, with the percentage going up to twenty-two once the federal government chips in something. In some rich states, including New York, an individual might be required to pay the additional costs to receive healthcare services through the Medicaid program. The law is clear on the program because it only offers medically necessary services and not any other type of service that Medicare might be offering. The beneficiaries of Medicaid include the nursing homes that specialize in childbirth (Popow, 2006). A law was introduced in 2008 that allowed the states to charge a fee in order to increase funding for the Medicaid program since many stakeholders complained that the program is expensive and the sources of funding are limited.

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Eligibility

Individuals aged sixty-five years are the only ones qualified to access healthcare services through the Medicare program in the country. Additionally, anyone wishing to enroll has to ensure that he or she possesses needed documents that prove his citizenship. Through amendments, people living with disabilities have the chance of accessing Medicaid healthcare services. However, such individuals should register with social security disability insurance. In extreme cases, Medicare supports healthcare services for individuals with special medical conditions. The eligibility for Medicaid is different because it entails the identification of individuals in need, unlike Medicare, which is clear on age and the medical conditions of those eligible. For one to qualify for enrolment into the Medicaid program, he or she has to be from a low-asset family. These groups include children from poor families, pregnant women, the elderly, and poor parents. At least two programs exist under the Medicaid program, one of them being Community Medicaid, which plays the role of serving those without any medical insurance, and Medicaid nursing home that covers the expenses associated with reproductive health for women. The federal rules governing the selection criteria for Medicaid do not apply uniformly because each state has unique features and demographics.

Benefits

Medicare offers its services through the four programs, including Part A, Part B, Part C, and Part D. The first plan is concerned with the hospital insurance whereby arrangements are made to ensure that all eligible citizens are covered. In case of any medical emergency, the government will not have to rush in to help, but instead contracted organizations will take responsibility and the role of the government would be to offset the bills. The second plan supplements the first plan because it offers additional insurance cover, even though the owner will have to chip in something. The third plan of the program monitors the distribution of essential drugs. Moreover, it is concerned with the administration and prescription of drugs to all eligible members. Part C is the most important because it unifies the benefits of the eligible member with those of his or her employer.

Standards

The agency charged with the responsibility of overseeing the implementation of the two programs sets standards that all stakeholders have to follow. Regarding information coverage and distribution, it states that any statistical data concerning the performance of the two programs should be availed to the public for scrutiny. The information should be factual. However, the personal information of clients should never be exposed to the public since this would be a breach of individual rights. Each state will be expected to provide consumer information, but the agency will offer data on information evaluation. The only valid information dissemination techniques are the internet, print media, storage media, telephone, and multi-media. The information provided has to be useful meaning that utility is given a priority. The data offered, as well as the behavior of employees, should be objective. Whenever the concerned authorities engage in business with other stakeholders, integrity has to be given priority.

Cultural proficiency is an additional concern that the organization always looks at when tackling the problems of the unfortunate. One of the best approaches in dealing with cultural challenges is tolerating diversity in the sense that healthcare experts have to realize the fact that the mainstream should have their way, but the minorities should have a say. Through this, divergences would be determined in the best way possible. For instance, the problem of dressing code that arises among various professionals would be best tackled by permitting every group to exercise its policy. In the healthcare organization, the administration should not try to bring in a certain rule that instructs people to drop their modes of dressing simply to support the recently established system. In addition, approval of cultural diversity would resolve the question of political civilization. For instance, while Americans tend to be patriotic, other cultures, particularly the Mexicans are more partisan. For that reason, healthcare groups should think about this fact when drawing the organization’s aspirations, objectives, and guidelines. The mental picture should not replicate the patriotic ideals and neither should it be based on jingoistic since this would frustrate one group. Culture can bring together people or it can as well act the main source of exceptional conflicts (Kerr, 2006).

For example, the culture of the Mexican people teaches them to be jingoistic, but European Americans are always obsessed with nationalism meaning that they are always pompous of the presented ways of life. Based on this, Mexicans infrequently detach personal life from professional life, which denotes that the family unit is the main socializing agent, as it gearshifts the life of the person even in parenthood. As a result, an individual would struggle to avoid condemnation and war of words from other family members. European Americans are known to be methodical implying that they seldom invoke feelings in making major managerial resolutions. In their daily lives, Mexicans believe that dressing has a role to play, especially in relation to performance at work. Dressing and well grooming are valued principles that elevate an individual’s status in society. For European Americans, the dress code and the outward show do not have any meaning, as performance is always given precedence. The healthcare institutions would probably go against the well-known standards and set of laws primarily because of defective structures and processes implying that it is not the aspiration of any expert to commit any error. Based on this, some of the known procedures ought to be adopted to make sure that the forward planner services utilized in all healthcare organizations in the nation are accessible and exceedingly effectual to realize their main function, as far as the provision of expert services is concerned. In this regard, the organization has to engage itself in any agenda or scheme efficiently.

A brief review of the healthcare systems in the nation discloses that technology should be utilized to ensure that the population receives better health. In general, the governing body is doing everything possible to convene the health needs of the populace, but much effort is considered necessary. A number of reasons exist as to why the sector will have to utilize a database in administering healthcare systems. The utilization of databases in operating healthcare systems is vital in several ways. For instance, it facilitates the transfer of information from one resource to the other meaning that it offers a solution to the conventional storage system, which is unproductive and disorganized. The novel system would permit microsecond reply, which translates to less memory use for large workloads. This is known to diminish database pre-core certification costs (Fried, 2008). Database storage system permits faster report production and real-time dispensation of information on larger pieces of information, which steps up various applications by up to twenty times the normal speed. This would definitely improve the performance of the organization, as well as the output of the labor force.

Use of Business Intelligence

Application of business intelligence in marketing new products entails the utilization of software referred to as TIBCO BPM, which enables the organization to save resources that would recruit up to one hundred employees. Through the software, quality service and cost-efficiency would be achieved since the major aim of any organization is to reduce the costs of production and gain a competitive advantage in the market. For quicker decision-making and policy formulation, the need for business intelligence is inevitable. The software allows data management, evaluation, and processing hence allowing the identification of feeble links within the organization for purposes of optimizing effectiveness in order to realize the operational benefit in the market.

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Use of data mart in the release of new product launch

Datamart refers to the access layer that is often employed in data warehouse surrounding whose major role is to disseminate data to other users. Based on this, it is always allied to a particular business line or team of managers since they serve an important role in the organization. Since the data mart contains limited information that is specific to a particular department or section, the marketing department of the organization is expected to own it. Therefore, it will be in charge of the hardware, software, and data itself. The marketing executive will have the opportunity to manipulate the data to suit the increasing demands of the customers.

Characteristics of high-quality information

Any piece of information should have at least five features, including, in order of correctness, wholeness, reliability, exclusivity, and suitability. For any piece of data to be considered excellent, it ought to be precise and functional. Furthermore, such data ought to be consistent for it to convene the major aims of the organization. Wholeness means that any piece of data should not be fractional, as it would misinform different stakeholders. When keying data into the database, it ought to be inclusive to avoid deformation.

Attributes and entities of the mortgage database

This entails some of the most significant traits of any entry, such as the report of the customer, the naming number, and the worker assigned the role of tackling various classes of customers in the organization.

Use of the data-driven website to run business

This involves a website that can perhaps be accessed and reorganized to show the needed data in the best way possible. Since the healthcare sector provides an exclusive type of service, it can employ this type of website as it informs customers on the best proffer in the market every minute.

References

Fried, J. (2008). Democrats and Republicans – Rhetoric and Reality. New York: Algora Publishing.

Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare Beneficiaries’ Costs of Care in the Last Year of Life. Health Affairs, 20(4), 188–195.

Kerr, J. (2006). The Best Practices Enterprise: A Guide to Achieving Sustainable World-Class Performance. Ft. Lauderdale: J. Ross Pub.

Popow, D. (2006). Claim Handling Principles, and Practices. Malvern, PA: American Institute for Chartered Property Casualty Underwriters/Insurance Institute of America.

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StudyCorgi. (2022, May 23). History and Standards of Medicare and Medicaid. Retrieved from https://studycorgi.com/history-and-standards-of-medicare-and-medicaid/

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