Health care is an essential element of the social sphere and has as its goal the preservation and strengthening of the health of the population through preventive, curative, and other types of activities of medical institutions. Medicare is a highly effective method to ensure that older adults can access sufficient medical aid, but the demographic shift to older age requires more program expansion.
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In the United States of America, there is no unified and clear system of a healthcare organization, but its model is a schematic form that can be represented by structural elements. The guarantor of providing medical care is the health insurance system, which is public and private (Strawbridge, Lloyd, Meadow, Riley, & Howell, 2015). Many Americans who do not have private insurance are covered by government programs such as Medicare and Medicaid, as well as other regional programs for the poor.
The current state of the Medicare program provides health insurance for all Americans over 65 with work experience of 5-10 years as well as those who are approaching this age and have serious health problems. It was established in 1965, and since 1972 it has also served the disabled and consists of four main parts. First, hospital insurance includes payment for hospital services, some forms of home care. Second, health insurance involves a fee for doctors and all kinds of outpatient services not included in the previous component (Colligan, Pines, Colantuoni, & Wolff, 2017). Third, preferred insurance is a plan combining the first two elements with an additional provision of different types of specialized medical care and prescription drugs on special conditions. Lastly, drug insurance is related to prescription drug costs (Colligan et al., 2017).
The effectiveness of Medicare is obvious, because, in 1991, this program reached 39.2 million people, in 2010 – 47.5 million, of which 39.6 million people over 65 and 7.9 million people with disabilities (Duncan, Ahmed, Dove, & Maxwell, 2019). By 2020, it is projected to include 61.3 million Americans. The program is partially funded by a special tax, which is paid equally by entrepreneurs and employees in the amount of 7.65% of the payroll, of which 1.45% is withdrawn by Medicare (Lloyd, Blackwell, Wei, Howell, & Shrank, 2015). Non-self-employed citizens, as well as small business representatives, pay a social tax of 15.3% of their income, of which 2.9% is deducted for this program. In total, the US government, at the expense of taxpayers, pays 52% of the cost of medical care for pensioners (Colligan et al., 2017).
In recent years, social and health insurance programs have faced serious difficulties associated with demographic changes. An aging population and an increase in the proportion of Americans are over 65. Social Security and Medicare provide benefits that are far greater than previous investments. If in 1950 16 workers provided one recipient of social insurance benefits, in 1996 – three employees, then by 2030, if current trends continue, only two employees will fall for each pensioner (Strawbridge et al., 2015). At the end of the 1990s, Medicare expenditures were 2.6% of GDP; in 2030, they are projected to be 7.5% of GDP. From 1991 to 2010, they have grown 2.1 times – from $ 244.8 to $ 522.8 billion (Colligan et al., 2017).
Medicare is a national social security program that provides insurance to US citizens who are over 65 who have worked and made contributions. It also provides health insurance for young people with certain medical conditions. The program has existed since 1966 and is covered by the expenses of the US federal government. In 2011, nearly half of the costs of inpatient care (47.2%) were covered by Medicare (Duncan et al., 2019).
Healthcare professionals can be classified as hospital units and their personnel. Unlike most ratings, hospital data is collected by them independently, and it looks as if no one is monitoring the collection and analysis of this data. However, this is not so, since data collection methods are carefully monitored, and each hospital undergoes regular validation and verification (Strawbridge et al., 2015). Thus, only data whose highest quality provides important and useful information for the consumer is used.
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Hospital ratings, according to patient estimates, are based on several key parameters. For instance, patient treatment results include prevention of infections, repeated hospitalizations, complications, and adverse events in surgical patients. The opinion of the patients themselves, including how clear and understandable the information was to the patients when they were discharged from the hospital (Parashuram, Kim, & Dowd, 2018). The doctor’s appointments and recommendations are critical, as well as whether the explanations about the drugs being taken were clear. Hospital practices, such as proper use of scanning and an electronic health card. Subsequently, these rating techniques can be combined to create a common security rating.
The effectiveness of the program is difficult to evaluate due to the instability of expenditure values. However, this does not mean that all expenses of the patient are covered from the funds of the program. They pay part of the services, and their participation in payments depends on the volume of these services. In 2014, 15.6% of Americans were covered by Medicare. It is expected that by 2050, their number will increase to 95.8 million people (Strawbridge et al., 2015).
The development of a quality assurance strategy for Medicare required its organizers to choose a clear conceptual framework and set program goals. First of all, the traditional model “structure – process – result”, known as the Donabedian model, and the model of continuous quality improvement were identified as a conceptual basis (Parashuram et al., 2018).
This program was not chosen by chance, because the American government pays considerable attention to the ratings of medical organizations, considering them as a fairly effective information and marketing tool for managing the quality of medical care. Therefore, it seems appropriate to review the ratings of indicators used to assess the quality of work in hospitals included in this program. Hospital Ratings 2011-2013 based on parameters that allow you to visually evaluate the quality of patient care from a state perspective (Colligan et al., 2017).
With the introduction of new quality assessment parameters, it is necessary to enlist the support of external experts to receive feedback on the new measurement methodology so that they can be included in the Ratings. The given system should be one of the most important elements of the rating system. Ratings should use a scale from 1 to 5, and a more accurate range is used to assess safety, which is from 0.5 to 5.5 (Strawbridge et al., 2015).
In addition to inpatient care, the program pays 100 days for the treatment of chronic disease in a nursing home. The patient receives a conclusion on the need for such care, as well as an unlimited number of doctor visits to the patient at home. Over 90% of Medicare is spent on hospital services, and only 9% on nursing and home care (Parashuram et al., 2018). Clients with terminal conditions can use hospitalization for up to 90 days twice a year, and one reserve hospitalization for up to 60 days (Lloyd et al., 2015).
On average, more than 20% of all medical and more than 30% of all hospital services are paid from government programs, mainly Medicare and Medicaid. For 5700 medical facilities, participation in these programs is the only source of income (Duncan et al., 2019). Thus, Medicare can be considered as a highly effective policy for medical assistance among older people.
Evaluation of the Implication of the Policy
The Medicare Hospital Part is funded by insurance tax from employers and employees and is designed to treat acute illnesses. It pays for 90 days of inpatient treatment, ending with discharge from the hospital, or stay in a nursing home for 60 days (Lloyd et al., 2015). The number of such periods per year is not limited. The subprogram also provides for a one-time stand-by hospitalization in case the client has exceeded the hospital stay.
The increase in the cost of medical care in recent years has forced the government to take voluntary responses in the form of tightening the rules for adherence to clinical protocols. Thus, it should increase the cost of the franchise paid by Medicare participants before starting the distribution of medical benefits to them.
In conclusion, the fundamental role of healthcare as an inalienable condition of society is recognized in the legislative acts of all civilized countries and is considered an important factor in the national security of the country. It is a system of public and state socio-economic measures ensuring a high level of protection and improvement of public health. Effective public policy contributes to the implementation of the main tasks of healthcare.
Colligan, E. M., Pines, J. M., Colantuoni, E., & Wolff, J. L. (2017). Factors associated with frequent emergency department use in the Medicare population. Medical Care Research and Review, 74(3), 311–327.
Duncan, I., Ahmed, T., Dove, H., & Maxwell, T. L. (2019). Medicare cost at end of life. American Journal of Hospice and Palliative Medicine, 36(8), 705–710.
Lloyd, J. T., Blackwell, S. A., Wei, I. I., Howell, B. L., & Shrank, W. H. (2015). Validity of a claims-based diagnosis of obesity among Medicare beneficiaries. Evaluation & the Health Professions, 38(4), 508–517.
Parashuram, S., Kim, S., & Dowd, B. (2018). Inappropriate utilization in fee-for-service Medicare and Medicare advantage plans. American Journal of Medical Quality, 33(1), 58–64.
Strawbridge, L. M., Lloyd, J. T., Meadow, A., Riley, G. F., & Howell, B. L. (2015). Use of Medicare’s diabetes self-management training benefit. Health Education & Behavior, 42(4), 530–538.
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