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The Impact of Medicare on Today’s Healthcare Ecosystem


Medicare is one of the government-funded health insurance programs in the United States. It offers health coverage for people older than 65 years, people of any age with specific disabilities, and people of any age with end-stage renal disease (Centers for Medicare & Medicaid Services, 2019). As an effective payer program, Medicare influences healthcare standards, reporting systems, reimbursement, and care, which will be discussed in this paper.

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Impact on Standards

Licensure establishes the standards of healthcare services’ quality for educators and care providers. Obtaining state licensure is a requirement for hospitals and physicians that cannot be ignored. Physicians’ and hospitals’ licensing is alike and covered by Conditions of Participation and Conditions for Coverage, including a National Provider Identifier (NPI) and enrollment application. Some licensed physicians prefer not to become program participants and not to sign a contract. In this case, 95% of the fee schedule amount is paid to the provider (“Lower cost with assignment,” n.d.). The same situation is with hospitals because the majority of organizations tend to become licensed independent practitioners in health care.

Impact on Clinical Quality Reporting Systems

Clinical quality reporting systems are determined by Medicare and ensure that patients have access to effectively delivered services. The Physician Quality Reporting Initiative is a voluntary reporting program for Medicare participants to guide hospitals and providers to submit data and evaluate the class of treatment that may be offered to a patient. Physicians use the Merit-Based Incentive Payment System that ties payments to quality and cost-efficient care and increases the use of healthcare information (Quality Payment Program, n.d.). Hospitals rely on the Value-Based Purchasing System and address four major domains, namely safety, clinical care, cost reduction, and care coordination (Centers for Medicare & Medicaid Services, 2017). Both systems make it possible to calculate the frequency of quality standards and pay enough medical attention to each service.

Reimbursement for Healthcare Services

Medicare explains the conditions of reimbursement for healthcare services provided by physicians and hospitals. A prospective payment system is offered to hospitals under Part A and includes a fixed amount of care for each patient regarding a primary diagnosis. The resource-based relative value scale is offered to physicians under Part B to explain the importance of resource costs. There is a fee schedule for reimbursement in Medicare to define fees that can be paid to physicians. Certified physicians file the claims and agree to accept the charge. If there is a necessity to write off an amount, a contractual type (the balance) is considered for several group codes (correction and reversal, patient responsibility, or adjustment).

Patient Access to Care

Medicare could push physicians to opt out by jeopardizing their financial abilities, which results in an evident shortage of primary care providers in medical schools. According to the chosen federal program, care providers who do not accept Medicare standards can charge any payments for their services. They sign private contracts and change prices as per their needs and interests. No specific rules and requirements are attractive for many practitioners, and their dependence on medical schools is minimal today.

Health information management cannot be neglected in care that is offered under Medicare standards. Governmental regulations are constantly improved both domestically and globally. Therefore, there is a need for a person who evaluates changes and applies them to practice. For example, a compliance officer takes responsibility for the creation and application of a program according to the current federal and state laws, as well as mitigating the risks. This profession needs to monitor compliance, and Medicare policies determine the required working knowledge.


Today, the healthcare ecosystem implements various health information management policies and technologies and improves care access. Regarding the conditions under which Americans receive treatment, it is expected to rely on governmental programs like Medicare to cover treatment costs. Medicare reimbursement includes the payments that licensed physicians and hospitals get for services offered to Medicare insurants. However, its impact on the health ecosystem is unpredictable, which results in re-evaluating the role of medical schools and compliance officers.

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Centers for Medicare & Medicaid Services. (2017). Hospital value-based purchasing. Web.

Centers for Medicare & Medicaid Services. (2019). Medicare program: General information. Web.

Lower costs with assignment. (n.d.). Web.

Quality Payment Program. (n.d.). MIPS overview. Web.

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