Performance Measurement Tools in Health Insurance

The paper encompasses the significance of outcomes and benchmarking as tools of performance measurement. It goes on and gives prompts on insurance methods used in the United States such as; fee for service, Preferred Provider Organization (PPOs), Managed care and Health Maintenance Organization.  A clear description on how both Medicare and Medicaid enables and disable the healthcare delivery is also given. The effects of the most trending issue in the US about the Affordable Care Act are well researched on its effects. The paper ends with proposals on how the health insurance funding in the United States could be changed.

Outcomes assessment is suitable for an organization to assess performance. It includes evaluating how the organization managed to meet its expected outcomes. If it’s implemented well all the parties interested which include patients, provider organizations, payers, and the whole health industry benefit from the investment of their time and money in their assessment. It leads to increase health, quality of life improvement, as well as efficient use of their money paid into the hospitals and insurance plans. For providers, the data from assessment results to improvement in clinical skills increased profits and other benefits. MCOs benefit from this method of assessment in increased profits as well as information that assist in shaping the patterns of practice and quality care based decisions (Mathidza, 2015).

Benchmarking constitutes a vital practice commonly done by organizations to define their best practices, make their baselines established and creating a competitive surrounding as well as developing the opportunities for improvement. Integrating this strategy in the firm leads to learning from valuable data that results in the innovation of new ideas and practices. It’s used as a tool to assess the performance and plan routes to improvement when at its best. In performance assessment, benchmarking allows the company to achieve significant milestones.

Firstly, it assists the organization and in this case health care providing organization to gain a clear perspective of the performance compared to other firms.  

It also enables a firm to identify its performance gaps as well as determining their areas of weakness to improve on.

It also gives the firm the basis to set their performance goals and expectations. It happens because they have known their weaknesses as well as their counterpart’s performances. It makes the company work to implement new strategies as well as accurately set their objectives.

A company that applies to benchmark can monitor its performance and also manage change. The employees of the healthcare institution develop a mindset of continuous improvement.

It is a method where one pays doctors or health provider for services provided. Examples of the services include office visits, consultation, and tests. It is funded separately for each rendered service. The health service providers benefit much from the method because incentives are given independently depending on the number of services provided. Patients lose because the providers only aim at the quantity and not quality care.  The physicians benefit from co-payments, but the patients suffer because they pay more (van Hasselt et al., 2015)

Overview of Health Insurance Methods in the United States

The Medicare Preferred Provider Plan gets offered by a private insurance company and its one of the Medicare Advantage Plans. The beneficiaries of the plan are patients who used doctors, hospitals and other healthcare vendors that have subscribed to the network of the program. Those who are non-beneficiaries are those that use healthcare service providers who are outside the system. One can pay for this plan as well as other Medicare plans. It has an extra pay than other methods in the healthcare exchange (Claxton et al., 2015).

It is a type of health insurance. They engage in contractual engagements with health care providers to provide services to members of the plans at reduced costs. They constitute the plan’s network. Subscribers who get their plans restricted by rules pay less. The cost of the plan depends on flexibility (Mathidza, 2015).  

It is a health care provider that provides coverage by annual or monthly payments. An HMO is a collection of medical insurance providers. They limit policies to medical aid given out by doctors under the HMO contracts. The costs of the systems cost lower because the clients have direct contact with the providers. Subscribers also have to consider out of pocket costs before subscribing (Tajeu, 2015).

Medicare has enabled healthcare and disabled health care delivery in the United States. Just like any other aspect of life, Medicare has its good and bad side as well (Arulanantham, 2014).

Firstly, it provides coverage to those who don’t have it as well as those who couldn’t manage to purchase it. Many aging people in the country have been allowed by the program to access coverage on healthcare when they could not have afforded it.  Medicare also provides coverage to many disabled Americans of young age who weren’t able to get good health care otherwise. Significantly, the program is very beneficial to these two groups of people (Baicker & Robbins, 2015).

Secondly, its costs are meager compared to other programs hence easy to subscribe. The enrollees are customarily offered part of a fee for free and required to pay a small amount monthly for Part B. once compared to standard hospital costs, the savings it provides are considerable.

Medicare has also led to improved medical standards in the USA. After its formation, the Senate gave measures for hospitals who could qualify for the care of patients in the program hence hospitals improved their services and standards to meet the requirements (Graham et al, 2018).

Medicare attracts fraudulent doctors in that doctors and health administrators bill drugs and services that were not provided hence benefiting from the service illegally. Secondly, it leads health care costs of the more older adult’s skyrocket. The program does not cover these costs well.

The cost of administering the program is vast. The government for instance spent a total of $588 billion on Medicare in the year 2016. That was approximately 15% of the total government budget. These entire amounts were usable in other health reforms.

Medicaid is made for low income individuals and families. It headed by the federal government but managed in the individual states. The program provides improvements in health care in many ways. The government guarantees medical practitioners who participate in providing health care for members of Medicaid a suitable remuneration. It leads to the motivation of the practitioners hence improving the healthcare services (Patel et al., 2014).  

Effects of Medicare and Medicaid on Healthcare Delivery

Medicaid has developed the accessibility of health care among people of all classes. The program got created to focus on low and middle income earning citizens. If not for the program, these people couldn’t access medical coverage.

It has undermined health standards in minor states in the US as the government allows wealthier countries to be allocated more money than the poorer states which have much healthcare need resource wise. The reimbursements of the program to doctors are very low as compared to what doctor’s charge usually. They discourage doctors and make hem neglect Medicaid patients (Levy et al, 2017). Small medical practitioners avoid these patients because the reimbursements are released after 37-155 days which is a lot of time. Patients are even neglected in private nursing homes by doctors citing that the Medicaid quota has been reached (Hsu et al., 2018).

Americans nowadays purchase health insurance in the health exchanges. It led to the end of dependence on employers cover or a group plan for health care insurance. It has reduced the cost of the healthcare plan by ensuring each American benefits.

Many American citizens are averaging to 16 million, who lacked health insurance, got it due to the introduction of the Affordable Care Act. It allows individuals who already have acute and critical conditions to gain health care insurance and also youths can stay in their parent’s insurance plans up to the age of 26 years. Considering the fluctuations of incomes of the employed citizens in the states, the ACA suits them when they buy the Health Insurance plans via the exchange. In case the salary goes down, they will have the chance to purchase plans of lower value, while if the salary increases they have the opportunity to change their policy to those of higher quality (Frean &Gruber & Sommers, 2017).  

The ACA provides the opportunities for the increase of competition thus enhancing quality and value addition in the policies presented in the market. The ACA also provides for the establishment of consumer protection policies hence making the business void of consumer exploitations.

According to all these beneficial provisions and advantages accruing from the ACA on the state health insurance exchange, it’s good to enact the requirements of the act in the states (Abney, 2014).

ACA has led to the expansion of Medicaid in about half of the nation. It is a delimitation because the health insurance was supposed to target low-income citizens in more than 50 states.

It has also led to the detection of more acute problems among the people than it was before. People have now been enabled to go for checkups frequently hence screening of many severe illnesses facing Americans. The Affordable Care Act has led to the increase in competition among the insurance policy vendors hence reducing exploitation to American citizens by the brokers.

Health costs in the states have decreased at a higher note due to the introduction of the act. Health practitioners have also increased the quality of their care to march the standards required in the Medicaid (Hickner-Cruz, 2015).   

Healthcare financing in the United States should make policy changes and adopt an equitable sharing of health care financing from the government. The states should be getting finances according to the extent of their needs. In the country, the developed states  receive higher amounts of funds that those who are underdeveloped. The vice means that their health care will remain undermined for a long time and it will never develop. The solution to the problem can well fit on the change of finance sharing policies (Patel & Rushefsky, 2014).

Conclusion:

The paper met all its requirements of evaluating the medical economic issues. It’s clear that Medicare and Medicaid have more benefits to the country than demerits. The affordable care act has led to the improvement of the Healthcare sector in a large extent. Changes in the healthcare financing are manageable through policy making by drafting policies that divide finances equally and equitably.

References:

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Frean, M., Gruber, J., & Sommers, B. D. (2017). Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act. Journal of Health Economics, 53, 72-86.

Graham, D. J., Reichman, M. E., Wernecke, M., Hsueh, Y. H., Izem, R., Southworth, M. R., … & Chillarige, Y. (2016). Stroke, bleeding, and mortality risks in elderly Medicare beneficiaries treated with dabigatran or rivaroxaban for nonvalvular atrial fibrillation. JAMA internal medicine, 176(11), 1662-1671.

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Hsu, H. E., Kawai, A. T., Wang, R., Jentzsch, M. S., Rhee, C., Horan, K., … & Lee, G. M. (2018). The Impact of the Medicaid Healthcare-Associated Condition Program on Mediastinitis Following Coronary Artery Bypass Graft. Infection Control & Hospital Epidemiology, 39(6), 694-700.

Levy, Helen, Grimes, Donald R., Ayanian, John Z., & Ehrlich, Gabriel M. (2017). Economic effects of Medicaid expansion in Michigan. The New England Journal of Medicine, 376(5), 407-410.

Mathidza, M. S. (2015). Improving performance management and development systems in the Department of Health, Limpopo Province (Doctoral dissertation).

Patel, K., & Rushefsky, M. E. (2014). Healthcare politics and policy in America. Public Integrity, 17(1), 94-96.

Tajeu, G. (2014). Health Maintenance Organization (HMO). The Wiley Blackwell Encyclopedia of Health, Illness, Behavior, and Society, 1014-1016.

van Hasselt, M., McCall, N., Keyes, V., Wensky, S. G., & Smith, K. W. (2015). Total cost of care lower among medicare fee?for?service beneficiaries receiving care from patient?centered medical homes. Health services research, 50(1), 253-272.