Running head: MEDICARE 1

Medicare
Sofia Eyakem
Seton Hall University














MEDICARE 2


In the growing society, health care needs of people constitute an important area that
requires a continuous surveillance. Especially, an accessibility to care appears to become a
central issue for some population groups due to their poor socio-economic conditions and the
family hardships. As a result, such groups are more vulnerable to a deficient health check up and
end up with health issues. However to overcome such health disparities, government agencies
have come up with special policies. For instance, Medicare is one such policy. The preset
description is concerned with highlighting about Medicare in view of its relevance to clinical
practice.
Medicare constitutes a federal health program of the U.S government that is intended to
subsidies to individuals who are eligible for the following criteria (Medicare, 2014). Individuals
above 65 years with permanent U.S. citizenship or legal residency for five years. Individuals
with a disability who has gathered a two year Social Security. Individuals with kidney failure
currently receiving dialysis or who requires a kidney transplant. As well as those who are
suffering from Lou Gehrig's disease (Medicare, 2014).
Medicare assists people when they could have severe health abnormalities in their life time but
are deficient in meeting the treatment expenditure.
Medicare parts
Medicare consists of four parts. The first part covers home health and hospice care, skilled
nursing facility, and in-patient hospital. The other name for the first part is Hospital Insurance or
simply part A. Many individuals do not pay a premium amount for this part as themselves or
their spouse had already made a payment while working through their payroll tax paying system.
In order to claim the benefits of first part, beneficiaries should meet some conditions (Medicare,
2013)
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The second part, also known as Part B or Medical Insurance covers every aspect of vital
medical services such as physicians services, outpatient care, wheel chairs, laboratory and x-ray
services. It provides coverage of different medical services that Part A did not cover, such as
certain home health care, services of physical and occupational therapists. US governments
Center for Medicare and Medicaid Services is an authentic source. It aims to cover 100 million
people and attain an increased quality care system through cost efficiency and improved health
(Medicare, 2013).
Another part is Medicare Part C, also known as Medicare Advantage. It represents a
private plan operated through Medicare. Under part C, private health insurance agencies could
provide benefits. Such private health plans of Medicare involving PPOs and HMOs represent
Medicare Advantage plans. As per the law part C should be similar in its potential to the routine
coverages of Part A and Part B. If needed, an individual could choose to obtain their Medicare
coverage through a Medicare Advantage plan rather than Original Medicare.
As for Medicare is the part D, it provides outpatient prescription drug insurance.
It is offered solely from private insurance companies that collaborate with the government.
Government does not directly provide this care. If anyone is desirous of seeking this coverage,
they must select and register in a private prescription drug plan. Enrollment for this part is open
during certain approved periods. If individuals like to enroll in part D, they should select part D
coverage that it complies with their Medicare health benefits. If they possess Original Medicare,
they must select only stand-alone Part D plan. So, it is the circumstance that determines if an
individual must sign up for a Medicare private drug plan or not (What does Medicare cover?
n.d.).
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Research shows that Medicare has become an important strategy to optimize the
profession and ensure quality care to the patients in real practice. Especially, nursing home
settings appear to gain benefits in this context (Stevenson, 2008).
Medicare and long term care pharmacies
In fact, nursing homes operate in a complex regulatory atmosphere that represents the
nursing homes pharmacy environment. Such pharmacy is intended to provide increased drug
requirement of residents. Nursing homes have been struggling to reduce medication errors and
enhance prescription practices. As such, they started relying on reforms and guidelines, and
gradually long term care pharmacies (LTCP) have become an integral part of the nursing home
pharmacy practice (Stevenson, 2008).
LTCPs provide drug management services and integrate with associated quality assurance
and improvement activities through their consultant pharmacists. However, Medicares part D
has brought many variations in the nursing homes pharmacy environment. To this end,
researchers have carried out a study to explore how part D has brought changes. They reviewed
several information sources and interviewed stakeholders. The study revealed that Part D has
contributed to high variations that surround formularies and drug management processes
(Stevenson, 2008). It has formed an extra burden on clinical and pharmacy staff with tensions
between the facilities requirement to quickly dispense the drugs and providing guarantee for
their coverage.
As a result, nursing home and LTCP stakeholders feel that they receive much variation
across Part D plans in their potential to address the needs of nursing residents. So, research
suggests further attention on Medicares part D in view of its positive and negative effect on
nursing homes in the long term (Stevenson, 2008).
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So, this aspect of Medicare is very relevant to our practice site because the center is
currently facing financial disparities that need immediate elimination. Discussing about a certain
modifications in Medicare with the potential stakeholders and health administrators could appear
beneficial for long-term care.
Donut hole. It refers to a coverage gap that many Medicare Prescription Drug Plans
possess. (Medicare, n.d.). Say, it refers to a temporary limit on what does a drug plan cover for
drugs. The gap starts after an individual and his or her drug plan has spent for the covered
medications. In 2014, if the individual and his or her plan expenses reach $2,850 on covered
drugs, then the individual is in the coverage gap.
As a result, individuals would pay 47.5% of the plans expenditure for covered brand
prescription medications. This coverage gap does not involve every individual. Even, those with
Medicare who obtain additional help paying Part D costs also do not enter the coverage gap.
(Medicare, n.d.)
Medicare for elderly patients. Many elderly patients spend much of their end of life period
in nursing homes (Huskamp et al., 2010). For these people, a reliable quality care serves as vital
component. But, available studies mention that end of life care has become a poor quality for
nursing home residents. There are reports on improper management of shortness of breath,
increased prevalence of unrelieved pain, and poor satisfaction among family members about care
and communication. Such defects have an association with financing arrangements for long-term
and end-of-life care services which are under the control of acceptability, fees, and regulatory
mechanisms (Huskamp et al., 2010).
Researchers mention that Medicare hospice policies do not fit properly with the end-of life-
care requirements of nursing home residents. The reason is poorly structured reimbursement
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approaches that distinguish the finance seeking services for nursing home residents from the
other hospice care financing. Hence, health experts suggest the development of a special end-of-
life Medicare benefit for nursing home residents. Services related should consider a
documentation that explains the service requirements where there is no need of physicians
certificate on patients prognosis or beneficiaries to choose it. Nursing homes should get direct
payment towards the services for end-of-life care and must play responsible role for their quality.
So, Medicare has good implications for patients during their end-of-life stage. It could
enable nursing home residents provide flexible services and resources while minimizing all care
discrepancies (Huskamp et al., 2010).
In view of the above it can be concluded that Medicare policy of US government is a
valuable policy. Its four parts A, B, C and D possess unique advantages. However, due to ever
growing needs of patients, Medicare requires a detailed exploration in nursing home settings and
the outcome that results could form a solid strength to the practice.










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References
Costs in the cover gap. (n.d.).Retrieved from
http://www.medicare.gov/part-d/costs/coverage-gap/part-d-coverage-gap.html
Huskamp, H.A., Stevenson, D.G., Chernew, M.E. & Newhouse, J.P. (2010). A new medicare
end-of-life benefit for nursing home residents. Health Aff (Millwood),29(1),130-5.
Koroukian, S.M., Xu, F. & Murray, P. (2008).Ability of Medicare claims data to identify nursing
home patients: a validation study. Med Care. 46(11),1184-7
Medicare Program- General Information. (n.d.) Retrieved from
http://www.cms.gov/Medicare/Medicare.html
Medicare. (2014). Retrieved from http://www.investopedia.com/terms/m/medicare.asp
Stevenson. D.G. (2008). Medicare Part D and the Nursing Home Setting.
Gerontologist,48(4),432441.
What does Medicare cover (Parts A,B,C and D). (n.d). Retrieved from
http://www.medicareinteractive.org/page2.php?topic=counselor&page=script&script_id=214