(Answered) NR 552 Assignment Week 4: Medicare Vs PPO Payment Models

Course 

NR 552 Economics Of Healthcare Policy

Purpose: The purpose of this assignment is to:

  1. compare and contrast two insurance plans payment models at a specified level of healthcare service (one governmental plan and one private plan),
  2. examine the patient population served by each insurance plan,
  3. investigate the impact of each payment plan on access to care, access to services or procedures, and patient outcomes,
  4. evaluate both insurance payment plans for economic, social, or ethical issues,
  5. present ideas in a clear, succinct and scholarly manner.

Due Date: Submit at the end of Week 4.

Requirements:

  1. Choose a level of care (primary, secondary, tertiary) to investigate payment models.
  2. … government provided insurance plan to investigate (Medicare, Medicaid).
  3. Choose any private insurance plan to investigate.
  4. Discuss the patient population each insurance plan represents.
  5. Define the payment models of the two insurance plans (government and private) when paying for services at the level of care you have chosen to review.
  6. Discuss the possible impact of each insurance payment model on access to care or choice of provider or facility.
  7. ……. insurance payment model on access to healthcare services or procedures.
  8. Discuss the possible impact of each insurance payment model on patient outcomes.
  9. Describe any economic, social or ethical issues that arise from having one insurance plan over another.
  10. The body of the scholarly paper is to be 3-5 pages in length excluding title and reference pages.
  11. Grammar, spelling, punctuation, references, and citations are consistent with formal academic writing and APA format as expressed in the 6th edition
  12. Include a minimum of three scholarly resources published within the past 5 years not including your textbook. References may include scholarly websites of organizations or government agencies and must be presented using APA format for electronic media.

SOLUTION  

Payment models are largely tied to the agreements between healthcare providers & payers, actual patients paying little role in how medical services are structurally funded.

Through Medicare, the government has more unilateral control over the pricing of services & the payment methods available. Typically, the payment model agreements reached between private insurers & providers mimic those reached between Medicare & providers. With less control over cost agreements, however, private insurance in a system that involves a large payer such as Medicare tends to increase dramatically in cost. With patients removed from the cost of the medical services they take dvantage of, costs have risen considerably. With a PPO plan, a person has the freedom to choose the providers of their tertiary care absent any need for referral from a primary care physican. However, they are still responsible for a significant portion of the medical costs they incur. ith Medicare, those who have paid Medicare taxes over the course of their lives receive extra beefits. Elderly & disabled people are given choices over what level of care they pursue, but they re still restricted in what the coverage they can afford provides in terms of quality & access.

Definitions

A preferred provider organization (PO) is essentially a broker of medical care that negotiates discounted prices from a networkof providers then charges access fees to insurance companies for the use of that network. In helthcare, a provider refers to the doctors, hospitals, & other professionals involved in the direct adinistration of care. An entity that provides health insurance is called the carrier. A subscriber to an insurance policy pays a premium in exchange for benefits, either covering the medical coss that individual incurs or sometimes in addition to the medical costs incurred by the individuals family. Those covered under a given policy are the

policy’s beneficiaries. The payer refers to the entity that actually transfers money to the provider in exchange for medical services. In a PPO policy, a patient is responsible for initial medical costs until the policy’s deductible is met, at which point the insurance carrier will pay coinsurance. Coinsurance is listed on a policy as the percentage of beneficiary medical costs an insurance company will pay after the deductible is met. Sometimes, policies that cover families have a deductible amount representative of the family’s aggregate medical costs & others offer family coverage with deductibles on a per-person basis. Deductible & coinsurance amounts are higher when a beneficiary uses a provider outside the PPO plan’s network, but subscribers to PPO policies are free to seek medical care wherever they choose & do not need a referral from a primary care physician to seek specialty care.

Patient Populations

Medicare is the largest single purchaser of personal healthcare in the United States, comprising 22% of overall healthcare spending in the country. Medicare is health insurance provided by federal & state governments for people aged 65 & older as well as disabled people under the age of 65. According to the Medicare Payment Advisory Commission (2017), 82.7% of Medicare beneficiaries are 65 & older without end-stage renal disease, accounting for 75.6% of Medicare spending.….please click the purchase button below to access the entire solution at $10