Health_Care_System_Evolution

Health Care System Evolution Brook Rayworth HCS310 September 26, 2011 Health Care System Evolution CMS or Centers for Medicare and Medicaid Services is a public-sector program, and one of the major financers of health care servicing a very large portion of the United States population. CMS is part of the government’s role in the health care system. Medicaid, according to “Medicare.gov the official U.S. Government Site for Medicare” (2001) is “a joint Federal and State program that helps pay medical costs for some people with limited incomes and resources” (para. 1). To receive a better understanding of how CMS has helped to evolve the health care system, in this paper the subjects to discuss are CMS’s benefit structure, a brief look at the origins of CMS, the competitive bidding program, and how CMS addressed congressional directives. Benefit structure Medicaid and Medicare are two different programs. Medicaid is a state governed program. Eligibility for Medicaid is intended for low income pregnant women, children under the age of 19, and for people 65 and over, are blind, are disabled, or in need of nursing home care (Medicare.gov the official U.S. Government site for Medicare, 2001). Medicare is a federal governed program. Eligibility for Medicare is intended for people who are 65 years of age and over, are permanently disabled to the extent that cannot work, or people of any age experiencing kidney failure or long-term kidney disease ("Medicare.gov The Official U.S. Government Site For Medicare", 2001). Although Medicaid and Medicare are different programs, some people do qualify for them both and are referred as ‘duel eligible’. Brief Origin One way to learn how Medicaid and Medicare have influenced current health care systems is to learn the origins and focus of the programs. According to a PowerPoint presentation from the Henry J. Kaiser Family Foundation, Medicaid was “enacted in 1965 as companion legislation to Medicare (Title XIX) that provided federal matching grants to states to finance care and focused on the welfare population: single parents with dependent children, aged, blind, disabled” (2005, slide 6). This enactment of Medicaid and Medicare led to an increase in utilization that also leads to an increase of costs and expenditures. It is this increase in cost expenditures that allowed Medicaid and Medicare help the health care system evolve by prompting decision makers of both the private and public sectors to ensure that with these increases that the quality of health care did not suffer. It should be noted that according to the PowerPoint presentation from the Henry J. Kaiser Family Foundation (2005), eligibility was not expanded to women and children until between the years 1984-1990. After 19 years CMS evolved enough to realize the importance of adding women and children to the benefit. Competitive Bidding Program In an effort to evolve the CMS came up with a program to replace outdated prices that Medicare was paying to help lower the costs and get more accurate prices in the process. This program, the Competitive Bidding Program, took effect on January 1, 2011 in certain areas of the following states: California, Florida, Missouri, Kansas, North Carolina, South Carolina, Ohio, Kentucky, Indiana, Pennsylvania, and Texas (Centers for Medicare and Medicaid Services, 2010). This program is expected to expand to more areas in the future. How it works is suppliers have to submit bids on particular supplies and equipment. These bids have to be lower than what Medicare now pays for those supplies and equipment. Based on the bids Medicare sets an amount it is willing to pay and as long as the suppliers are qualified and accredited they are chosen to be contract suppliers. Rising health care costs are addressed with this program as well as access to quality medical equipment, supplies, and services from credible suppliers, and it helps to limit fraud and abuse within the Medicare program ("Medicare.gov The Official U.S. Government site for Medicare," 2010). Congressional Directives Funding for CMS comes from the government. Congress has the responsibility of deciding how funding is dispersed to the CMS. The U.S. Constitution gives Congress this power and Congress gets the funds by levying taxes. This power has various provisions stated in the Constitution and is called the congressional “power of purse” (United States Government Accountability Office, 2008, p. 2). However, Congress still can set the terms and conditions for receiving this funding. According to Medicare.gov the Official U.S. Government site for Medicare (2010), “the private sector and the Federal government rely heavily on the NQF-endorsement process to identify potentially useful quality measures” (para. 2). CMS is using those measures to meet the terms and conditions set by Congress to receive the full amount of funding they are permitted annually. Federal and private sector provider quality measurement efforts greatly have improved because of this process. Conclusion Since 1965 CMS has been expanding to help cover more of the uninsured people whom because of their inability to pay have put financial burdens on hospitals and medical facilities. However, the uninsured also benefit by receiving health care they could not receive without the help from CMS. It becomes clear how CMS has helped to evolve the health care system. First they expanded to include women and children that greatly increased utilization of the program and the costs and expenditures; however, it also prompted decision makers to step up and ensure that the quality of health care did not suffer. Then CMS created the competitive bidding program that helped to lower costs on durable medical equipment, established more accurate prices, and gained more credible and trustworthy suppliers. Finally CMS used the NQF’s potentially quality measures to address congressional directives to ensure that they received proper funding for the program (that helps millions of people get the health care they need) while uniting the federal and private sectors. References Centers for Medicare and Medicaid Services. (2010). Durable Medical Equipment and Supplies. Retrieved from http://www.medicare.gov/Publications/Pubs/pdf/11363.pdf Medicare.gov the official U.S. Government site for Medicare. (2001). Retrieved from https://questions.medicare.gov/app/answers/detail/a_id/65/~/what-is-medicaid-and-who-does-it-cover%3F Medicare.gov the official U.S. Government site for Medicare. (2010). Retrieved from https://questions.medicare.gov/app/answers/detail/a_id/2285/kw/The%20Competitive%20Bidding%20Program The Henry J. Kaiser Family Foundation . (2005). Key Medicare and Medicaid Statistics [PowerPoint slides]. Retrieved from http://www.kff.org/medicaid/upload/Key%20Medicare%20and%20Medicaid%20Statistics.pdf. United States Government Accountability Office. (2008, January). Congressional directives selected agencies' processes for responding to funding instructions. Report to Congressional Addresses, p. 2. [pic][pic]