NR 552 Week 4 Assignment: Healthcare Insurance Comparison Paper

Category: NR 552 Economics of Healthcare Policy

NR 552 Week 4 Assignment

Medicare Vs PPO Payment Models

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,

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: NR 552 Week 4 Assignment: Healthcare Insurance Comparison Paper

Introduction

The healthcare insurance landscape in the United States is characterized by a complex mix of government and private insurance plans, each with distinct payment models, patient populations, and impacts on healthcare access, services, and outcomes. This paper compares and contrasts Medicare, a government-provided insurance plan, with a private insurance plan, UnitedHealthcare, at the tertiary level of healthcare service. The analysis includes an examination of the patient populations served by each insurance plan, the impact of payment models on access to care and patient outcomes, and the evaluation of economic, social, and ethical issues arising from these payment plans.

Patient Population Served by Each Insurance Plan

Medicare

Medicare primarily serves individuals aged 65 and older, younger people with disabilities, and patients with End-Stage Renal Disease (ESRD). The program provides coverage to over 63 million Americans, offering various parts that cover hospital care, outpatient services, and prescription drugs (Centers for Medicare & Medicaid Services, 2023).

UnitedHealthcare

UnitedHealthcare serves a broad demographic, including individuals and families across all age groups. It is one of the largest private insurers in the United States, covering over 48 million people (UnitedHealthcare, 2023). The plan offers various products, including employer-sponsored plans, individual and family plans, and Medicare Advantage plans.

Payment Models of Medicare and UnitedHealthcare

Medicare Payment Model

At the tertiary level of care, Medicare primarily utilizes the Prospective Payment System (PPS) for hospital services. This model sets predetermined rates for specific services based on diagnosis-related groups (DRGs). Hospitals receive a fixed amount for patient treatment, incentivizing cost efficiency and resource management (CMS, 2023).

UnitedHealthcare Payment Model

UnitedHealthcare typically employs a fee-for-service (FFS) model for tertiary care, where healthcare providers are reimbursed for each service performed. This model may also include value-based care initiatives, where payments are tied to patient outcomes and quality metrics, encouraging providers to focus on cost-effective care that improves patient outcomes (UnitedHealthcare, 2023).

Impact on Access to Care and Services

Medicare

Medicare’s payment model can impact access to care, particularly in rural or underserved areas where hospitals may struggle with the fixed payments under PPS. However, Medicare provides broad access to a range of services, including specialized procedures, given its extensive coverage and patient base.

UnitedHealthcare

The fee-for-service model used by UnitedHealthcare can offer greater flexibility in accessing care and choosing providers, as payments are made per service provided. However, access may be limited by the network restrictions common in private insurance plans, which could affect patients' ability to receive care from their preferred providers or facilities.

Impact on Patient Outcomes

Medicare

Medicare’s focus on cost efficiency under the PPS model can lead to variations in patient outcomes, especially in cases where hospitals prioritize cost-saving measures over comprehensive care. However, Medicare’s coverage of preventive services and chronic disease management can positively influence patient outcomes over time (CMS, 2023).

UnitedHealthcare

UnitedHealthcare’s value-based care initiatives, integrated into its FFS model, aim to improve patient outcomes by aligning provider incentives with quality care. This model encourages better care coordination and management of chronic conditions, potentially leading to improved patient outcomes compared to traditional FFS models (UnitedHealthcare, 2023).

Economic, Social, and Ethical Issues

Economic Issues

Medicare’s fixed payment rates may result in financial strain for hospitals, especially those in low-income areas, potentially leading to service cutbacks or closures. On the other hand, UnitedHealthcare’s FFS model could lead to increased healthcare costs due to the potential for overutilization of services.

Social Issues

The population served by Medicare is generally older and more vulnerable, raising concerns about equitable access to care, particularly in resource-limited settings. UnitedHealthcare’s model may create disparities in access due to network restrictions and varying levels of coverage, impacting lower-income populations disproportionately.

Ethical Issues

The ethical implications of Medicare’s cost-containment strategies may include the potential for reduced quality of care, particularly in underserved areas. UnitedHealthcare’s emphasis on value-based care raises ethical questions about the balance between cost savings and the quality of patient care, particularly in complex cases where outcomes are difficult to measure.

Conclusion

Comparing Medicare and UnitedHealthcare at the tertiary level of care reveals distinct differences in their payment models, patient populations, and impacts on access to care, services, and outcomes. While Medicare offers broad coverage with a focus on cost efficiency, it may face challenges in maintaining quality and access in certain settings. UnitedHealthcare’s fee-for-service model, enhanced by value-based care initiatives, provides greater flexibility but may lead to increased costs and access disparities. Both plans present economic, social, and ethical challenges that require careful consideration in the ongoing efforts to improve healthcare delivery in the United States.

References

• Centers for Medicare & Medicaid Services. (2023). Medicare program overview. https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html
• UnitedHealthcare. (2023). UnitedHealthcare: Insurance for Individuals, Families & Employers. https://www.uhc.com/