Challenges in Medicaid Managed Care, Essay Example

Medicaid and Medicare are government programs that have allowed the impoverished and elderly to access medical care. Many critics of these programs believe their implementation is too costly, and that there is not sufficient room in the federal budget to continue to support them (Santerre & Neun, 2012). However, others argue that the benefit of such programs outweigh the detriments and improve the economic situation of the country. While taxes fund such programs, it is necessary to understand that the public would pay more money for the care of the individuals that qualify for these programs through the need to compensate their medical bills, which would be much higher without these programs in place. Furthermore, contributing to the care of these individuals helps build towards a healthier country, in which the effects of health among the impoverished and elderly can ultimately contribute to the health of the population as a result of epidemiological principles.

Medicaid and other forms of government provided health care are important because it helps manage the costs of health care. As such, it is closely monitored for efficiency in a manner that confers benefit to the young, low income families, and elderly members of society. Medicaid is reimbursed both by federal and state, which allows people to access these programs independently of their location; it is purely needs based. As a result, however, some problems arise because state funds must be issued to support these programs as well, and the extent to which states must pay depends upon the size, needs, and income of the state. As a consequence, not all individuals are eligible for Medicaid coverage. States that can only cover a certain number of individuals must rank them based on the priority of their cases, which means that many people cannot gain health insurance coverage if they need it. Furthermore, the number of people who are able to access coverage or cannot access it depends upon the state from which these individuals derive. This is unfortunate because the Medicaid program is supposed to be equal for all individuals that are eligible for the program and who are currently enrolled.

While Medicaid and Medicare programs are typically considered to fall under the same category, there is a greater level of opposition present against the Medicaid program. While the elderly individuals who are eligible for Medicare often have spent their lives working, therefore contributing to the funds in this program themselves, individuals on Medicaid are often not present in the workforce, due to disability or an inability to acquire a job that is reasonably able to support them. These individuals are able to apply for this program to ensure that despite their employment status, they are able to receive care. However, many critics of the program believe that individuals should not receive these government funds for free, and should be required to work or perform some type of service in exchange. This creates a variety of challenges with regards to Medicaid managed care that must be considered, not only for economic purposes but in terms of the actual quality of care these patients receive as well.

According to existing economic knowledge, the efficiency of a health economy can be analyzed based on its performance. These performance factors include cost, access, and quality of medical care. Since economic resources are usually scarce, society tries to produce the best combination of goods and services using least cost methods that results in trade off. This has resulted in the need to modify Medicaid practices. Currently, this version of insurance is heavily impacted by cost and use. As a consequence, many individuals that rely on its use are not able to get quality care, which is exemplified by the small amount of time doctors are able to spend with their patients in addition to the types of services the insurance covers.

As mentioned above, one of the leading concerns of Medicaid managed care is that individuals who subscribe to these programs are not receiving care that is equal to those who utilize health insurance to see their physicians. Physicians are typically able to select which forms of insurance they will accept, and this is usually related to the specific forms of care that these agencies cover and how this connects to the type of care that the doctor provides. In many cases, doctors will elect to not accept insurance if they believe that they will not be fairly compensated from these programs. However, doctors are not permitted to withdraw from accepting Medicaid, which creates problems for the quality of care that many patients that rely on this program receive. The first problem associated with this insurance is that doctors will want to spend less time with these individuals. Despite the number of tests and guidance that these patients may need, the doctor will not profit if he or she spends a long time with these individuals because there is a cap on the reimbursement costs that can be provided by the Medicaid program. Therefore, many physicians break their ethical vows to their field, creating a disparity in health care that exists despite the fact that these individuals have insurance. As a consequence, impoverished individuals, including those on the Medicaid program are more likely to suffer from uncontrolled diabetes and related preventable health problems.

An additional concern is that even when physicians do not need to run a lot of tests on patients using Medicaid, they will find a way to ensure that they can bill for the maximum amount of reimbursement allowed. This is one technique that physicians use to offset the costs of seeing these patients, and billing for care that was not given is certainly an illegal technique. In doing so, these physicians are taking advantage of the government and tax payer funds in order to accomplish their own means. However, many of these individuals believe that they are justified because they need to support themselves in order to keep their businesses afloat. While accepting Medicaid is financially challenging for the physician, however, it is essential for them to accept this form of insurance despite associated risks. This insurance was set up as a means to help individuals that are unable to acquire their own insurance, and for this program to be successful, everyone including the physicians needs to participate.

In terms of epidemiological principles, health care professionals claim that Medicaid is an effective program because it allows many individuals to have access to primary preventative care, when this would not have been possible otherwise. Primary preventative care often includes vaccinations and the provision of other materials that will prevent the onset of serious illness. Therefore, Medicaid allows individuals in need to have access to the flu shot in addition to other necessary vaccinations that help protect not only their health, but the health of the public as well. It is important to understand the concept of herd immunity to comprehend how this occurs. When individuals in the population are provided with vaccinations, they are less likely to get the disease they are being protected against. Furthermore, once they are protected, they will be less likely to infect another individual. Therefore, providing the impoverished with vaccinations is important because it helps reduce the likelihood that other members of the population who have not received the vaccination will get sick. This is an example of how Medicaid helps promote public health. When individuals with this insurance recognize the importance of care, they can contribute directly to the benefit of the overall population.

Despite the utility of this concept, many individuals who have been allotted Medicaid care do not understand this and other health care concepts, and are unlikely to use the care they are given unless they find themselves in an emergency. While this is the general case for many individuals with private insurance as well, this happens disproportionately to individuals that rely on Medicaid. It is important to understand that many of the people using Medicaid have had bad experiences with doctors in the past, including being billed for aspects of care that they did not expect to need to provide. Since money is still a problem for these people despite their access to care, transportation to the physician is also problematic, as is finding the time to leave work to actively seek care. These individuals are generally worried about their survival but do not fully understanding how seeking medical care could assist with this, as the need to work and earn money for food and other necessities is more immediately important. While these problems could be resolved in part due to the establishment of education programs and the provision of additional support services, this would be considered costly and therefore pose an additional challenge to the implementation of the Medicaid program. An additional economic concern is how the Medicaid program is related to supply and demand. Health economic deals with health how health resources are allocated and Medicaid services are distributed in society. This is an important understanding because it means that the cost of health care services and goods can vary between locations, therefore preventing the acquisition of these services from being equal on another front. Some of these resources include medical supplies example pharmaceutical goods and latex rubber gloves or lines. It also includes personnel, such as physicians and lab assistance. In some states, such as New York, costs are high due to an increased cost of living. In addition, there are also many people so some doctors prefer to spend less time with their patients. This is responsible for compromising patient care.

It is important to consider that part of the reason that care is compromised for patient on Medicaid is that they elect to not use the care that they are given. When this occurs, many people who are not eligible for this health insurance are prevented against its access. Overall, this has a harmful impact on not only the health of these individuals, but also on the health care supply and demand. If there appears to be a low demand for government funded insurance, it is likely that less of it will be awarded in the future due to its inherent expense.

Studies have shown that individuals on Medicaid are not only poorer than the average individual; they are also sicker (Paradise & Garfield, 2013). These studies have been conducted within recent years and have shown that at least 35% of the individuals that are eligible for Medicaid care have chronic illnesses, such as diabetes. Furthermore, the study conducted by Paradise & Garfield demonstrates that all individuals eligible Medicaid live below the poverty line. This is tied into the fact that the government would need to spend additional medical funds on these individuals in order to provide them with treatment at to return them back to their normal health. Even when the physicians these individuals see support this mission, individuals with this form of insurance are typically less compliant with regards to the wishes of their health care advisors. While these individuals wish to recover, they often do not understand what is necessary in order to ensure that they can enact their doctor’s wishes, and in other cases they are simply not motivated to do so. For example, there are many individuals on Medicaid that visit their physicians for complications related to diabetes, yet they are unwilling to regularly check their blood glucose levels or take their insulin. Rather, they attend the doctor looking for a quick fix, such as surgery, when their feet start to become impaired as a consequence of their health habits. These individuals are also less likely to comply with dietary and exercise recommendations, which ultimately means that the health care advice provided to them by their physicians will not be beneficial in helping them recover. This problem could also be resolved with additional funding, but again, these support services would require additional room in the budget for these individuals. Monitoring programs would help these individuals recover, but in many cases, health care professionals would have to travel to the homes of these individuals. While there are some non-for-profit organizations that provide this kind of care, this would not be feasible for regularly practicing physicians who would make more profit by remaining within their office to provide care.

In terms of financial challenges related to this program, it is essential to consider that the costs of the program are rising. This is mainly related to the influx of immigrant populations from other nations who have yet to establish themselves in this country. Furthermore, the descendants of the individuals are typically not able to work due to cultural constraints, such as failure to understand the English language, which makes it more challenging for these individuals to find jobs. Economists are worried that despite the low costs that are associated with the program for each patient that seeks care, the number of individuals who are eligible for the program and need to use it will grow past the point of sustainability. While most people think of Medicaid as a government funded and operated program, it is important to consider that this is no longer the case due to the growing expense related to management of the program. As a consequence, private health insurance companies have become partners in the operations of this program.

“Beginning in 1982 and accelerating in the 1990s, states began to address these problems by contracting with private health insurance companies to provide care for at least some Medicaid beneficiaries through capitated contracts with what became known as Medicaid Managed Care Organizations (MCOs)” (Book, 2012). Starting in 2010, these organizations handled the care of more than half of the individuals enrolled in Medicaid programs. However, while this type of solution helps to offset initial costs for the government, it ultimately makes the program become expensive because the private health care organizations aim to profit from such partnerships, whereas the program as facilitated by the federal government only had the care of its citizens under consideration.

Another major criticism of the program is that it lacks actuarial soundness. When private health insurance companies calculate their monthly charges and copayments, they need to perform calculation that determine how much their services are worth based on the risk of sickness and associated costs for a variety of medical needs. As a consequence, these programs can sustain themselves in a manner that allows them to profit while providing their client with necessary health care and their doctors with reimbursement. These programs work because they allow these payments to contribute to the pool of money that is then used to fund the patients and physicians who request it.

When physicians request funds from these organizations, they more accurately track what the money is being requested for and how much was needed over time. In this manner, the company can determine if the physician is asking for too much, which also helps them to mitigate risk. However, Medicaid does not have these programs in place. Since their goal is to offer a small price for medical services, there is little consideration about where the funds for the program comes from, which makes it challenging to support. Without having created a program that is actuarially sound, there will be increasing demands for funds as the popularity of the program continues to grow, with no end in sight. Since this money comes directly from the tax payers, it will become necessary for taxes to be increased or for the Medicaid budget to increase if this program is to be sustainable. Furthermore, there is little money available for determining whether the charges to the program are fraudulent, which results in the government program naturally losing funds.

Overall, the challenges related to the implementation of Medicaid is related both to the needs of the population the program intends to serve in addition to the natural state of the program’s implementation. For Medicaid to be completely effective, it is necessary to supplement this program with other safeguards including education programs and patient monitoring to ensure that their health advice can be followed despite their personal habits. In addition, it is important to help these individuals with the resources necessary to visit the doctor when work conflicts and transportation fees are problematic. Furthermore, it is necessary for the government to reconsider how this program works. Currently, it is too expensive and popular to be sustainable, which will continue to be problematic because more and more people will need the services that it provides. Therefore, it is necessary for government officials to recognize these problems and address them in an economically sound manner. While the Medicaid program has the ability to do much good for those who need it, it isn’t currently being utilized to its fullest extent.

References

Book R. (2012). Benefits and Challenges of Medicaid Managed Care. Forbes. Retrieved from http://www.forbes.com/sites/aroy/2012/10/18/benefits-and-challenges-of-medicaid-managed-care/

Paradise, J., Garfield R. (2013). What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight on the Evidence. Retrieved from http://kff.org/report-section/what-is-medicaids-impact-on-access-to-care-health-outcomes-and-quality-of-care-setting-the-record-straight-on-the-evidence-issue-brief/

Santerre. E. R. & Neun. P. S. (2012). 5th Edition- Health Eonomics Theory, Insights , and Industry Studies.