What are the roles of government-sponsored healthcare programs

If you fall under one of these categories, you may be eligible to start receiving health care with the assistance of federal programs. In addition, Native Americans may be eligible to enroll in a government-sponsored health care program if they meet certain requirements. Whether you want to obtain health care coverage for a short amount of time or you are looking for long-term assistance, these government programs can serve as resources for residents who qualify under different categories.

This article will help you learn about the different available plans and help you make a decision regarding what the best option for you and your family is. Moreover, the available government budget for these services also plays a role in eligibility.

It is important to note that veterans who became disabled as the result of a service-related incident receive priority in the VHA program. As a general rule, eligible veterans can obtain these benefits through one of 22 regional health care systems offering coverage through the VHA. Furthermore, the VHA program assists veterans with both physical and mental health needs.

In addition, Tricare coverage can be extended to the dependents of military service members, which means that entire families can gain health care coverage through this program.

Retired military personnel younger than 65 years of age are also eligible to receive health care coverage through the Tricare program. If you are older than 65 years of age and receive Social Security benefits due to a disability , you can enroll in the Medicare program offered by the government and gain access to health care coverage.

Moreover, seniors suffering from an end-stage renal disease are also qualified to receive benefits through the Medicare program. Furthermore, with your Medicare benefits, you will receive basic health coverage and be entitled to preventative care options as well.

These processes and the health care providers they monitor should be capable of assessing how well patients with chronic conditions are being managed across settings and time.

This capability necessitates consolidation of all clinical and service use information for a patient across providers and sites, a most challenging task in a health care system that is highly decentralized and relies largely on paper medical records. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values and circumstances guide all clinical decisions Institute of Medicine, Informed patients participating actively in decisions about their own care appear to have better outcomes, lower costs, and higher functional status than those who take more passive roles Gifford et al.

Most patients want to be involved in treatment decisions and to know about available alternatives Guadagnoli and Ward, ; Deber et al. Yet many physicians underestimate the extent to which patients want information about their care Strull et al. Patient-centered care is not a new concept, rather one that has been shaping the clinician and patient relationship for several decades. Authoritarian models of care have gradually been replaced by approaches that encourage greater patient access to information and input into decision making Emanuel and Emanuel, , though only to the extent that the patient desires such a role.

Some patients may choose to delegate decision making to clinicians, while patients with cognitive impairments may not be capable of participating in decision making and may be without a close family member to serve as a proxy. Patients may also confront serious constraints in terms of covered benefits, copayments, and ability to pay discussed below under benefits and copayments.

Principle of Patient Autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. The current focus on making the health care system more patient-centered stems at least in part from the growth in chronic care needs discussed above. Effective care of a person with a chronic condition is a collaborative process, involving extensive communication between the patient and the multidisciplinary team Wagner et al.

Patients and their families or other lay caregivers deliver much if not most of the care. Patients must have the confidence and skills to manage their condition, and they must understand their care plan e. For many chronic diseases, such as asthma, diabetes, obesity, heart disease, and arthritis, effective ongoing management involves changes in diet, increased exercise, stress reduction, smoking cessation, and other aspects of lifestyle Fox and Gruman, ; Lorig et al.

Pressures to make the care system more respectful of and responsive to the needs, preferences, and values of individual patients also stem from the increasing ethnic and cultural diversity that characterizes much of the United States. Although minority populations constitute less than 30 percent of the national population, in some states, such as California, they already constitute about 50 percent of the population Institute for the Future, A culturally diverse population poses challenges that go beyond simple language competency and include the need to understand the effects of lifestyle and cultural differences on health status and health-related behaviors; the need to adapt treatment plans and modes of delivery to different lifestyles and familial patterns; the implications of a diverse genetic endowment among the population; and the prominence of nontraditional providers as well as family caregivers.

Although there has been a virtual explosion in Web-based health and health care information that might help patients and clinicians make more informed decisions, the information provided is of highly variable quality Berland et al. Some sites provide valid and reliable information. There are also notable efforts to provide consumers with comparative quality information on providers and health plans.

These efforts are discussed further in Chapter 5. There is little doubt, however, that we are embarking on a long journey to determine how best to make valid and reliable information available to diverse audiences with different cultural and linguistic capabilities Foote and Etheredge, In general, communication with consumers is enhanced through the use of common terminology, standardized performance measures, and reporting formats that follow common conventions.

At the program level, the predilection of each government program to design and operate its health care quality enhancement processes independently is a serious problem.

Although the focus of this report is on quality enhancement processes, the committee believes it important to acknowledge other important program features—such as benefits, payment approaches, and program design and administration—that influence quality. Just as the quality enhancement processes of the government programs are being assessed in this report, these other aspects of program design must be evaluated in the future for alignment with the objectives of those processes.

Health insurance was established in the United States in the s and s as a way to help the average person cope with the high costs of hospital care Stevens, Today hospital care, although still very expensive, consumes about one-third of the health care dollar, and other facets of health care, such as prescription medications 9 percent with a growth rate of Increased demand for these other facets of care reflects the growth in chronic care needs discussed earlier as well as new treatment options stemming from the extraordinary advances made in medical knowledge and technology, including minimally invasive surgery.

Medicaid Florida c. The benefit package of an insurance program has a direct effect on the likelihood of patients receiving needed health care services Federman et al. Although there are frequent changes in the benefit packages of the various government health care programs, these modifications have not always kept pace with the needs, especially the chronic care needs, of the populations being served Bringewatt, When one assesses the extent to which the government health care programs provide coverage for benefits important to persons with chronic conditions, the results are mixed see Table The basic Medicare package, for example, generally does not cover outpatient prescription drugs or personal care, and coverage is very limited for preventive services, nursing home services, family counseling, and dietitian—nutritionist services.

Medicare payment mechanisms are designed for acute care, often by a single provider; there is no Medicare payment mechanism that recognizes care delivered by a team of providers to an individual with mul-.

Medicaid Arizona c. Medicaid Connecticut c. These three states were selected at random, and may or may not be representative of Medicaid plans in general. Other government programs offer important benefits in specific areas. VHA provides extensive mental health outpatient and inpatient services, especially for veterans with service-related disabilities.

Medicaid provides residential care to the disabled and mentally retarded and long-term care for the elderly as a major part of program spending. Its benefit package is very comprehensive, including complex therapies for chronic conditions and congenital neurological disorders, such as cerebral palsy and Down syndrome, although states vary substantially in the scope of such benefits.

Note that IHS is not included in Table because it is not an entitlement program or an insurance plan; therefore, it has no established benefit package Indian Health Service, It is estimated. Cost-sharing provisions are also important. Persons with chronic conditions are the heaviest users of health care services. Deductibles and especially copayments can be sizable for these individuals. Some government health care programs, such as VHA, have minimal cost-sharing provisions, while others, especially Medicare, make more extensive use of such provisions.

In some instances, the quantity and duration of certain repetitive services may be limited unless the person shows functional improvement, not just stability or a slowing of decline Anderson et al. Such analyses should be conducted under alternative financial scenarios, including budget neutrality and varying levels of growth in expenditures. Efforts should also be made to understand how well the benefit packages of various government health care programs meet the needs of vulnerable populations and how well these packages fit together for those who are dual- or triple-eligible.

Efforts to improve quality of care will be far more effective if implemented in an environment that encourages and rewards excellence. Unfortunately, current methods of payment to health plans and providers have the unintended consequence of working against quality objectives.

This is true for both capitated and FFS payment methods. Capitation is a payment arrangement in which health plans are paid a fixed amount for each enrollee under their care, regardless of the level of services needed by and actually provided to the person. Some health plans also pay physicians on a capitated basis for certain outpatient care, putting them at some degree of financial risk.

Capitated payment rates are usually based on the average cost per enrollee of the enrolled group, often with adjustments for demographic characteristics e. Capitation rates are usually not adjusted for the health status of the enrolled population.

Therefore, health plans and providers receive the same payment for someone who is less healthy and more likely to use a large number of services, such as a person with a. Health plans or clinicians that develop exemplary care programs for persons with chronic conditions may, as a result, attract a disproportionate share of these individuals.

Under capitated payment systems, this situation has a highly negative financial impact on the health plan and providers Luft, ; Maguire et al.

Persons with chronic conditions are more likely both to use services and to use a greater number of services during the year than those without chronic conditions. The average number of inpatient days per year is 0. Risk adjustment is a mechanism designed to ensure that payments to health plans and other capitated providers more accurately reflect the expected cost of providing health care services to the population enrolled.

Capitated plans and providers caring for a population that includes less healthy, higher-cost enrollees should receive higher payments. As more states require their entire Medicaid populations, including those who are disabled and have high health care needs, to enroll in managed care, adjustment of payments becomes even more necessary to ensure quality of care for enrollees Maguire et al.

Some states have addressed this issue. Michigan, for example, has created a separately funded capitated option for children with special health care needs Department of Health and Human Services, Numerous options exist for risk-adjusting payments, but their application in government health care programs has been limited Ellis et al.

Regardless of whether the beneficiary is enrolled in an indemnity or capitated plan, the physicians on the front line of care delivery in the private sector are generally compensated under FFS payment methods Center for Studying Health System Change, ; Institute of Medicine, Under FFS payment, physicians have strong financial incentives to increase their volume of billable services e. Sometimes the incentives of FFS or other physician payment methods are attenuated by incentives e.

In a — survey of a nationally representative sample of physicians, fewer than 30 percent indicated that their compensation was affected by performance-based incentives, a result similar to findings from a survey conducted in — Stoddard et al. When they are used, performance-based incentives are more likely to be tied to patient satisfaction 24 percent and quality measures 19 percent than to measures that may restrain care, such as profiling 14 percent.

Services such as e-mail communications, telephone consultations, patient education classes, and care coordination are important for the ongoing management of chronic conditions, but they are not reimbursable events. Moreover, physicians who communicate with patients through e-mail or telephone to emphasize patient education, self-management of chronic conditions, and to coordinate care may experience a reduction in overall revenues if these uncompensated services have the effect of reducing patient demand for or time available to devote to reimbursable face-to-face encounters.

There is no perfect payment method; all methods have advantages and disadvantages. FFS contributes to overuse of billable services e. Overuse, especially the provision of services that expose patients to more potential harm than good, is a serious quality-of-care and cost concern. On the other hand, capitated payments may contribute to underuse—the failure to provide services from which patients would likely benefit.

This is especially true when there is a good deal of turnover among plan enrollees so that the long-term cost consequences of underuse tend to be borne by another insurer. Although particular payment methods may contain a bias towards underuse or overuse, it is important to note that the quality-of-care literature contains ample evidence of both phenomena occurring in both FFS and capitated payment systems, reinforcing the notion that payment is but one, albeit an important, factor influencing care Chassin and Galvin, The committee believes enhancements can be made in both capitated and FFS payment approaches to encourage the provision of quality health care.

It should also be noted that there are some promising efforts under way to design alternative payment approaches and evaluate their impact on quality. The National Health Care Purchasing Institute, a nonprofit research institute supported by The Robert Wood Johnson Foundation, has identified various incentive models that might be effective in motivat-.

Quality bonuses —An additional annual payment is made to a provider usually 5 to 10 percent of annual compensation based on the achievement of certain performance goals. Numerous efforts are under way to test some of these approaches.

Examples include the following:. PacifiCare in California has developed a quality index that profiles providers on the basis of measures of clinical quality, patient safety, service quality, and efficiency. This information is used to reward providers on the basis of their performance, as well as to construct a tiered system of premiums, copayments, and coinsurance rates for enrollees that vary inversely with provider performance in terms of quality and efficiency Ho, Blue Shield rates hospitals on the basis of measures of quality, safety, patient satisfaction, and efficiency Freudenheim, It may be hoped that much more will be known about the impact of various financial and non-financial incentive models in the near future.

This initiative is being evaluated under an Agency for Healthcare Research and Quality contract. Benefits coverage and payment methods are among the most important design features of the six government health care programs reviewed in this report, but they are not the only ones that influence the likelihood of patients receiving high-quality care. Other important features include delivery system and provider choices, fluctuations in eligibility and delivery system options, and administrative efficiency.

In some government health care programs, consumers have multiple options in terms of delivery system and choice of providers, while in others the options are more limited. Under Medicare, 87 percent of beneficiaries have chosen to enroll in FFS arrangements, which provide extensive choice of clinicians and hospitals.

Enrollment in managed care is mandatory for the majority of the Medicaid population in most states, and in some instances, there is little or no choice of plan. Studies of the clinical quality in terms of both medical care processes and patient outcomes in managed care and indemnity settings consis-. But it is clear that some consumers have strong preferences for one delivery system over another, and that most prefer to have choice Gawande et al. Limited choice of health plans may or may not seriously constrain the choice of clinicians and hospitals, since plan networks vary greatly in size and structure Lake and Gold, In the private sector, there has been a pronounced trend in recent years toward larger networks of providers in response to consumer demand for more extensive choice Draper et al.

In the absence of comparative quality information on providers, consumers apparently equate choice with quality. The design and financing of some government health care programs result in frequent changes in eligibility and delivery system options that disrupt patterns of care delivery. Since , 2. Of the health plans that remain, the proportion offering prescription drug coverage during the period through dropped from 73 to 66 percent, and the proportion charging zero premiums to beneficiaries from 62 to 39 percent Gold and McCoy, Under Medicaid, beneficiaries move in and out of the program as their eligibility changes in accordance with minor fluctuations in income, causing beneficiaries to lose contact with providers and further complicating the tracking of care.

Lastly, efforts must be made to reduce administrative burden. In recent years, there has been a steady growth in regulatory requirements in most if not all of the government health care programs. The American Hospital Association has identified new or revised regulations pertaining to hospitals that have been issued by federal agencies since , of which 57 are significant. Some of these regulations relate to quality enhancement processes and data requirements, while others relate to such areas as payment, patient confidentiality and privacy, and fraud and abuse.

The current practice of promulgating separate regulations for each type of provider e. Unnecessary regulations frustrate clinicians and reduce the time available to devote to patient care. They can also interfere with the movement of individuals across settings, thus hampering the transition from hospital to nursing home to home health agency, for example. Regulatory burden must also be fair. These issues are addressed further in Chapters 3 and 4.

In summary, while technically comprising separate areas of analysis, the issues of benefits, payment, program design, and administration are inextricably linked to achieving consistent levels of high-quality care. Administration on Aging. Agency for Health Care Administration. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 3. American Hospital Association. Patients or Paperwork? Anderson, G. Hall, and T. When courts review medical appropriateness.

Med Care 36 8 Health Aff 20 6 Bailit Health Purchasing. Berland, G. Elliott, L. Morales, J. Algazy, R. Kravitz, M. Broder, D. Now comes Robert Frank, a Cornell economist, who has proposed ways of overcoming opposition to some kind of government- and therefore taxpayer- funded solution to the problem. He has put his finger on the two main obstacles to major change in the current system, insurance company opposition and higher taxes. He suggests that insurance companies, who have acted in good faith to respond to incentives provided by the market, could be subsidized for their losses while their managements shift their health insurance strategies, perhaps to provide only supplemental private coverage.

He proposes that the other obstacle, higher taxes, could be overcome through an effort to educate the public about the long-term economic benefits of such a move. How his proposal would fare in the face of previous failures is a real question. Given their magnitude, failure to solve these problems in the U. But are we addressing them with the creativity they deserve?

For example, to combat opposition to a tax increase, could tax credits for later use when savings kick in be issued to individuals and businesses in the amounts by which their taxes are increased?

To provide universal insurance, could the government provide vouchers along with consumer-oriented education to all uninsured to be used at their discretion for their own care? In other words, could a consumer-driven solution be combined with a single-payer system? What can the U. What is the government's role in U.

Major Issues pertaining to Government Sponsored Health Care Programs Some of the major issues faced by government in arrangements and organizations of funded health care services are discussed below. Healthcare Expenditures As technology and science has been advancing day by day, so as it affects the healthcare services and medications. It has advanced the medical systems and treatments thus added into the total cost and expenditures associated to it. This has become a constant issue for both public and private healthcare settings.

However these changes has ultimately improved the lives of patients and decreased sickness and death rates effectively. The federal government and state is playing an active role in allocating more and more funds to government healthcare program and affecting private insurance institutions. In addition, these higher costs are striking private industry heavily.