U.S. government and private sector health care financing models.


consider a scenario in which you are asked to compare U.S. government and private sector health care financing models.

Scenario
The hospital board of directors has made a request for you to provide and present a report to them on government and private sector healthcare financing models. As part of the report, the board of directors has asked you to also provide an overview of the types of Medicare policies and provider incentives for pay for performance. As part of the report, you have been tasked with completing two parts of the report.

Your report should include the following information:

A table that compares a government and private sector healthcare model.
A 300-word summary on the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance.
Instructions
Consider the scenario and complete both parts of this assignment using the Week 8 Assignment Template [DOCX] Download Week 8 Assignment Template [DOCX]for comparison of the government and private sector health care financing models. Complete the template using your own words and write a 300-word summary on the types of Medicare policies and provider incentives for pay for performance below the table. Three creditable sources are required for the assignment

Part 1: Comparing Health Care Models
In Part 1 of this assignment, you will compare the cost, access, reimbursement, and quality of government and private sector models. Choose one government and one private sector model from the list below and begin your research.

Government
Medicare.
Medicaid.
Veteran’s Administration.
Private Sector
Employer Provided Insurance.
HMO.
PPO.
One of the characteristics that you will consider—quality—should be assessed using the Centers for Medicare and Medicaid Services (CMS) Quality measures. Optional resources to aid your assessment can be found at:

National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures ReportsLinks to an external site..
Quality Measures: How They Are Developed, Used & MaintainedLinks to an external site.
HEDIS Measures and Technical ResourcesLinks to an external site..
Part 2: Summary of Medicare Policies and Provider Incentives for Pay for Performance

write a 300-word summary on the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance.

 

 

Sample Answer

 

 

 

 

 

Comparison of U.S. Healthcare Financing Models and Medicare Policies

 

This report compares the Medicare financing model (Government Sector) with the Employer-Provided Insurance model (Private Sector) and provides a summary of key Medicare policies and the transition to pay-for-performance incentives

 

 

Medicare is a comprehensive federal health insurance program whose scope primarily covers Americans aged 65 and older, younger people with certain disabilities, and people with End-Stage Renal Disease. The program is structured into four main parts: Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage, managed care plans), and Part D (Prescription Drug Coverage).

Insurance premiums vary by part. Part A is typically premium-free for those who have worked and paid FICA taxes for over ten years. Parts B and D require monthly premiums that are standardized but can be income-adjusted (known as IRMAA—Income Related Monthly Adjustment Amount). Medicare beneficiaries may also pay deductibles and co-insurance.

The policy regarding managed care and competition is centered on Medicare Advantage (Part C). These plans are offered by private insurance companies approved by Medicare. They encourage competition by allowing beneficiaries to receive their Medicare benefits through a managed care network (HMOs or PPOs) that often includes extra benefits like vision or dental, paid for by the government based on a risk-adjusted capitated rate.

Provider payments have shifted significantly away from traditional fee-for-service (FFS) toward value-based purchasing (VBP), which includes provider incentives for pay for performance. The goal is to reward quality and efficiency, not just volume. Key incentives are provided through programs like the Merit-based Incentive Payment System (MIPS), which adjusts Medicare Part B payments to providers based on performance in four categories: quality, improvement activities, promoting interoperability, and cost. Hospitals participate in the Hospital Value-Based Purchasing Program, where a portion of their Medicare payments is withheld and redistributed based on their performance in domains such as patient experience, clinical care outcomes, and efficiency. This shift aims to reduce costs and improve patient outcomes by aligning financial incentives with quality standards set by CMS. (Word Count: 298)

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