Introduction
Medicare and Medicaid systems providing medical services have been the center of American healthcare for a few decades. While it has been a well-functioning and dominantly accepted framework, the American healthcare system has been criticized for its inability to provide quality care for people across all socioeconomic spectrums. To oppose the criticism of the current system, policymakers supplement well-established frameworks with additional departments, regulations, and eligibility criteria to cultivate equal access to healthcare for all. This paper will examine the Medicaid system, investigate the role of the Quality Improvement Organization, review the Medicaid qualifications, discuss the impact of the Affordable Care Act, and analyze healthcare professionals as changemakers.
Quality Improvement Organization
Quality Improvement Organization (QIO) is a necessary component of the Medicare system. It oversees the operation of the Medicare program as a whole and assists in evaluating and implementing changes within the program’s environment. It is operated under the federal government and the U.S. Department of Health and Human (HHS) Services’ National Quality Strategy (Centers for Medicare and Medicare Services, 2020). Its primary goal is to ensure that people receive the best quality of care for lower costs. It consists of a number of qualified experts, doctors, and other health professionals whose aim is to increase care quality and enhance patients’ satisfaction, safety, and well-being (McWilliams et al., 2016). In a sense, professionals of QIO fulfill the role of stewards of assessment – they carefully review the services that hospitals and other medical institutions provide and implement changes if needed. More specifically, QIO is responsible for reviewing, investigating, and addressing all the complaints, appeals, and concerns that come from the patients’ side.
If to examine the role of QIO in improving the care of the Medicare services, its impact is fundamental. Firstly, as mentioned above, the group of QIO professionals examines all the inquiries regarding the quality of Medicare services. Furthermore, they are obliged to guarantee that “Medicare pays only for services and goods that are reasonable and provided in the most appropriate setting” (Centers for Medicare and Medicare Services, 2020, p. para. 3). The department of Beneficiary and Family-Centered Care (BFCC)-QIOs is responsible for reviewing the appeals of patients when they disagree with the medical provider’s decision to discontinue or discharge them of particular services.
Apart from tackling individual appeals and concerns of the patient population, reviewing law and regulation violations is also within QIO’s jurisdiction, which provides it with the ability to assess and facilitate policymaking. More specifically, it is the obligation of QIO to ensure that the Medicare services provided by the medical institutions adhere to the Emergency Medical Treatment and Labor Act (EMTALA). A specific program within the QIO called Quality Innovation Network-QIO unites medical workers, providers, and other relevant stakeholders to facilitate the optimization of healthcare systems and, consequently, influence policymaking (McWilliams et al., 2016). The abundance of information gathered from QIO’s operation helps them to create an evidence-based approach to make data-based decisions. It also helps medical professionals to implement the policy and related regulations quicker, as well as to adapt it to the cultural and regional differences of each particular area (McWilliams et al., 2016). Furthermore, QIO is one of the first responders when it comes to inequalities of healthcare, which makes them more aware of specific issues and their context (McWilliams et al., 2016). Thus, the broad scope of information that QIO gathers in the process of reviewing complaints and appeals helps policymakers to make decisions based on evidence rather than assumptions.
Qualifications for Medicare and Medicaid Benefits: Serving the Vulnerable Populations
Medicaid and Medicare qualifications cover an extensive group of people that can be considered vulnerable populations. Overall, pregnant women, children, people with disabilities, and the elderly are the ones who are qualified for federal aid. Furthermore, people and households with low incomes are also eligible for the programs (Sommers et al., 2019). Despite the original intent of help and an extensive list of benefits qualifications, some populations remain unattended by these programs due to their ineligibility. It is virtually impossible to consider all the communities in need since every individual has a set of cultural, socioeconomic, and psychological characteristics that broad program qualifications cannot account for. However, there are some specific issues that have been unaccounted for within Medicare and Medicaid systems that can be modified to provide better care for those who need it most.
One of the significant issues worth examining is the recent change in Medicaid qualification that now requires a considerable amount of previously eligible applicants to work. This regulation, as introduced by the Trump administration, has yielded mixed results (Sommers et al., 2019). The initial intent of the newly introduced qualification is aimed at increasing the level of employment among disadvantaged individuals who receive Medicaid. The policymakers hypothesized that receiving federal medical aid in the form of these programs results in people’s unwillingness to work (Sommers et al., 2019). Conversely, this new regulation would, hypothetically, motivate people to work and receive their insurance as employees (Sommers et al., 2019). In several states, it is now mandatory for receivers of Medicaid who are legally able to work to show their work history, volunteer hours, or work exemption.
Contrary to the predictions made by policymakers, this regulation did not make people healthier. The results of the study of Arkansas Medicaid receivers showed that more than 40% of people lost access to healthcare with no ability to receive other insurance (Sommers et al., 2019). A portion of people who started working lost their privileges since their income level rose; however, their work positions were not qualified for work insurance, leaving them more vulnerable than before. As it concerns individuals who were unable to receive benefits for other reasons, the lack of policy clarity and inability to file documents have been highlighted as the primary barriers (Sommers et al., 2019). These eligibility criteria appear to harm vulnerable populations, such as people who have a mental disability, addiction, or those in complex family situations (Sommers et al., 2019). Therefore, this policy has to be revised to, firstly, increase the ease of access to filing the necessary documentation and, secondly, exclude vulnerable individuals from the list of those who are required to work.
Affordable Care Act
The Affordable Care Act was introduced to exceed the coverage of medical services for more Americans and ensure that residents who need medical care the most have the opportunity to receive it. Although the Act was the necessary improvement at the time and significantly enhanced the quality of care, a number of issues related to health inequalities remain. Firstly, one of the benefits of the Affordable Care Act is the increased funding for Medicaid programs across the states (Courtemanche et al., 2018). Due to the Act’s implementation, more than twenty million American citizens who previously did not have any insurance received the opportunity to apply for the Medicare or Medicaid programs. According to Courtemanche et al. (2018), the median rate of a 10% increase in insurance coverage among disadvantaged individuals is noticed nationwide. Evidently, this finding suggests that the Affordable Care Act was beneficial for many people since it allowed them to seek medical care despite their socioeconomic background.
The second benefit of the Affordable Care Act that can be highlighted is the rise of accountable care organizations that spur collaboration and increased efficiency within the healthcare system. To elaborate, this improvement helped many private and federally-funded programs such as Medicaid to develop institutions and campaigns aimed at reducing spending on medical services and the degree of fragmentation (Courtemanche et al., 2018). The concept of fragmentation is relatively widespread in healthcare and is defined as a failure in aligning the goals, methods, and resources needed in the treatment of individuals (Courtemanche et al., 2018). Fragmentation has been a prominent cause of poor management of funds and increased risk of patient harm. The Affordable Care Act, due to the introduction of Accountability Organizations, was able to minimize fragmentation and cultivate collaboration.
However, there are also downsides to the Affordable Care Act. One of them is the rise in taxes that is the direct effect of the Affordable Care Act enabling more people to receive healthcare. The need for additional funding to sustain more extensive amounts of patients within the American system of healthcare requires additional funds (Courtemanche et al., 2018). While this downside is predicted to be temporary since an increased level of quality of life will eventually benefit the economy and return the spending, the current rise in taxes can be considered a problem.
From the same source of concern, lack of funding, the second problem of the increased price for premium insurance arises. Again, this is explained by the fact that more people are now covered by federal programs such as Medicaid and Medicare and receive free healthcare (Courtemanche et al., 2018). The government ensures that more disadvantaged individuals receive primary care through the increase in prices for premium packages. However, this trend presupposes that fewer middle-class citizens will not be able to afford the services they were previously entitled to. While this change might be beneficial if one is to look at the American population’s overall health, the individual ability to seek premium healthcare suffers.
Healthcare Leader and Advocacy for Cost-Effective Care
As a mindful and responsible healthcare leader, I have to be an active advocate for cost-effective and efficient care for vulnerable populations. This can be done through careful research, observation, contribution to policymaking, and adaptive leadership. To start with, the concept of adaptive leadership is defined by Belrhiti et al. (2018) as “actions of individuals in formal managerial roles who plan and coordinate organizational activities (the bureaucratic function)” (p. 1076). More specifically, adaptive leadership combines formal managerial responsibilities and hands-on experience. Thus, adaptive healthcare leaders should not only theorize about the needed change but get involved in the medical setting to pinpoint specific issues and challenges that patients might struggle with (Belrhiti et al., 2018). As a result of such an approach, one is able to recognize the problems as first responders and then have the ability and power to enact changes.
Therefore, the fundamental basis of good healthcare leadership is being observant, attentive, and action-oriented. If to examine the cost-effectiveness of care for vulnerable populations, healthcare leaders should pay special attention to the patients coming from disadvantaged environments (Belrhiti et al., 2018). Acknowledging the struggles they face in a medical setting, such as inability to afford treatment or medication, lack of insurance, specific illnesses, or threats that the population is endangered by, is the key to change-making. After witnessing the need for cost-effective healthcare first-hand, adaptive leaders can engage in a formal setting with other professionals, government officials, and policymakers (Belrhiti et al., 2018). Communicating the issues of vulnerable populations through data and an evidence-based approach is also essential (Belrhiti et al., 2018). Every healthcare leader must consider the disadvantaged individuals and seek equal access to medical services since advocacy is a key to helping all patients, which is the primary goal of any clinician.
Conclusion
In conclusion, it can be said that while there are some assessment and monitoring efforts within Medicaid and Medicare to prevent inequalities in healthcare, they do not fulfill the role of ensuring equal access to medical services. Affordable Care Act, in its turn, has yielded both beneficial and harmful results. Furthermore, the ongoing changes in eligibility criteria for federally-funded insurance appear to be discriminative and exclude certain groups of people. Thus, the role of a healthcare leader is especially prominent in attempting to eliminate stigma and discard any barriers to receiving treatment. Adaptive leadership is one of the vital change-making approaches to tackle the issue of the cost-effectiveness of healthcare.
References
Belrhiti, Z., Nebot Giralt, A., & Marchal, B. (2018). Complex leadership in healthcare: A scoping review. International Journal of Health Policy and Management, 7(12), 1073-1084. Web.
Centers for Medicare and Medicare Services. (2020). Quality Improvement Organizations. CMS. Web.
Courtemanche, C., Marton, J., Ukert, B., Yelowitz, A., Zapata, D., & Fazlul, I. (2018). The three-year impact of the Affordable Care Act on disparities in insurance coverage. Health Services Research, 54(1), 307-316. Web.
McWilliams, J., Hatfield, L., Chernew, M., Landon, B., & Schwartz, A. (2016). Early performance of accountable care organizations in Medicare. New England Journal of Medicine, 374(24), 2357-2366. Web.
Sommers, B., Goldman, A., Blendon, R., Orav, E., & Epstein, A. (2019). Medicaid work requirements: Results from the first year in Arkansas. New England Journal of Medicine, 381(11), 1073-1082. Web.