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Medicare Impact on Healthcare Ecosystems Essay

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Updated: May 23rd, 2020

Medicare is an important part of the healthcare ecosystem in the US. It ensures that many Americans have access to healthcare. This paper reviews five aspects of Medicare.

Impact of Medicare on Licensure, Certification, or Accreditation

The US medical system requires healthcare facilities and professionals to apply for licensing before offering medical services. The issuance of licenses depends on compliance with state laws and federal regulations (American Health Lawyer Association, 2013). Healthcare facilities must be at a minimum acceptable standard to receive licenses to offer medical licenses. On the other hand, healthcare professionals must also meet given criteria to qualify for a license. Licenses ensure that healthcare facilities and professionals have the capacity to offer a certain minimum standard of care.

Certification of healthcare facilities and healthcare professionals is a means of verifying the credentials of the facility and the healthcare professionals. Certificates usually give patients the confidence that healthcare providers have the skills needed to handle their concerns. On the other hand, it gives patients the assurance that the healthcare facility taking care of their needs maintains the requisite standards of care in the eyes of the authorities.

Accreditation is a voluntary process where a healthcare institution subjects itself to evaluation by an accrediting agency (Niles, 2010). Accreditation is important because it helps an institution to communicate to the stakeholders its commitment to quality in various aspects of its operations. The Joint Commission runs several voluntary accreditation programs for healthcare institutions. These programs can help healthcare institutions to demonstrate their commitment to quality as participants in Medicare.

How Does Medicare Influence Clinical Quality?

Medical services depend on the facilities and standards of a healthcare institution, as well as the skills of the medical personnel in the facility. In this sense, Medicare influences clinical quality in two ways. First, Medicare reimbursements depend on the quality of care provided by physicians. Secondly, Medicare reimbursements depend on the quality of care provided by healthcare institutions.

The Physician Quality Reporting System (PQRS) developed by the Joint Commission ensures that physicians send quality reports to qualify for incentive pay (LaTour & Eichenwald, 2013). Physicians can qualify for incentive pay for their quality reports show that they have offered high-quality services to their patients. On the other hand, physicians who do not file quality reports run the risk of losing some money by pay adjustments from the Joint Commission. If they fail to file their reports, they risk earning less money.

The Hospital Value-Based Purchasing (HVBP) Program helps to guarantee clinical quality in healthcare institutions (American Health Lawyer Association, 2013). The goal of this program is to ensure that hospitals focus on the quality of care, and not just the quantity of care given to patients.

The main aspects considered under this program include the process used by the hospital to handle patients, the experience of the patients during care, the outcome of the medical interventions given by a healthcare institution, and the efficiency of the process (American Health Lawyer Association, 2013).

How does Medicare Influence Reimbursement?

Medicare influences reimbursement in the following ways. First, Medicare, under the Joint Commission, has rates dictating how much physicians should charge for each service (American Health Lawyer Association, 2013). These rates are indicative of the health services that physicians can charge patients.

Secondly, Medicare provides prospective payments to hospitals as a cost-cutting measure (Omachonu & Einspruch, 2010). Healthcare institutions receive a fixed amount of money based on the number of patients they will serve, and based on the average cost of providing these services. The model of prospective pay came into being as a cost-cutting measure. The thinking was that hospitals would become cost-conscious if they suffer a penalty for offering expensive services. In this regard, hospitals keep the balance of any money given to them under Medicare prospective pay if they do not spend it on healthcare. On the other hand, the hospital must find new resources to cater for any shortfalls if they spend more money than the sums allocated to them under Medicare. These limits make hospitals more cost-conscious.

The third way in which Medicare influences reimbursements is by incentive pay programs affecting physicians and healthcare institutions (Niles, 2010). Physicians are liable to a pay adjustment if they fail to submit quality reports, while at the same time, they are eligible for incentive payments if they submit quality reports. In this regard, Medicare dictates the reimbursements made to physicians and healthcare institutions.

How Medicare Influences Patient Access

Medicare influences patient access in three ways. First, Medicare provides a reliable source of funds for healthcare institutions. The institutions can only access these funds if they offer healthcare services. Therefore, healthcare institutions have an incentive to offer services. Secondly, Medicare improves access to healthcare by providing a source of funding for healthcare. Many people who have no funds for healthcare or an insurance cover to take care of their healthcare needs tend to put off seeking medical attention until their health situation deteriorates (Niles, 2010). In this regard, Medicare reduces the tendency of avoiding to seek medical attention.

Role of the Health Informatics Professional in Medicare

The Health Informatics Professional plays a very critical role in Medicare. Medicare is data-intensive because of the regulatory demands and the need to measure its effectiveness on a continuous basis. The three main roles that they play are as follows. First, the Health Informatics Professional provides guidance in the development of the tools needed to assess the effectiveness of Medicare programs (Niles, 2010). Secondly, the Health Informatics Professional provides the skills needed to make projections on the cost of healthcare and to work out the possible implications. Thirdly, the professional provides the skills needed to evaluate the qualitative aspects of healthcare.

Impact of Medicare on the Health Informatics

Medicare continues to transform health informatics in many ways. Medicare is data-driven. Therefore, the only way Medicare can exist is in an environment of health informatics. Medicare requires detailed reports in standard forms that support systemic evaluation. This means that every healthcare institution must invest in data entry and analysis equipment related to system management. This shows that Medicare is leaving a lasting influence on health delivery by promoting data-driven and evidence-based approaches. To healthcare

Medicare is also influencing the development of health informatics through the development of conceptual tools for managing health care (LaTour & Eichenwald, 2013). Prospective reimbursement was a new concept to the healthcare fraternity. Traditionally, people paid for medical services after receiving medical attention. Insurance companies still use this model. However, Medicare provided the basis for radical change in how to finance healthcare.

Medicare is also making healthcare professionals keen on the use of data. The experiences of these professionals percolate into the entire healthcare ecosystem, even where Medicare does not exist. In this sense, Medicare is transforming modern healthcare delivery models.


American Health Lawyer Association. (2013). Medicare Conditions of Participation (Conditions for Coverage). Web.

LaTour, K. M., & Eichenwald, S. (2013). Health Information Management: Concepts, Principles, and Practice. New York, NY: AHIMA. Web.

Niles, N. J. (2010). Basics of the U.S. Healthcare System. Sadbury, MA: Jones & Bartlett Learning. Web.

Omachonu, V. K., & Einspruch, N. G. (2010). Innovation in Healthcare Delivery Systems: A Conceptual Framework. The Innovation Journal: The Public Sector Innovation Journal, 15(1), 1-20. Web.

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