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Example research essay topic: Medicare Beneficiaries Managed Care - 2,007 words

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Medicaid was enacted in the same legislation that created the Medicare program-the Social Security Amendments of 1965. Prior to the passage of this law, health care services for the indigent were provided primarily through a patchwork of programs sponsored by State and local governments, charities, and community hospitals. Before 1965, Federal assistance to the States for the provision of health care was provided through two grant programs. The Social Security Amendments of 1950 provided Federal matching funds for State payments to medical providers on behalf of individuals receiving public assistance payments.

In 1960, the Kerr-Mills Act created a new program called Medical Assistance for the Aged. This means-tested grant program provided Federal funds to States that chose to cover the medically needy aged, who were defined as elderly individuals with incomes above levels needed to qualify for public assistance but in need of assistance for medical expenses. In 1965, Congress adopted a combination of approaches to improve access to health care for the elderly. The Social Security Amendments of 1965 created a hospital insurance program to cover nearly all of the elderly (Medicare Part A), a voluntary supplementary medical insurance program (Medicare Part B), and an expansion of the Kerr-Mills program to help elderly individuals with out-of-pocket expenses, such as premiums, co-payments, deductibles, and costs for uncovered services. At the same time, Congress decided to extend the Kerr-Mills program-now the Medicaid program-to cover additional populations including farm lies with children, the blind, and the disabled. In general, Medicaid provides three types of critical health protection: (1) health insurance for low-income families and people with disabilities; (2) long-term care (LTC) for older Americans and individuals with disabilities; and (3) supplemental coverage for low-income Medicare beneficiaries for services not covered by Medicare (e.

g. , outpatient prescription drugs) and Medicare premiums, deductibles, and cost sharing. Medicaid does not provide medical assistance to all low-income individuals. Traditionally, Medicaid has been available only to persons in certain categories: members of families with children and pregnant women, and to persons with disabilities or who are aged or blind. Low-income individuals who did not fit into one of these categories, such as childless couples or adults without disabilities, typically did not qualify for Medicaid-regardless of how low their income. Program waivers and additional mandatory eligibility groups have provided States with opportunities to extend Medicaid services to populations beyond the traditional welfare-defined groups. Initially, eligibility for Medicaid was linked to receipt of cash assistance from Aid to Families with Dependent Children (AFDC) and, starting in 1972, Supplemental Security Income (SSI).

Over time, legislative changes to the Medicaid program and the AFDC welfare program have led to the creation of certain Medicaid groups where eligibility is based solely on income and resources, not receipt of cash assistance. Some of these non-cash groups are referred to as the poverty-related groups. Congress created these groups in the late 1980 s in an effort to expand Medicaid coverage of pregnant women and children by drinking Medicaid eligibility from receipt of AFDC. Poverty-related groups are an increasing proportion of Medicaid eligible individuals. Certain Medicare beneficiaries-State Medicaid programs must provide supplementary assistance to low-income Medicare beneficiaries. All Medicare beneficiaries with incomes below the FPL receive Medicaid assistance for payment of Medicare premiums, deductibles, and cost sharing.

These individuals are qualified Medicare beneficiaries (QMBs). In addition, individuals at the lowest income levels are entitled to full Medicaid benefits, which provide coverage for services not covered by Medicare such as outpatient prescription drugs. Medicare beneficiaries with income levels slightly higher than the FPL receive Medicaid assistance for payment of Medicare premiums. These individuals are specified low-income Medicare beneficiaries (Slabs). States have the option to provide Medicaid coverage to other groups. These optional groups fall within the defined categories previously mentioned but the financial eligibility standards are more liberally defined.

Optional eligibility groups include: Poverty-related groups-States may choose to cover certain higher-income pregnant women and children defined in terms of family income and resources. For example, some States have chosen to cover pregnant women and infants with family incomes up to 185 percent of FPL or higher. Medically needy-States may choose to cover individuals who do not meet the financial standards for program benefits but fit into one of the categorical groups and have income and resources within special medically needy limits established by the State. Individuals with incomes and resources above the medically needy standards may qualify by spending down-Le. , incurring medical bills that reduce their income and / or resources to the necessary levels. The Medicaid program is jointly financed by the States and the Federal Government.

Medicaid is an entitlement program and the Federal spending levels are determined by the number of people participating in the program and services provided. Federal funding for Medicaid comes from general revenues. There is no trust fund for Medicaid as there is for Medicare Part A or Social Security. The Federal Government contributes between 50 percent and 83 percent of the payments for services provided under each State Medicaid program. This Federal matching assistance percentage varies from State to State and year to year because it is based on the average per capita income in each State.

States with lower per capita incomes relative to the national average receive a higher Federal matching rate. The Federal matching rate for administrative costs is uniform for all States and is generally 50 percent, although certain administrative costs receive a larger Federal matching rate. During the early 1990 s, nearly every state legislature began efforts to encourage or require Medicaid beneficiaries to enroll in managed care. New York State policy makers followed the national trend, declaring in 1991 that the state's 58 local social services districts each had to develop a plan to enroll 50 percent of their beneficiaries in managed care over the next several years. The state's policy assumption was that local districts would encourage but not require enrollees to join managed care. Local districts could, however, seek federal permission to initiate a mandatory enrollment program.

One such mandatory enrollment initiative already was under way in southwest Brooklyn. By most accounts, between 1992 and early 1995, implementation of the state's managed care initiative proceeded incrementally and relatively smoothly. 1, 2 In New York City, the number of managed care enrollees grew from just over 50, 000 to around 300, 000 (out of a total Medicaid enrollment of approximately 1. 6 million). In March 1995, newly elected Governor George Pataki requested permission from federal officials to require nearly all Medicaid beneficiaries to enroll in managed care. This proposed acceleration of the implementation process prompted the managed care industry to begin a marketing blitz.

Between March and September of 1995, New York City managed care enrollment grew to nearly 480, 000. Perhaps surprisingly, however, the enrollment spurt was short-lived. By the fall of 1995 the number of New York City managed care enrollees was actually declining, so much so that by June 1998 managed care enrollment had slipped to 378, 000. The decrease seems due primarily to two factors. First, in response to allegations of fraud and abuse, Medicaid regulators sharply restricted health plan marketing. Second, in 1996 state officials sharply reduced the health plan capitation rates.

The decline in Medicaid managed care enrollment could have caused state officials to revisit the planned mandatory managed care initiative. It did not. State officials remain determined to proceed with the conversion to managed care. The effort got a boost in July 1997 when federal officials approved the state's plan to begin requiring most of the state's 2. 5 million Medicaid clients to enroll in managed care. The new initiative will have a dramatic effect in New York City, where Medicaid managed care enrollment is expected to more than quadruple in about a year and a half, that is, to grow to more than 1. 5 million by late 1999. The implementation of Medicaid managed care poses new challenges for government policy makers, health plans, and medical providers.

In this paper, we report on a study that examines these management challenges. The focus is on six issue areas: management information systems, marketing and enrollment, access to care, management of care, rate setting, and Medicaid politics. During the past two decades, Medicaid spending on behalf of the blind, individuals with disabilities and the elderly has grown significantly. This change reflects the growing Medicaid disabled population and the spiraling costs associated with institutional LTC services. While the aged, the blind, and people with disabilities account for only 26 percent of all Medicaid persons served in FY 1998, the Medicaid payments made on their behalf account for 71 percent of program payments. The largest group, children, account for only 16 percent of all Medicaid payments.

This pattern in distribution of Medicaid payments by eligibility group goes back to the mid- 1970 s. Since 1975, Medicaid payments for the elderly and disabled have exceeded payments for adults and children. During the late 1970 s and early 1980 s, payments for the elderly and the disabled have generally been similar, with payments for the elderly slightly higher. Starting in 1987, however, payments for individuals with disabilities began to surpass payments for the elderly.

Furthermore, since 1992, there has been a dramatic growth in spending for the disabled. One explanation for the two views of Medicaid politics is that regulated industries always complain of overregulation and regulators always complain that politicians and interest groups are obstacles to appropriate regulatory activity. Under this interpretation, the back-and-forth in New York is inevitable. There is, however an explanation for the bifurcated views of New York's Medicaid politics, one that is rooted in political and programmatic history.

The story begins with Medicaid politics in New York long before managed care entered the scene, specifically with a Medicaid bureaucracy that has operated in a fragmented, decentralized, and interest group dominated political environment, that produced the nation's most expensive Medicaid program. Nursing home policy illustrates the point. Nursing homes in New York receive more than twice the public funds that their counterparts in California get. Why?

One reason is that New York's labor unions are more successful than their California counterparts in ensuring that nonprofessional health care workers are paid well above the minimum wage. Moreover, New York's advocacy community is active and influential, as are the nonprofit nursing home owners that dominate much of the market. There also are several government agencies that play a role in setting Medicaid policy, not all of which make cost containment a high priority. In California, in contrast, state Medicaid officials have long enjoyed significant bureaucratic discretion and have used it to keep nursing home reimbursement low. Effective implementation of Medicaid managed care in New York State has been slow going: it is taking time for enrollees, providers, and health plans to adjust and adapt. Government officials need to be more analytical about the limits of progress to date and more sensitive to concerns and problems of various stakeholders.

State Medicaid priorities should include more than cost containment. Bibliography: Clark, W. D. and Hulbert, M.

M. : Research Issues: Dually Eligible Medicare and Medicaid Beneficiaries, Challenges and Opportunities. Health Care Financing Review 20 (2): 1 - 10, Winter 1998. Health Care Financing Administration, Center for Medicaid and State Operations: FACT SHEET, Medicaid and Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) Infection, Health Care Financing Administration. Baltimore, MD. April 2000 a, Health Care Financing Administration: Home and Community-Based Service Waivers Summary Report. April, 1999.

Health Care Financing Administration: 1998 National Health Expenditures. Internet address, http: //www hcfa. gov / stats /not-act/. September 2000 b. Health Care Financing Administration, Office of the Actuary: Data from estimates based on President's fiscal year 2001 budget January 2000 c.

National Center for Health Statistics: Health, United States, 2000. DHHS Pub. No. (PHS) 00 - 1232. Public Health Service. U.

S. Government Printing Office, Hyattsville, MD. 2000. Regenstein, M. and Schroer, C. : Medicaid and Managed Care for Persons with Disabilities: State Profiles. Report of the Kaiser Commission on Medicaid and the Uninsured. Washington, DC.

December 1998.


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Research essay sample on Medicare Beneficiaries Managed Care

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