A 77 year old female, Mrs. Zwick, was admitted to the hospital for 5 days, after suffering a stroke. She then was transferred to a skilled nursing facility for rehabilitation. She was projected to stay for 21 days. Unfortunately, she was diagnosed with a urinary tract infection that was acquired from the hospital 10 days after her stay. She then needed to take IV antibiotics which extended her stay to 40 days. Mrs. Zwick was then sent home from the skilled nursing home with a walker and some medications.
Her Medicare insurance includes Part A, Part B, and Part D. The daughter will be taking care of her medical bills. She is concerned because she does not know the difference between medicare and medicaid. Before being discharged she asks me for assistance. Both mother and daughter are unaware that the urinary tract infection was acquired during the hospital stay. Based on the coverage requirements Mrs. Zwicks Medicare part A will cover the care that was given her at the skilled nursing facility and the home health care services.
The home health care is covered if the doctor decides that she needs care at home, the agency is approved by the Medicare program, she is homebound and cannot leave her home without help and that you need intermittent nursing care, physical therapy, speech therapy, or occupational therapy. Part B will cover the walker for her to use as an outpatient. It helps to pay for the “durable medical equipment such as oxygen equipment, wheelchairs, walkers, and other medically necessary equipment that your doctor prescribes to use in your home” (1). Her portion for part B is $99.
90 each month. Part D will cover the medications. She must first get prior authorization, then their are limits on the quantity she can get and then she and her doctor must do step therapy which means that she can try one or more similar drug first that is lower cost before the plan will cover the more expensive prescribed drug.
On February 8, 2006, President Bush signed the Deficit Reduction Act of 2005 (Pub. L. 109-171) (DRA) which contained language creating a system for quality adjustment of Medicare payments for inpatient hospital services.
The law required the Secretary of Health and Human Services (HHS) to identify at least two hospital-acquired conditions which could have reasonably been avoided through the application of evidence based guidelines and would be subject to the adjustment in payment. (Morgan, 2006).
These Medicare policies affect reimbursement for the hospital acquired infection that Mrs. Zwick acquired. Anything that is in relation to the infection will have to be absorbed by the hospital that gave her the infection. It is unethical for the hospital to not inform the patient and medicare about the hospital acquired infection.
Since it was not acquired previous to entering the hospital it is not the responsibility of the patient. The second case is about Mr. Davis who was diagnosed with sickle cell anemia in childhood. He has had this disease for such a long time he knows what is required and how he needs to manage it.
Due to this illness in which he was hospitalized twice he was fired from his job. He has had such a hard time with his medical care here in the United States that he is wishing he lived in another country with better access for healthcare. The Consolidated Omnibus Budget Reconciliation Act (COBRA) will allow Mr.
Davis to continue his insurance coverage while he is out of work by paying a portion or all of what his employer was paying previously. This allows him to not have a lapse in coverage for when he is employed again. Also he will be able to continue his care and be added to a new policy without the worry of being turned down because of a pre-existing condition. He may be required to pay up to 102 percent of the cost of the plan. COBRA requires that the group health plan that has more than 20 employees such as Mr. Davis’ employer to offer him an extension of his health plan.
(Solis, n. d. ). One of the challenges that the state or local government face in providing care for patients like Mr. Davis is that he will inevitably end up in the Emergency room which will be more expensive then if he had routine preventative care. This expense will be absorbed by the hospital that may end up having to close the emergency room due to the expenses of so many uninsured patients. Another challenge is that if the closure of the emergency room does happen then this will cause the State to not have the ability to take care of the uninsured medically needy residents.
One step that state or local government could take to address one of the challenges for patients that are uninsured is to provide a form of medicare to them if they are unemployed, but in return to make sure they have routine exams to prevent emergency room visits. This will keep the costs down and the patients healthier. If Mr. Davis was a citizen of Switzerland he would be able to afford the insurance because it is based on his income. It is true that he will not have to pay as much as an employed person but he may still have to pay. The cost for each person is based on their age and their income.
Switzerland citizens pay only up to 8% of their income for insurance. They are always covered for all preexisting conditions. Most medications are covered by the insurance as well. If you need a specialist you must be referred. It is a private insurance that is very well organized. He would get the care he needed without worrying about the cost. Once he got back on his feet and was employed he will have to pay more in taxes than in the United States but his insurance would be guaranteed (Reinhardt, 2004). The medical care in the United States has a lot to be desired. But the care received is very good if we are insured.
It is unfortunate when more and more people are losing their jobs and then their insurance. If we are not of an age to receive Medicare or have children so we can qualify for a state insurance it is a very hard situation. References Morgan, R. National Conference of State Legislators, (2006). Medicare nonpayment for hospital acquired conditions Reinhardt, Uwe (September 8, 2004). “The Swiss health system: regulated competition without managed care”. JAMA 292 (10): 1227–1231 Solis, H. (n. d. ). Cobra continuation coverage assistance under arra. Retrieved from http://www. dol. gov/ebsa/COBRA. html.