Financial reimbursement models in healthcare are billing systems that allow healthcare organizations to be compensated for the services offered to patients, whether directly from patients or by insurance payers. In this regard, various financial reimbursement models have been adopted in the United States, given the fact that the field of healthcare billing is highly complex and that none of the models are flawless. Similarly, the models used by various clinics, healthcare institutions, or hospital networks also vary because each has its functions and goals (Brooks et al., 2021). The government-run health insurance programs, Medicaid and Medicare, fall under this category as they are designed to cater to American citizens’ healthcare costs. According to Sukul et al. (2019), the Medicaid insurance program provides coverage for citizens with low or limited income. On the other hand, the Medicare insurance program is designed for citizens living with disabilities or individuals aged 65 and older.
While both programs are government-administered and funded by taxpayers, several differences exist between them, particularly regarding the populations they are intended to serve, cost-sharing, and covered services. Brooks et al. (2021) state that the Medicare insurance program is designed to provide financial assistance for medical needs to senior citizens and their families. Individuals living with disabilities, regardless of their ages, are also eligible for Medicare insurance benefits. Additionally, people in the final stages of kidney ailments meet the program’s eligibility requirements (Wadhera et al., 2020). The Medicare insurance program is divided into two main branches – Medicare Advantage and Original Medicare – which cater to various cases and populations (Agarwal et al., 2020). While the Original Medicare insurance plan covers inpatient and outpatient medical services for eligible patients, the Medicare Advantage insurance plan offers the same coverage options with additional choices, such as hearing, vision, and dental care.
On the other hand, the eligibility for the Medicaid insurance program primarily depends on an individual’s income level and family size. The healthcare costs covered by Medicaid include routine medical care, treatments, or major hospitalizations (Agarwal et al., 2020). Through the Affordable Care Act, the Medicaid insurance program extends its coverage to people with low incomes by establishing minimum income thresholds across the United States. However, even though 39 states have adopted the expansion of the Medicaid insurance program through the Affordable Care Act, 12 states are yet to adopt the expansion (USAGov, n.d). As a result, many people with no access to low-cost health insurance have been left uninsured. According to Mazurenko et al. (2018), some states have chosen to leverage the expansion of the Medicaid insurance program to raise revenue, allowing them to reduce other taxes or fund other priorities. Other opponents of the Medicaid expansion program, such as Texas State, have argued that the program is financially unsustainable and poorly managed (Mazurenko et al., 2018). Additional arguments against the expansion of Medicaid hold that the program delivers poor health outcomes, encourages government dependence, and crowds out people with disabilities and children who need it most.
As a Family Nurse Practitioner, the most critical role in healthcare provision is to ensure and help enhance the patients’ overall wellbeing. This role involves empowering patients through healthcare advocacy, enabling access to vital insurance services, such as Medicare and Medicaid. According to Ducharme et al. (2017), patients deserve access to professional expertise, considering the complex nature of the modern healthcare system. In this regard, healthcare advocacy offers patients support, comfort, and empowerment during challenging moments. In this case, my role as a Family Nurse Practitioner when interfacing with Medicare and/or Medicaid recipients would be to help them figure out the best coverage plans, explain complex terminologies, such as coinsurance and copays, and help coordinate ease of access to the insurance services.
Agarwal, R., Liao, J. M., Gupta, A., & Navathe, A. S. (2020). The Impact of Bundled Payment on Health Care Spending, Utilization, And Quality: A Systematic Review: A systematic review of the impact on spending, utilization, and quality outcomes from three Centers for Medicare and Medicaid Services bundled payment programs. Health Affairs, 39(1), 50-57.
Brooks, C., Fowler, E., Seshamani, M., & Tsai, D. (2021). Innovation at the Centers for Medicare and Medicaid Services: a vision for the next 10 years. Health Affairs Blog. August, 12.
Ducharme, M. P., Bernhardt, J. M., Padula, C. A., & Adams, J. M. (2017). Leader influence, the professional practice environment, and nurse engagement in essential nursing practice. JONA: The Journal of Nursing Administration, 47(7/8), 367-375.
Mazurenko, O., Balio, C. P., Agarwal, R., Carroll, A. E., & Menachemi, N. (2018). The effects of Medicaid expansion under the ACA: a systematic review. Health Affairs, 37(6), 944-950.
Sukul, D., Hoffman, G. J., Nuliyalu, U., Adler-Milstein, J. R., Zhang, B., Dimick, J. B., & Ryan, A. M. (2019). Association between Medicare policy reforms and changes in hospitalized Medicare beneficiaries’ severity of illness. JAMA network open, 2(5), e193290-e193290.
USAGov: Centers for Medicare and Medicaid Services. (n.d.). Web.
Wadhera, R. K., Figueroa, J. F., Maddox, K. E. J., Rosenbaum, L. S., Kazi, D. S., & Yeh, R. W. (2020). Quality measure development and associated spending by the Centers for Medicare & Medicaid Services. JAMA, 323(16), 1614-1616.