C489 Task 3.docx - Organizational Systems Task 3 Organizational Systems and Quality Leadership Task 3 SAT1-0517\/1217 Ashley Williams Western Governors

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Unformatted text preview: Organizational Systems Task 3 Organizational Systems and Quality Leadership Task 3, SAT1-0517/1217 Ashley Williams Western Governors University Organizational Systems Task 3 Healthcare Financing A1. Country to Compare The United States healthcare system differs vastly from that of Great Britain. A1. Access Great Britain has a healthcare system called the National Health Service (NHS) that is funded by the state. Children, adults, retired, and unemployed British residents all can receive the same kind of care for free no matter how expensive. Universal coverage is provided and includes preventative care like immunizations, rehabilitation services, and even end-of-life care (Frayer, 2018). The United States healthcare system is much different. Over half of insured residents have private insurance, either through their job or directly purchased. Children can receive health benefits for free through federally funded programs such as Medicaid or Medicare if they are disabled before age 22, not married, or have end-stage renal disease that requires dialysis. They can also be covered through their parents’ private insurance for a copay or through state funded income-based benefits which may cover all or part of their bill (International Health Care System Profiles, n.d.). Retired Americans, usually at age 65, are eligible for Medicare. Medicare requires a premium that is based on work history and the amount of Medicare taxes paid in to the government (Medicare Eligibility Overview, n.d.). Unemployed Americans are eligible for Medicaid. Organizational Systems Task 3 A2A. Coverage of Medications Medications are sometimes covered by Great Britain’s NHS. If a NHS hospital prescribes a medication, it is free. However, medications prescribed by outpatient physicians require a copayment in which the Department of Health determines the cost. The only exceptions to copayments are patients who qualify with a low income, residents who are under age 15 and ages 60 and older. 16-18 year olds who are full time students as well as women who are pregnant or have delivered within 12 months do not have to pay copayments. Incurable diagnoses, disabled residents and cancer patients are also exempt (International Health Care System Profiles, n.d.). Over-the-counter medications are paid for out of pocket just like the United States (Plonkee, 2016). Medications are sometimes covered in the United States but are based upon many factors. One factor is the type of insurance one has. Private insurance companies have a list of covered medications called a formulary. With a prescription, those drugs will be covered fully or with a copay. The copay is based upon the drug group it falls under on the formulary. There is also an amount that must be paid out of pocket first before insurance will begin paying called a deductible. If the deductible is not met, one might have to pay full cost or a percentage of the cost of the medication. Medicare and Medicaid also has a formulary. Based on the classification of the drug, it may or may not require a small copay. Public healthcare systems can also deny coverage of a drug. One can appeal the decision but still might get denied and have to pay the full cost out of pocket. A physician may also specify that particular medication is required and it still may get denied (What You Need to Know…, 2016). Organizational Systems Task 3 A2B. Referral to See a Specialist British residents are able to choose any NHS hospital to receive care, but are required to choose a specialist within that hospital group. Patients usually base their choice of NHS hospital on the length of wait list, service availability, and location of the hospital (Plonkee, 2016) Consults with specialists are often done while inpatient but can also be completed in the outpatient setting (International Health Care System Profiles, n.d.). Americans may or may not require a referral based on the type of insurance one has. Some private insurance companies require a referral to see a specialist while others do not. A preferred provider organization (PPOs) allow one to choose a specialist without a referral and health maintenance organizations (HMOs) have more limits on specialist choice. HMOs may require the specialist to be within network or payment may be denied (International Health Care…, n.d.; Referral, n.d.). Medicaid and Medicare recipients can see a specialist with a referral but has to ensure that specialist will accept public health insurance. Many specialist will not because there are limits imposed on the amounts charged (International Health Care…, n.d.). A2C. Coverage for Preexisting Conditions Preexisting conditions are not an issue with Great Britain’s healthcare system. Healthcare is a right, not a choice. NHS covers everyone no matter what preexisting condition he/she may have (Plonkee, 2016). Organizational Systems Task 3 Health insurance policies in the United States cannot refuse payment for citizens with preexisting conditions effective January 1, 2014, no matter if public or private insurance. There is one exception for “grandfathered” healthcare insurance policies. Individuals who enrolled on or before March 23, 2010 that can deny coverage for preexisting conditions (HHS Office & Public Affairs, 2017). A3. Finance Implications for Healthcare Delivery The state collects taxes from payroll and general taxation and uses that to pay for quality care and treatments in Great Britain. Most physicians are employees of the state and have fixed salaries which are paid from the taxes collected but they can also practice privately. That makes healthcare free for patients, no matter their income, high or low (Frayer, 2018). However, because everyone is required to pay taxes to fund NHS, Great Britain’s taxes are more expensive. The financial crisis of 2008 decreased tax revenue which cut funding to the NHS causing increased wait times, long waiting lists for outpatient appointments, and rationing of drugs (Flayer, 2018). Healthcare is most the most expensive in America. To help contain those costs, many choose generic drugs versus name brand or choose private insurance plans that have a high deductible, if they are usually in good health. The high deductible plans come with lower monthly premiums but requires the recipient to pay a large amount out of pocket before insurance begins to cover any procedure or medication. Former president, Barack Obama, initiated the Affordable Care Act that was supposed to decrease consumer costs and increase overall American health by requiring health care coverage. If not, a penalty was imposed when income taxes were filed. Many US citizens who were not eligible for healthcare coverage due to Organizational Systems Task 3 finances being too high for private insurance but too low for Medicaid as well as individuals with preexisting conditions were able to obtain coverage for an affordable cost. However, those who were already covered experienced increased premiums related to insurance companies having to provide low cost coverage to those with low incomes. (International Health Care…, n.d.). Organizational Systems Task 3 References Frayer, L. (2018, March 07). U.K. Hospitals Are Overburdened, But the British Love Their Universal Health Care. Retrieved December 5, 2018, from HHS Office, & Public Affairs. (2017, January 31). Pre-Existing Conditions. Retrieved December 14, 2018, from International Health Care System Profiles. (n.d.). Retrieved December 5, 2018, from International Health Care System Profiles. (n.d.). Retrieved December 5, 2018, from Medicare Eligibility Overview. (n.d.). Retrieved December 10, 2018, from Plonkee. (2016, August 26). Home. Retrieved December 5, 2018, from Organizational Systems Task 3 Referral - HealthCare.gov Glossary. (n.d.). Retrieved December 10, 2018, from What You Need to Know About Prescription Drug Costs and Coverage. (2016, October 13). Retrieved December 10, 2018, from ...
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