Introduction
Vulnerable populations experience adverse health outcomes because they live in areas excluded from services which makes them unable to participate in health programs due to a lack of awareness. Health coverage is important because it makes it easy to afford healthcare services and protects people from financial strain when unexpected illness or accident happens. Insurance helps people avoid huge medical debts and protects the acquired financial assets. Vulnerable populations do not have access to healthcare coverage because their socio-economic status does not favor them. Another advantage of healthcare coverage is that it connects people to a constant source of care which enables easy access to the infrastructure where the providers work with patients in providing continuous, comprehensive, and coordinated healthcare services.
The vulnerable populations often struggle to get healthcare coverage because of their backgrounds such as financial strain, homeless, elderly, and people with disabilities (De Chesnay & Anderson, 2019). Healthcare coverage makes people more productive because they can lead better lives by ensuring they get healthcare services conveniently because of constant premium contributions. A reduction in mortality rates of people is important to vulnerable individuals in society as it increases awareness of leading healthy lives and ensuring they improve their status.
Purpose statement: To identify how healthcare coverage is linked to vulnerable populations, describe the purpose for diagnosis of related groups, select a major and alternative healthcare plan, and the impact of nursing interventions.
Diagnosis Related Groups (DRG)
Diagnosis Related Group is utilized when grouping patients who have the same conditions and treatment. DRG is used by Medicare to help reimburse hospitals for inpatient stays depending on patient diagnosis and care given during the stay (Enewold et al., 2020). It means that the hospitals get paid a fixed amount for every patient depending on the DRG assigned to the patient. DRGs are more specific because they represent specific groups of people with similar conditions or diseases and they classify them according to diagnosis and treatment.
The Diagnosis Related Groups make hospital funding depending on a predefined payment rate on the diagnosis processes in the 495 classification. It incentivizes the appropriate utilization of services provided which lowers the length of stay, appropriate use of treatment and diagnostic procedures, and a reduction in the general bed capacity. Implementation of a DRG system in a hospital contributes to a reduction in admissions and advocates for more outpatient services and a steady decline in the bed occupancy rate and per capita hospital bed supply (Shi & Singh, 2022). Despite its positive impact, it is affected by falsification of reported case severity to increase revenue collection which ensures a balanced health service system is achieved.
Payment for DRGs has contributed to reduced overuse of health services because it has a financial risk to healthcare providers. DRGs have contributed to an improvement in efficiency, control of the cost of treatment, and a reduction in the length of stay which contribute to the maintenance of the standards of care. It is important to note that providers’ behaviors determine the quality, efficiency, cost, and equity of healthcare services provided to patients.
Medicaid Healthcare plan (major option)
Medicaid has been considered the major healthcare option for patient X aged 67. Medicaid covers many people like people with disabilities, the elderly, children, pregnant women, and low-income adults. It covers both state and federal governments hence it caters to the health of many Americans (Geruso et al., 2023). Patient X qualifies for Primary Care Case Management Option in Medicaid coverage. In this case, patient X is to be provided with a primary care physician who will provide the required care (Shi & Singh, 2022). The physician will be paid every month for the services given. Another option is the Comprehensive Risk-based Managed Care which is an additional treatment choice that can be used for patient X. The additional plan offers services such as X-ray tests, home healthcare, outpatient services, and therapeutic and diagnostic therapies. The additional treatment option provides a variety of home-based services needed by patient X.
Unfortunately, both care plans may limit access to care for patient X because of the Medicare Advantage Care plan. There are some restrictions such as the use of physicians only in the plan’s network which may be utilized by this choice. The restriction limits Patient X’s choice of healthcare providers and services. Another restriction is that there are care programs available for children which have particular eligibility criteria and needs that patient X will have to meet to get care. Medicaid long-term care services may limit a patient’s access to medical services because of the need to incur an additional cost from the patient. Patient X is likely to experience care restriction because of the financial burden (Lloyd et al., 2019). Medicaid’s long-term care services and eligibility depend on the children’s care program which limits patient X’s access to healthcare.
Medicare (second major healthcare plan)
Medicare is designed to care for 65years or older individuals. Patient X is 67 years; thus, he will benefit from the program. The Original Medicare option has Part A and B insurance plans where patient X has the power to choose any healthcare organization or doctor under Medicare. Another option available is the Medicare Cost Plan which also facilitates care for patient X since it does not have restrictions. Medicare Advantage restricts access to care services and patients under the option may be required to meet a certain criterion such as choosing doctors under the plan’s network (Enewold et al., 2020). Additional costs restrict access to care services by the patient making it difficult to seek comprehensive care services.
Impact of nurse interventions
Nurse interventions to promote self-care for patient X include monitoring of the recovery process. The nurse should regularly assess the condition of the patient to determine if there is an improvement or deterioration in outcomes. It becomes easy for the nurse to set both long and short-term goals with the patient. The anticipated outcomes of care are controlling symptoms, preventing complications, and direct care based on self-determined options (Shi & Singh, 2022). The second intervention is guiding the patient in accepting the needed amount of dependence because the patient at times needs help in determining the safe limits of trying to be independent and when asking for assistance. The third intervention is presenting positive reinforcement for all activities done through education and noting down partial achievements. Patient X may have a challenge seeing progress. A nurse can promote positive reinforcement through daily activities by organizing them into achievable steps which makes the patient a sense of accomplishment. The last intervention is focusing on the patient’s strengths and optimal level of function as patient X receives support and guidance in learning to perform self-care activities.
Conclusion
In conclusion, the paper identifies how healthcare coverage is linked to vulnerable populations, describes the purpose for diagnosis of related groups, selects a major and alternative healthcare plan, and the impact of nursing interventions. Insurance allows many people to access healthcare services including the vulnerable populations. Insurance helps people avoid huge medical debts and connects people to a constant source of care. Programs such as Medicare and Medicaid have been encouraged by various governments to ensure that vulnerable populations access healthcare services. Implementation of a DRG system in a hospital contributes to a reduction in admissions and advocates for more outpatient services and a steady decline in the bed occupancy rate and per capita hospital bed supply. Nursing inventions for a patient include close monitoring, guiding the patient in accepting the needed amount of dependence, presenting positive reinforcement for all activities done through education, and focusing on the patient’s strengths and optimal level of function.
References
De Chesnay, M., & Anderson, B. (2019). Caring for the vulnerable. Jones & Bartlett Learning.
Enewold, L., Parsons, H., Zhao, L., Bott, D., Rivera, D. R., Barrett, M. J., … & Warren, J. L. (2020). An updated overview of the SEER-Medicare data: enhanced content and applications. JNCI Monographs, 2020(55), 3-13.
Geruso, M., Layton, T. J., & Wallace, J. (2023). What difference does a health plan make? Evidence from random plan assignment in Medicaid. American Economic Journal: Applied Economics, 15(3), 341-379.
Lloyd, J. T., Maresh, S., Powers, C. A., Shrank, W. H., & Alley, D. E. (2019). How much does medication nonadherence cost the Medicare fee-for-service program? Medical Care, 57(3), 218-224.
Shi, L., & Singh, D. A. (2022). Essentials of the US healthcare system. Jones & Bartlett Learning.
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