Healthcare and Regulations

Introduction & Healthcare Coverage and Vulnerable Populations

Describe the importance of healthcare coverage (insurance)

According to National Academies Press-U.S. (2001), healthcare coverage plays a critical role in maintaining a healthy population by enhancing access to healthcare services and protecting people from financial shocks due to the high cost of healthcare services. Health care coverage in the United States can either be public or private insurance. Medicare and Medicaid are the most common public healthcare coverages in the United States. Access benefits due to insurance covers can be measured through predictive and indicator access, where predictive measures the process of accessing while indicators measure the outcomes of access. Insured people have regular access to care because they have more visitations than uninsured people. Therefore, insured people have access to preventive care that may also lead to early diagnosis of conditions. With healthcare coverage, people eliminate financial barriers to accessing healthcare. Most healthcare coverage pays for almost all medical bills and long-term care as long as the health provider is certified. This paper involves a Nursing Quality Indicator (NQI) virtual simulation activity through the Sentinel tool to explore the impact of nursing decisions across the care continuum on the quality and safety indicators of structure, processes, outcomes, and cost improvement.

Discuss two ways healthcare coverage is beneficial (helpful) for the vulnerable/ uninsured populations.

According to Meng et al. (2011), vulnerable populations do not have access to standard care because they are too expensive or unavailable. Secondly, they are often uninsured because healthcare coverage is too expensive. Healthcare coverage benefits vulnerable or uninsured populations because it reduces health inequality by enhancing access to care and protects them from financial shocks due to possible medical bills. Both federal and state governments have developed strategies to increase health coverage for insured people. Medicare is a public health insurance at the federal level that targets elder people aged 65 years and above, plus some citizens with certain disabilities or conditions. Medicaid is another public health coverage jointly run by federal and state governments targeting people with limited incomes and resources. These schemes allow vulnerable populations to submit monthly contributions that, in turn, help to settle medical bills in case they access health care services. Vulnerable people include the elderly, children, marginalized and disadvantaged people, people with disabilities, unemployed, among others. Uninsured people have to pay out of their pocket for physician visitation, and they are mostly likely to forgo care until serious conditions develop (Pollack & Kronebusch, 2004). Secondly, insured people enjoy protection from financial shocks to unplanned and heavy health care costs. Uninsured people pay out-of-pocket for medical bills and long-term care unless they receive them for free from donors. Moreover, uninsured people are more likely to suffer from serious conditions that require advanced and expensive care because of a lack of preventive care.

Diagnosis Related Groups

Describe the purpose of Diagnosis Related Groups (DRGs)

The purpose of DRG is to enhance control of healthcare costs and regulate hospital disbursement rates. Therefore, it improves efficiency and effectiveness for quality and safety indicators such as health outcomes, cost, processes and structures. For instance, the hospital admission and discharge process is a critical factor in determining the GRSs. Diagnosis-related group (DRG) refers to a case mix comprehensive system that allows health care coverage schemes to create groups of patients with similar diagnoses or conditions. The creation of a diagnosis-related group is to enhance the effective management of available resources for maximum output.

Explain the impact of DRGs on length of stay and payment of services.

The ultimate goal of DRG is to create a pre-determined payment rate for the 495 DGG classifications on diagnoses and procedures. Therefore, the ultimate goal is to ensure hospitals do not take advantage to maximize bed occupancy to increase profits. Hospitals that perform better regarding the health care outcomes of certain DGGs receive incentives. The incentives promote efficient and effective resource use for optimal care outcomes. It also leads to shortening the length of stay and reduces overall bed occupancy.

Discuss how quality indicators and measures now impact payments for DRGs.

GRGs have positively impacted the quality indicators and measures of cost, outcome, process and structures. The prospective Payment System (PPS) was an innovative approach to replacing the cost-based payment system within the Medicare scheme. The main objectives DRGs of providing quality inpatient care and efficient use of resources and procedures have been met and maintained. Quality indicators of process and structure have improved as the new payment system discourages unnecessary procedures and allows the concentration of complex procedures to healthcare facilities with a high frequency of such procedures. The cost incentive approach has also led to another innovative delivery system that restrains cost by allowing a high concentration of limited resources.

Medicare Plan A

The patient case in this discussion is Arnold Cook, a 78-year-old retired fireman. Arnold has undergone a total hip replacement surgical procedure and is now admitted to the medical surgical unit. Medicare Plan A provides the best care plan for this patient to receive care for pain management in a specialized facility and frequent consultation with physicians. A preferred care plan should also extend into specialized nursing care for the patient to receive support from her wife and adult children to enhance the recovery process and mobility (Yayac et al., 2020). The patient’s plan, for now, is to regain mobility to travel around the world with her grandson.

Medicaid

Medicaid is a public healthcare coverage run by the federal government targeting senior citizens aged 65 years and above and other citizens qualified to the additional criteria covering some disabilities and conditions. Arnold is 78 years old and therefore qualifies for this program. The two best care plans for Arnold under this second major healthcare plan are to enhance safety and reduce falls and facilitate mobility recovery and rehabilitation (Hoang, 2022). Medicaid program allows patients to have freedom of choice of preferred health facility and providers. It also allows for long-term care and frequent visitation by preferred physicians. The least good care plans include serving dinner in bed and assisting with transfer despite the pain. Allowing the patient to have dinner will hurt all four quality and safety indicators while allowing transfer despite main have negative impact on most of the four quality indicators.

Impact of Nursing Interventions

Nurses have a critical role in aiding patients in effective recovery after surgery. The following are some of the post-operative nursing interventions with their rationale according to Rnpedia (2017)

1. Perform exercises with the operative hip, such as leg lifts, quadriceps, and gluteal muscle setting. Rationale: It facilitates early mobilization by enhancing joint pain and possible complications.
2. Encourage and educate patients on participation and the importance of activities of daily living (ADLs). Rationale: It helps the patient to maintain independence and have a sense of control over the recovery process.
3. Perform exercises on other joints such as toes and figures. Rationale: They are critical as they help the recovery of the replaced joints.
4. Frequent assessment of changes in pain characteristics, changes in skin colour, temperatures and sensitivity. Rationale: This may help nurses determine the slippage of the prosthesis and the need for medical intervention as early as possible.

Conclusion

Healthcare coverage significantly benefits the insured and is critical in achieving a healthy population. Vulnerable and insured populations are at risk of limited access to healthcare and high financial burden due to emergency medical bills. Having the best healthcare plan is critical as it optimizes quality and safety indicators of cost, outcome, process and structure.

References

Hoang, H. (2022). Nursing Intervention for Patient with Total Hip Replacement.

Meng, Q., Yuan, B., Jia, L., Wang, J., Yu, B., Gao, J., & Garner, P. (2011). Expanding health insurance coverage in vulnerable groups: a systematic review of options. Health policy and planning, 26(2), 93-104.

National Academies Press (US). (2001). Why Health Insurance Matters. Coverage Matters – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK223643/#:~:text=For%20individuals%20and% 20families%2C%20health,still%20not%20affordable%20to%20some.

Nursing Quality Indicators (NQI) – Sentinel U | Nursing simulations, Virtual Nursing simulation. Sentinel U | Nursing Simulations, Virtual Nursing Simulation. https://www.sentinelu.com/videos/product-demonstration/nursing-quality-indicators-nqi/

Pollack, H., & Kronebusch, K. (2004). Health insurance and vulnerable populations. Health policy and the uninsured, 110-134.

Rnpedia. (2017). Total Hip Replacement Surgery Nursing Care Plan & Management. RNpedia.https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/total-hip-replacement-surgery/

Yayac, M. F., Harrer, S. L., Janiec, D. A., & Courtney, P. M. (2020). Costs and outcomes of Medicare Advantage and traditional Medicare beneficiaries after total hip and knee arthroplasty. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 28(20), e910-e916.