Organizational Systems and Quality Leadership in Public Health

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This essay answers questions from two scenarios about Mrs. Zwick and Mr. Davis who are both sick and need medical insurance cover. Medicare part A will fully cover the inpatient care within the hospital for the five days Mrs. Zwick spends there. It will also cover meals and semi-private room and general nursing. She will pay $ 1156 deductible and no co-pay at the hospital. After being transferred to the skilled nursing home, the costs that will be covered include meals and the semi-private room, rehabilitation services, skilled nursing and other supplies and services. She will pay $ 144.50 (Carmen, 2010).

Since Mrs. Zwick qualified for Medicare part A, she automatically qualifies for Medicare part B. Mrs. Zwicks costs that will be covered by Medicare part B include the charges made by physicians, X-rays and other charges out of the hospital (Carmen, 2010). Medicare part B will cover all the costs incurred at the skilled nursing home.

It will cover any other costs such as those of medication, any visits by the doctors, medical equipment such as the walker she was given, health services out of the hospital and laboratory tests. Medicare part B has a deductible of $140. It has co-pay because she will pay 20% of her costs. The insurance will cover the remaining 80 percent of these costs. Mrs. Zwick pays a premium every month that is subject to adjustments every year. In the year 2012, the premium has been set at $99.90 every month.

These premiums will cater for 25 percent of the actual costs that Mrs. Zwick will incur after leaving the hospital. The remaining 75 percent will be taken care of by the federal government from revenue obtained through general taxation (Carmen, 2010). Certain services may have no costs for Mrs. Zwick to pay. Since there is a deductible of $140 for Medicare part B she will have to pay all the costs up to the time she meets the early deductible for part B before the share belonging to Medicare is paid. After the deductible has been paid she will just pay 20 percent of the amount approved for Medicare.

Medicare part D allows Mrs. Zwick to get her drug prescription at a lower cost from her own pocket. Mrs. Zwick has automatic enrolment because she has Medicare part A and Medicare part B (Carmen, 2010). All her costs will not be covered though. She will not pay anything to be covered under Medicare part D.

The policies of Medicare require that insurance does not cover costs for mistakes, infections and preventable conditions that patients get while staying in hospital. Therefore, the insurance program does not allow her to be reimbursed for the additional care she received (Carmen, 2010).

Based on the law, the hospital should carter for the costs of hospital-acquired infection. Since she was in hospital when she acquired the infection, it was the hospital that was allowed by law to pay for the costs of treatment for the infection. It is therefore unethical for Mrs. Zwick to have incurred the costs because ethical requirements do not allow her to be fleeced of her money unfairly. She can seek legal action against the hospital for failing in its ethical obligations (Carmen, 2010).

Mr. Davis has group health insurance from his former employer. Therefore, he has the right to continue with his insurance coverage via the group plan even when he is not at work. Mr. Davis will therefore remain on his former employers insurance coverage list since he was terminated for absenteeism due to his illness (Carmen, 2010). Coverage will continue for a period of up to18 months or more depending on the circumstances. Mr. Davis will have to pay for insurance coverage.

When Mr. Davis was still in employment, his employer may have taken care of all or a certain portion of his group health premiums. After leaving employment, he ceased getting any benefits. COBRA requires that he pays the full amount of the premiums. This comprises the amount of premium that he used to pay while still an employee and the contribution amount that his former employer made. He will also be required to pay an administrative fee of 2 percent (Carmen, 2010). Mr. Davis will be expected to pay group premium rates.

This is an advantage to him because these rates are lower when compared to individual rates. Because there is a possibility that some time may have passed between the time of losing his job and the time of making the COBRA election, he may be required to pay premiums in a retroactive manner from the time he left the job. The very first premium will be used to cover the period since his last day at his former employers factory (Alyssa, 2008).

One major challenge is that the number of those without insurance is on the increase. As people get older, the rate of chronic disease goes up and the changing lifestyle also contributes to the same. Another challenge is the increasing costs of medication. Those without insurance incur very high expenses some of which may have to be compensated.

In this, the state or local government spends a lot of money. To address the challenge of rising expenses the state should make it compulsory for everyone in the U.S to have health insurance. This will ensure that the number of uninsured people drops considerably (Alyssa, 2008).

Retired persons, children and the unemployed have medical cover in Germany, Great Britain, Japan and Switzerland. For medical coverage, it would not be better for Mr. Davis because in Germany, Great Britain and Switzerland he would be expected to pay part of the costs for his treatment from his pocket. In Japan, he would be better off because he can get medical cover (Alyssa, 2008). When in Japan he would not be required to pay for his treatment with his own money.

In Germany, patients have reduced cost-sharing if they want a referral to go and see a specialist. Great Britain and Switzerland require patients to register with General Practitioners for them to get referrals to a specialist. Japan has no restrictions on seeing a specialist. Coverage for pre-existing conditions is available in Great Britain but not in Germany.

Within Switzerland and Japan, Mr. Davis wont get insurance cover (Alyssa, 2008). Japan is the most suitable place for him to go. The recommendation in this paper is that all people should strive to get medical insurance cover. This reduces the burden that the government has to bear.

References

Alyssa, K.S. for insure the uninsured project (2008). Health care systems around the world, 36. Web.

Carmen, D. (2010). Income, poverty and health insurance coverage in the United States (2005). Darby: Diane Publishing.

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Organizational Systems and Quality Leadership in Public Health

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