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Medicare has always been a topic that generates a great deal of interest and concern among Americans. With the recent veto and veto override in legislation concerning Medicare, it has become an even hotter topic. Putting politics aside, Medicare, the nation’s largest health insurance program, does benefit the patients it was created to serve.

Medicare was established nearly 43 years ago by the federal government to address the medical needs of older American citizens. One clear benefit for the patient is that it is an entitlement program similar to Social Security and enrollment is not based on financial need. Because it is a federal program, the rules for eligibility remain constant throughout the nation and coverage remains constant regardless of where an individual receives treatment in the United States.

Being the largest publicly funded health care program, Medicare plays an essential role in insuring the needs of America’s elderly and disabled populations. Initially the program covered approximately 19 million persons who were age 65 and older. In 2000, nearly 39 million people were enrolled in the program, which is almost one in eight Americans. By 2030, enrollment is estimated to reach nearly 78 million people or one-fifth of the U.S. population.

Because of its size, nearly $256.8 billion in spending in fiscal year 2002, the program plays an important role in the overall health care system. When Medicare began, inpatient hospital care accounted for nearly two-thirds of the program’s spending. As trends in healthcare have shifted away from the inpatient setting, Part B of the program has expanded, now representing some forty percent of spending, which is nearly equal to that spent on inpatient care. In addition, skilled nursing-facility care and home health agencies, which can provide post-acute services, have also increased in importance.

“Medicare’s coverage for physical therapy, occupational therapy, and speech therapy in a skilled nursing facility setting assists the patient in rehabilitating back into living as independently as possible,” said Craig Laman, administrator of Bells Nursing Home. “Without these services, many patients would not recover as well from their illness or injury and would not be able to return to living a more independent lifestyle. It allows patients to receive the therapy necessary without having to rely upon their own or family resources.”

For Medicare patients, whether in a skilled nursing facility or receiving home care services, there is also the benefit of eliminating multiple trips to medical facilities, clinics and centers to receive the range of services required. Much of the therapy can be provided in private homes or nursing homes. “In the nursing home setting, Medicare will cover the cost of room, board, therapy services, and nursing care for the appropriate time period allowed,” said Laman.

“Home care services, such as skilled nursing care, rehabilitative services such as physical therapy, occupational therapy, and speech therapy, medical social workers and home health aides who assist with various activities of daily living, provide patients the opportunity to stay home longer,” said Tracy Batey, RN, patient care representative for Extendicare of Tennessee. “From a home health perspective, the staff can serve as the eyes and ears of the physician, getting a better idea of the environment the patient will remain in once treatment is completed,” said Batey. “All services are under physician’s order with the physician reviewing each client’s chart to see how treatment is progressing.

Medicare also serves as a patient advocate. The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services, administers Medicare. Recently the CMS added a five-star quality rating system of America’s nursing homes, giving each up to a five-star rating. The system is designed to provide patients and their families an easy to understand assessment of nursing home quality.

Through its consumer information websites, CMS offers information on the quality, patient satisfaction, and cost of care. CMS also has rating systems for health and prescription drug plans, as well as a Compare Website that assists beneficiaries and their family members in making nursing home, home health care, and hospital choices by providing measures of quality of care, staffing, and survey inspection information.

“Medicare audits the care patients receive. We all have quality measures that are required for reimbursement. These range from the certification/qualifications of our staff to the use of universal precautions, all of which benefit the patient by working to ensure they are getting good quality care,” said Batey. “As reimbursement is outcome driven, agencies can be compared according to these. The CMS compiles this information and consumers can compare this information in order to make a more educated choice in the service provider for home care, nursing home care, and even hospitals.”

Medicare also has stepped in to make older nursing homes safer for residents. Under a relatively new regulation issued by CMS, older facilities that escaped modern regulations requiring wall-to-wall sprinkler systems to protect residents from fire, will now have to get the systems installed if they want to continue to serve Medicare or Medicaid beneficiaries. The CMS in 2005 required all long term care facilities without the sprinkler systems to install battery-operated smoke alarms in all patient rooms and pubic areas. Compliance with these mandates is tied to reimbursement.

“The program affords patients a better quality of life in that it covers services that can restore them to a more functioning state,” said Tom Lannom, Director of Therapy for Bells Nursing Home. “Without it, many if not most patients could be facing financial straits in the midst of an already trying time. In some cases, given the choice of paying out of pocket for these services or doing without them, the patient would go without the benefits of restorative therapy.”

“In terms of Home Health Services, Medicare is a better option than private insurance as it allows the patient to receive the appropriate level of care in a timely manner to meet the needs of the patient without regard to prior approval or variances in coverage from plan to plan,” said Batey. “If physicians dropped out of the program, the number of patients that could stay home would decrease. Without Medicare, there would be an increase in hospitalization rates and nursing home placement for patients because illness symptoms would not be managed as well.”



August 2008

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