Posted: October 25th, 2023

Financing and Reimbursement in the United States Healthcare System

Disc1, Public insurance in the United States is one of the most complex systems in the world. Explain Medicare and the four main parts of this insurance (Parts A, B, C, and D), and identify what each part covers. How is Medicaid different than Medicare, and who/what is covered under the Medicaid program? Use a reference to help support your response.

Disc2, Define retrospective and prospective reimbursement methods. In what way did retrospective reimbursement contain perverse financial incentives? Use a reference to support your response.

Presentation.

The focus of this assignment will be on the foundation and processes that have been established, bringing the U.S. health care system to where it is today. You will also consider how current and future plans for financing and reimbursement are currently impacting cost and access of health care.

Create a 7-10-slide presentation that includes detailed speaker notes for each slide. In your presentation, explore the following points:

How was health care financing and insurance established in the United States?
What is the purpose of different health care insurances? Describe the difference between public and private insurance structures.
What reimbursement methods are used in the United States (e.g., bundled services, fee-for-service)? What are retrospective and prospective reimbursements? Describe one benefit and drawback.
Do not count the title slide or the references slide when determining whether you have met the required number of slides for this assignment.

A minimum of two references, in addition to your textbook, is required for this assignment.

While APA style format is not required for the body of this assignment, solid academic writing is expected, and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Financing and Reimbursement in the United States Healthcare System

The healthcare system in the United States is a complex network of both public and private insurance structures that have developed over decades. This paper will explore the foundations of health insurance in America and examine key reimbursement methods that have shaped the current landscape. Specifically, it will define Medicare and Medicaid programs, retrospective and prospective reimbursement, and analyze incentives within different models.
Medicare and Medicaid Programs
Medicare is the national social insurance program administered by the federal government providing health insurance for Americans aged 65 and older, as well as younger people with disabilities and those with end-stage renal disease (Centers for Medicare & Medicaid Services, 2022).[3] It consists of four main parts that cover various services. Part A finances inpatient hospital stays, skilled nursing facilities, hospice and home health without premiums for most beneficiaries (Centers for Medicare & Medicaid Services, 2022). Part B covers certain doctors’ services, outpatient care, and durable medical equipment with a monthly premium (Centers for Medicare & Medicaid Services, 2022). Part C allows joining a private Medicare Advantage plan that must cover all Part A and B benefits (Centers for Medicare & Medicaid Services, 2022). Lastly, Part D helps pay prescription drug costs through approved private plans with premiums and cost sharing (Centers for Medicare & Medicaid Services, 2022).
Medicaid, distinct from Medicare, is a joint federal-state program providing medical assistance for certain low-income and needy people (Centers for Medicare & Medicaid Services, 2022).[4] Eligibility and coverage varies significantly between states but generally includes children, pregnant women, elderly adults and people with disabilities (Centers for Medicare & Medicaid Services, 2022). While Medicare serves all those aged or disabled, Medicaid eligibility depends on meeting financial and category requirements in each jurisdiction.
Retrospective and Prospective Reimbursement

Historically, retrospective reimbursement involved paying providers after services based on submitted charges and costs (Waters et al., 2004).[5] This system created perverse incentives as it rewarded over-utilization of services and did little to control escalating costs (Waters et al., 2004). In contrast, prospective reimbursement sets predetermined payment rates for medical cases prior to delivery dependent on patient diagnosis (Waters et al., 2004). This model aims to incentivize efficiency and restrain spending by removing financial motivation for excessive treatment (Waters et al., 2004).
Conclusion
In summary, the establishment of Medicare, Medicaid and transition to prospective reimbursement have shaped the current complex landscape of the United States healthcare system. Ongoing debates around financing and models seek to balance incentives for quality, access and cost-control.

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