Healthcare Management and Delivery: Payment, Settings, and Quality
Coverage and payment
Medicare is a federal program for people aged 65 and older, certain people with disabilities, and people with end-stage renal disease; Part A covers inpatient hospital and related care, Part B covers outpatient and provider services, Part C is Medicare Advantage, and Part D is prescription coverage. Medicaid is a federal-state program with income-based eligibility. Know the incentive structure of payment models: fee-for-service rewards volume; capitation pays a fixed per-member per-month amount and rewards controlling utilization; diagnosis-related groups pay a prospective amount per inpatient discharge; bundled or case rates pay a set amount for an episode. Value-based purchasing, readmission penalties, and accountable care organizations tie payment to quality and total cost.
Settings and levels of care
Distinguish primary, secondary, tertiary, and quaternary care; inpatient versus observation status; skilled nursing facility, home health, hospice, and long-term care. Understand the continuum of care, care transitions, the patient-centered medical home, utilization management, critical pathways, and accreditation and quality measurement.
Traps to watch
Mixing Medicare and Medicaid eligibility; confusing Part A and Part B; confusing capitation with case rates; assuming observation status satisfies the inpatient qualifying stay for Medicare skilled nursing facility coverage.
Worked example
A patient spends three days in observation and then needs skilled nursing care. Under traditional Medicare, observation time generally does not count toward the inpatient qualifying hospital stay, so skilled nursing facility coverage is not triggered. The correct action is to clarify status with the hospital and explore alternatives such as home health or a custodial placement.