Understanding Healthcare Coverage for Vulnerable Populations
School
Post University**We aren't endorsed by this school
Course
BSN 436
Subject
Nursing
Date
Dec 9, 2024
Pages
6
Uploaded by yemotee
1Healthcare Policy and Regulation: Healthcare delivery and quality outcomesDepartment Name: Post UniversityCourse Number: SIMPATH 436Instructor: Nov 9th , 2024
2HEALTHCARE COVERAGE AND VULNERABLE POPULATIONSHealthcare coverage ensures that individuals can access necessary medical care withoutfinancial hardship. Health insurance coverage provides essential health services for vulnerableand uninsured populations that these populations may find unaffordable. Insurance oftencovers preventive services, medication, and primary care visits, reducing the incidence ofuntreated health issues and costly emergency care (Burns et al., 2024). It describes howdifferent options of healthcare coverage support or hinder access to care and analyzes the roleof DRGs and charity care in care facilities, focusing on quality and nursing interventions.HEALTHCARE COVERAGE BENEFITS FOR VULNERABLE POPULATIONSHealth insurance coverage supports vulnerable populations in their preventive and primarycare services. It can facilitate regular visits to a primary care provider, thus enabling themanagement of chronic conditions and preventing serious health consequences. It alsoprovides support for medication coverage, which is highly important for people with chronicdiseases who, without coverage, may have to forgo necessary treatments due to financialconcerns. Improvement in preventing illnesses and medication use results in fewer hospitaladmissions and better health management in the community.DIAGNOSIS RELATED GROUPS (DRGS)The diagnosis-related groupings classify all hospital cases into several hundred groups. Theclassification is based on a patient's diagnosis, therapy, and other needs, which makes billingand reimbursement easy for hospitals because fixed rates have been set for certain diseases. As
3long as fixed payments dictate DRG categories, diagnosis-related groups might affect a patient'sduration of stay because hospitals must work within the established amount for each diagnosis.DRG reimbursements are also increasingly tied to quality indicators like patient condition andreadmission rate (Huepenbecker & Meyer, 2022). Such incentives motivate healthcareorganizations to provide high-quality care at low cost.MEDICARE PLANMedicare provides comprehensive coverage for seniors and disabled people. Primary care andhospital coverage help Medicare enrollees access treatment. Primary care appointments helpbeneficiaries manage chronic diseases, get wellness checks, and get specialist referrals, which isespecially helpful for older persons who need constant health monitoring. Medicare also coversinpatient hospital care, ensuring patients obtain necessary care (Figueroa et al., 2020).Additionally, Medicare's restrictions may limit certain patients' access. Medicare covers manyservices but rarely covers long-term custodial care for people with severe chronic conditions.Medicare limits patients' prescription drug options if their treatments are not reimbursed.These coverage gaps might make it hard for recipients to get complex health care.PREFERRED PROVIDER OPTION (PPO) PLANA Preferred Provider Option (PPO) plan is a private insurance model that allows beneficiariesflexibility in choosing healthcare providers, often without referrals. PPOs offer greater choice byallowing out-of-network providers and direct access to experts. Other plans need referrals froma primary care physician to see specialists, limiting access. PPOs cover specific out-of-network
4treatments, giving policyholders more flexibility and access to providers. There are PPO limitsthat can affect patient access. Patients may need help to afford out-of-network services due tohigher out-of-pocket charges. Limited preventive services coverage may discourage regularcheck-ups and screenings, which are crucial for early diagnosis. Due to cost, people may skippreventive or specialist care.NURSING INTERVENTIONS FOR SAFE, HIGH-QUALITY CARENurses take the lead in encouraging patients to practice self-care themselves. Nurses provideevidence-based interventions to ensure safe, quality healthcare. First, nurses can educatepatients about their medications- that is, the purpose of their medication and the need forcompliance. Such an intervention would be helpful for those patients who have chronicconditions and must take medicines continuously for stability. Second, preventative care suchas nutrition, exercise, and routine screenings can unblock the disease processes and helppromote health (Grant, 2024). A third intervention would be care coordination amongproviders for continuing patient care across many settings, notably for hospital-to-hometransfers. To improve patient safety and reduce hospitalization complications, the nurse shouldmonitor quality care indicators, including fall prevention and pressure ulcer monitoring. Eachdirect care action improves health outcomes by fulfilling patients' short- and long-term needs.
5CONCLUSIONHealth insurance determines whether people receive care, especially the extent to whichvulnerable populations are covered. Medicare and PPO plans have various strengths andweaknesses in facilitating access to necessary healthcare services. DRGs supplement theapproach of structured reimbursement for hospitals based on quality and effectiveness. Charitycareis a method that provides services to people who cannot pay for themselves. Nurses aregreat at promoting quality care through selective interventions and advocating for preventionand self-care. These components make a healthcare system that aims to improve access,quality, and efficiency for a diverse patient population.
6ReferencesBurns, A., Vest, J. R., Nir Menachemi, Olena Mazurenko, Musey, P. I., Salyers, M. P., & Yeager, V. A.(2024). Availability of behavioral health crisis care and associated changes in emergencydepartment utilization. Health Services Research. https://doi.org/10.1111/1475-6773.14368Figueroa, J. F., Wadhera, R. K., Frakt, A. B., Fonarow, G. C., Heidenreich, P. A., Xu, H., Lytle, B., DeVore, A.D., Matsouaka, R., Yancy, C. W., Bhatt, D. L., & Joynt Maddox, K. E. (2020). Quality of Care andOutcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized WithHeart Failure. JAMA Cardiology, 5(12), 1349. https://doi.org/10.1001/jamacardio.2020.3638Grant, P. (2024). Proactive Care. 87–107. https://doi.org/10.1007/978-3-031-69944-3_7Huepenbecker, S. P., & Meyer, L. A. (2022). Our dual responsibility of improving quality and questioningthe metrics: Reflections on 30-day readmission rate as a quality indicator. Gynecologic Oncology,165(1), 1–3. https://doi.org/10.1016/j.ygyno.2022.03.001