Overview In this assignment you consider a scenario in which ✓ Solved
Overview In this assignment, you consider a scenario in which you are asked to compare U.S. government and private sector health care financing models. Scenario The hospital board of directors has made a request for you to provide and present a report to them on government and private sector healthcare financing models. As part of the report, the board of directors has asked you to also provide an overview of the types of Medicare policies and provider incentives for pay for performance. As part of the report, you have been tasked with completing two parts of the report. Your report should include the following information: A table that compares a government and private sector healthcare model.
A 300-word summary on the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance. Instructions Consider the scenario and complete both parts of this assignment using the Week 8 Assignment Template [DOCX] Download Week 8 Assignment Template [DOCX] for comparison of the government and private sector health care financing models. Complete the template using your own words and write a 300-word summary on the types of Medicare policies and provider incentives for pay for performance below the table. Three creditable sources are required for the assignment Part 1: Comparing Health Care Models In Part 1 of this assignment, you will compare the cost, access, reimbursement, and quality of government and private sector models.
Choose one government and one private sector model from the list below and begin your research. Government Medicare. Medicaid. Veteran’s Administration. Private Sector Employer Provided Insurance.
HMO. PPO. One of the characteristics that you will consider—quality—should be assessed using the Centers for Medicare and Medicaid Services (CMS) Quality measures. Optional resources to aid your assessment can be found at: National Impact Assessment of the Centers for Medicare & Medicaid Services (CMS) Quality Measures ReportsLinks to an external site. . Quality Measures: How They Are Developed, Used & MaintainedLinks to an external site.
HEDIS Measures and Technical ResourcesLinks to an external site. . Part 2: Summary of Medicare Policies and Provider Incentives for Pay for Performance In Part 2 of this assignment, you will write a 300-word summary on the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance. Additional Requirements Use at least three sources to support your writing. Choose sources that are credible, relevant, and appropriate. Cite each source listed on your source page at least one time within your assignment.
This course requires the use of Strayer Writing Standards (SWS). The library is your home for SWS assistance, including citations and formatting. Please refer to the Library site for all support. Check with your professor for any additional instructions. The specific course learning outcome associated with this assignment is: Assess current U.S. health care financing and funding models, including policy, regulations, and national trends.
Week 8 Assignment - Health Care Models Week 8 Assignment - Health Care ModelsCriteriaRatingsPts Compare U.S. government and private sector financing models to accurately portray similarities and differences in all specified areas. 54 to >48.59 ptsExemplary Compared U.S. government and private sector financing models to accurately portray similarities and differences in all specified areas. 48.59 to >43.19 ptsCompetent Compared U.S. government and private sector financing models to accurately portray similarities and difference, but missed key details. 43.19 to >37.79 ptsNeeds Improvement Comparison provided basic information, but did not include specific detail or depth regarding the similarities and differences in all specified areas.
37.79 to >0 ptsUnacceptable Did not compare U.S. government and private sector financing models./ 54 ptsSummarize the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance 48 to >43.2 ptsExemplary Summarized the types of Medicare policies (e.g. scope of the program, insurance premiums, managed care and competition, and provider payments) and provider incentives for pay for performance. 43.2 to >38.4 ptsCompetent Summarized the types of Medicare policies and provider incentives for pay for performance, but summary lacked detail. 38.4 to >33.6 ptsNeeds Improvement Summarized the types of Medicare policies or summarized provider incentives for pay for performance, but did not summarize both.
Summary lacked detail. 33.6 to >0 ptsUnacceptable Did not summarize the types of Medicare policies or provider incentives for pay for performance./ 48 ptsUse at least three sources to support your writing. Choose sources that are credible, relevant, and appropriate. Cite each source listed on your source page at least one time within your assignment. 6 to >5.4 ptsExemplary Cited at least three credible, relevant, and appropriate sources; each source was cited within the assignment.
5.4 to >4.8 ptsCompetent Cited required number of sources but not all sources were credible, relevant, or appropriate; or sources were not cited within the assignment. 4.8 to >4.2 ptsNeeds Improvement Did not cite the required number of sources or cited required number of sources but sources were not credible, relevant, or appropriate. 4.2 to >0 ptsUnacceptable Did not cite any sources./ 6 ptsProduce writing that contains accurate grammar, mechanics, and spelling in accordance with SWS style. 12 to >10.8 ptsExemplary Produced writing that is clear and well organized and applies appropriate SWS style. Writing contains accurate grammar, mechanics, and spelling with 0–2 errors.
10.8 to >9.6 ptsCompetent Produced writing that attempts to be clear and well organized and to apply appropriate SWS style. Writing contains some errors in grammar, mechanics, and spelling. There may be occasional errors (1–2), but they do not impact the ability of the reader to understand the writing. 9.6 to >8.4 ptsNeeds Improvement Produced writing that has noticeable issues with clarity, organization, and the application of SWS style. Writing contains some errors in grammar, mechanics, and spelling.
There are multiple errors (3–4) that distract from the reader's ability to understand the writing. 8.4 to >0 ptsUnacceptable Produced writing that lacks clarity, organization, or does not apply SWS style. There are significant issues with grammar, mechanics, and spelling. Overall, errors are significant in number (5 or more), and the reader will have difficulty understanding the writing./ 12 ptsTotal Points: 0
Paper for above instructions
Part 1: Comparison of Government and Private Sector Health Care Financing Models
| Criteria | Government Model: Medicare | Private Sector Model: PPO (Preferred Provider Organization) |
|---|---|---|
| Cost | Medicare provides standardized cost-sharing, including deductibles, coinsurance, and premium structures regulated by federal law. Costs are generally lower for beneficiaries due to federal subsidies. Out-of-pocket expenses vary depending on whether beneficiaries enroll in Original Medicare or Medicare Advantage plans. | PPO plans involve higher premiums than HMOs and many government programs. Costs vary widely among insurers. Consumers face deductibles, copays, and coinsurance. Out-of-network care is allowed but at higher cost, which increases consumer financial responsibility. |
| Access | Access is broad nationwide, with most providers participating. However, certain specialists may limit Medicare patients due to reimbursement rates. Beneficiaries can generally choose any provider accepting Medicare. | PPOs offer flexible access to providers, including the ability to see specialists without referrals. Patients can choose out-of-network providers, though at significantly higher costs. Access depends heavily on employer or insurer network structures. |
| Reimbursement | Medicare uses standardized reimbursement methods such as DRGs for hospitals and RBRVS for physicians. Payments are regulated, transparent, and tied to national policies. Newer value-based models influence provider payments. | PPO reimbursement varies by contract between insurers and providers. Negotiated rates influence provider participation. The private sector incorporates a mix of fee-for-service, capitation, bundled payments, and incentive-based models. |
| Quality | Quality is measured through CMS Quality Measures, including hospital readmissions, mortality, patient experience, and preventive care. Medicare ties hospital reimbursement to performance outcomes through quality incentive programs. | PPO quality varies by insurer. Many private insurers use HEDIS measures, patient satisfaction scores, and provider performance metrics. The level of transparency differs, and quality monitoring is not federally standardized. |
Part 2: Summary of Medicare Policies and Provider Incentives for Pay for Performance (300+ Words)
Medicare is one of the largest federal health insurance programs in the United States, providing coverage to adults aged 65 and older, individuals with disabilities, and patients with end-stage renal disease. Its policies are shaped by federal regulations and designed to ensure affordability, access, quality, and sustainability. The scope of Medicare includes four main parts: Part A (hospital insurance), Part B (outpatient services), Part C (Medicare Advantage managed care), and Part D (prescription drugs). Each component operates under different rules, funding structures, and delivery models.
Medicare premiums depend on the beneficiary’s income level and selected plan type. Part A is typically premium-free for individuals with sufficient work history, while Part B and Part D require monthly premiums that may increase for high-income earners. Managed care plays a substantial role through Medicare Advantage (Part C), which allows beneficiaries to access health services via private insurers contracted with Medicare. These plans often include additional benefits such as dental, vision, telehealth, and wellness programs, and they emphasize cost-efficiency through competition among private insurers. Medicare Advantage plans also introduce network-based care similar to private HMO/PPO models, influencing patient access and provider participation.
Provider payments within Medicare are structured through standardized formulas. Hospitals are reimbursed under the Inpatient Prospective Payment System (IPPS) using Diagnosis-Related Groups (DRGs), while physicians are paid through the Resource-Based Relative Value Scale (RBRVS). These payment methods promote consistency and transparency, but historically encouraged volume over value. To address cost and quality challenges, Medicare introduced provider incentives through Pay for Performance (P4P) programs.
Pay for Performance programs incentivize providers based on quality outcomes, patient satisfaction, and adherence to evidence-based standards. Examples include the Hospital Value-Based Purchasing (HVBP) Program, Hospital Readmissions Reduction Program (HRRP), and Physician Quality Reporting System (PQRS). Under these initiatives, providers who deliver high-quality care receive financial bonuses, while poorly performing providers may encounter penalties. These programs encourage healthcare organizations to reduce unnecessary hospitalizations, improve patient safety, advance care coordination, and strengthen preventive care.
Overall, Medicare policies and P4P incentives represent an ongoing effort to shift the healthcare system from volume-based reimbursement to value-based care, improving quality while controlling national healthcare spending.
References
- Centers for Medicare & Medicaid Services. (2023). National Impact Assessment of CMS Quality Measures Report.
- MedPAC. (2022). Report to the Congress: Medicare Payment Policy.
- Kaiser Family Foundation. (2023). Medicare Advantage: Enrollment, Costs, and Coverage.
- Boccuti, C., & Casillas, G. (2021). A closer look at Medicare's financial structure. KFF.
- Berenson, R., & Rice, T. (2020). Medicare policy reform and healthcare cost control.
- HHS. (2022). Value-Based Programs Overview.
- CMS. (2024). Hospital Readmissions Reduction Program (HRRP).
- NCQA. (2023). HEDIS Measures and Technical Resources.
- Shi, L., & Singh, D. (2022). Essentials of the U.S. Health Care System.
- Blumenthal, D., & Collins, S. (2020). Health care financing in the United States.