Master of Public Health
Health Services Research & Administration
First Committee Member
David W. Palm Ph.D
Second Committee Member
Stephen M. Peters, M.A.
Third Committee Member
Jonathan D. Rouse, DPM
Government health insurance plans such as Medicaid and Medicare were created with the intention of providing elderly, low-income, or disabled citizens with affordable and quality health insurance through government-contracted providers (Baicker et al., 2013). Medicare is a government health insurance program that provides healthcare to United States citizens 65 years and older, regardless of their income or past medical history. Medicaid was implemented as an assistance program to provide health insurance for low-income Americans and their families. Medicaid is administered by each state independently, which creates variation in reimbursement rates, services, and structure. (Grabowski, 2007).
Providers accepting Medicare and Medicaid payments agree to receive lower reimbursement rates in comparison to private insurance. Private insurance programs offer providers rates based on group contracts and affiliated capitation programs and typically reimburse higher than government payment models (Mark et al., 2020). Providers see a significant revenue difference between private pay and government reimbursement. For an established patient office visit, commercial insurers paid an average of 126 percent of Medicare rates (Mark et al., 2020). For many providers, especially if they have an overabundance, or their patient base skews heavily on government patients, their revenues and financial well-being can be strained (Mark et al., 2020).
Lower reimbursement, coupled with higher expenses of caring for these patients, complex CMS guidelines, and increased Medicare and Medicaid enrollment, often can jeopardize providers financially. This project aims to complete a financial impact assessment of four clinics to determine the impact of Medicare and Medicaid guidelines, reimbursement rates, and increased enrollment and apply that data to a financial decision tool that can assist in determining clinic decisions.
Abdul-Hakim, Jamilah J., "Financial Analysis of New Medicare and Medicaid Guidelines, Reimbursement Rates, and Increased Enrollment on Four Nebraska Clinics" (2022). Capstone Experience. 200.