C489 Task 3 - Grade: pass PDF

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Organizational Systems Task Three

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C489 Task 3

Deana Dench WGU February 28, 2021

Organizational Systems Task Three

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Healthcare Utilization and Finance A:1. Country of Choice -United States of America vs. Japan A:2 Comparing Access of Healthcare for Children, Unemployed Persons, and Retirees Comparison of the healthcare systems of Japan and the United States proves that there are many differences. Japan has mainly universal healthcare that is funded by taxes and individual contributions (Matsuda, 2020). Residents of Japan can be enrolled into health insurance by either employment or by a residence-based plan. In addition to premiums, the Japanese pay 30% coinsurance for most services, and also copayments. Children and retired adults have decreased coinsurance rates, and there is a yearly family payment maximum for health care and long-term care services depending on age and income. Employment insurance plans cover 59% of Japanese, whereas residence-based plans comprise the remainder of the population. The residence-based plans are divided into two categories: Citizen Health Insurance, which is issued to unemployed people age 74 and under; and Health Insurance for the Elderly, which covers all adults age 75 and older (Matsuda, 2020). The United States has a variety of ways to get medical insurance. Most individuals with health insurance attain it through their employer or pay for private insurance (Cherry & Jacob, 2019). The premiums for private health insurance are extremely high and often not affordable for Americans. Because of this, many do not have health insurance and must pay directly out of pocket. Children are insured through their parent’s insurance. If their parents are not insured, there are government programs specifically for children. Medicaid offers health coverage for

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children and non-employed persons. Eligibility is based on individual income or parental income. Retired Americans have health coverage by a different government program called Medicare. Individual must be age 65 or older to qualify. Other options are the Patient Protection and Affordable Care Act (PPACA). This allows Americans to get health insurance through there employer that may have not previously offered health insurance as a benefit. The U.S. military covers active-duty soldiers and their families with the program Tri-Care (Cherry & Jacob, 2019). A:2a Coverage for Medications Japan’s Statutory Health Insurance System (SHIS) provides many benefits, of those, include approved prescription medications (Matsuda, 2020). SHIS enrollees must pay 30% coinsurance rates for health services and pharmaceuticals. There are no deductibles but there is the coinsurance and co-payment fees. The fees are set by the government. Because of the universal health care in Japan, all residents should have access to coverage for any needed medications (Matsuda, 2020). All United States residents should have access to medications, however, the ability to pay for them is completely different. If citizens have health insurance, these will cover most of the medications costs minus the co-payment (Cherry & Jacob, 2019). If one is without any source of insurance, they must pay for medications out of pocket. Sometimes these medications are not expensive and paying for them without insurance is relatively easy. Many pharmacies have common prescription drugs at a discounted rate to allow citizens to obtain needed medications (Cherry & Jacob, 2019).

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A:2b Referrals for Specialists In Japan, there is not a requirement for referrals to see a specialist doctor (Matsuda, 2020). In the U.S., most types of insurance providers do not require referrals. Health Maintenance Organization (HMO) types of insurance do require referrals to see specialists. With Preferred Provider Organization (PPO), citizens do not usually need a referral for a specialist, however, it is highly recommended to use a provider from the network to avoid paying much higher copayments (Cherry & Jacob, 2019). A:2c Coverage for Preexisting Conditions Because Japan uses universal healthcare, every citizen is covered for insurance. Their salary, age, or preexisting conditions do not alter the availability of healthcare (Matsuda, 2020). After the year 2010, preexisting conditions in the United States are no longer a factor in insurance coverage. The Affordable Care Act eliminated preexisting conditions as a way for insurance companies to deny coverage or charge higher premiums (Cherry & Jacob, 2019). A:3 Two Financial Connections to Healthcare Delivery In Japan, healthcare is provided for every person. It is paid for with taxes and individual contributions (Matsuda, 2020). Because of this, the taxes for the employed are higher and impact healthcare delivery. Another impact on healthcare in Japan is the SHIH coinsurance rates. The rate is 30% for most citizens. However, children and elderly are exempt from coinsurance. The coinsurance rates can become costly for many Japanese (Matsuda, 2020). Healthcare costs in America are frequently the subject for news programs and politicians. Cost of healthcare is very high in the U.S. One financial impact on citizens is that insurance companies tend to regulate health care costs for individual Americans (Cherry & Jacob, 2019). A person’s insurance company can deny a needed procedure or medication and pass the total cost

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to that person. Or insurance companies can charge higher premiums for persons with unhealthy lifestyles, such as, smoking or being overweight. Another financial impact on healthcare delivery is readmission rates. Hospitals sometimes discharge patients before they should, and the patient must be readmitted within a certain timeframe because of a relapse of illness or inability to recover. Because of the frequency of readmissions, many initiatives have been developed to drastically reduce this rate for Americans (Cherry & Jacob, 2019).

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Cherry, B., DNSc, MBA, RN, NEA-BC, & Jacob, S. R., PhD, MSN, RN. (2019). Contemporary Nursing (8th ed.). Elsevier. https://doi.org/https://wgu.vitalsource.com/#/books/9780323554206/cfi/6/40!/4/2/4/2@0: 0 Matsuda, R. (2020, June 5). International Health Care System Profiles: Japan. www.commonwealthfund.org. Retrieved February 28, 2021, from https://commonwealthfund.org/international-health-policy-center/countries/japan...