Medicare, Medicaid, and Military and VA Healthcare Programs

Function

Medicare

• Provides health insurance for people aged 65 and older and those with specific disabilities or chronic conditions.
• Comprises 4 parts:
  • Part A (hospital insurance)
  • Part B (medical insurance)
  • Part C (Medicare Advantage)
  • Part D (prescription drug coverage)
• Pays for various healthcare services, including hospital care, physician services, diagnostic tests, and preventive services.

Medicaid

• Provides healthcare coverage for low-income individuals and families, pregnant women, children, and persons with disabilities.
• Is jointly funded by the federal and state governments, with each state having some flexibility in determining the eligibility requirements and covered services.
• Covers a wide range of healthcare services, including hospital care, physician services, prescription drugs, and long-term care.

Military and VA Programs

• Provide healthcare services to military personnel, veterans, and their families.
• Offer various healthcare services, including primary care, mental health, rehabilitation, and long-term care.
• Focus on providing accessible and comprehensive care to military personnel and veterans, including those who live in rural areas.

Medicare, Medicaid, and Military and VA Programs provide healthcare services to vulnerable populations in the United States. Medicare is a federal program that provides health insurance to individuals 65 years or older and younger individuals with disabilities. Medicaid is a joint federal and state program that provides healthcare services to low-income individuals and limited resources. Military and VA programs offer healthcare services to active-duty military personnel, veterans, and their families.

The programs offered in Medicare, Medicaid, and the Military and at the VA serve different functions and aim to improve health outcomes for their beneficiaries.

Medicare: Medicare offers various programs to improve health outcomes for beneficiaries. The Medicare Advantage program allows beneficiaries to receive care through a private health plan rather than traditional Medicare. This program has been shown to improve health outcomes by reducing hospitalizations and emergency department visits. The effectiveness of this program is supported by level 1 evidence. The Chronic Care Management program is designed to improve the management of chronic conditions among beneficiaries. This program effectively improves patient outcomes, such as reducing hospitalizations and improving patient satisfaction. The effectiveness of this program is supported by level 2 evidence.[6]

Medicaid: Medicaid offers programs to improve access to care and manage chronic conditions among its beneficiaries. The Medicaid Health Home program enhances care coordination for beneficiaries with complex medical needs. This program has been shown to reduce hospitalizations and improve access to care. The effectiveness of this program is supported by level 3 evidence. The Medicaid Managed Long-Term Services and Supports program provides beneficiaries with long-term care services and supports in the community rather than in institutional settings. This program has been shown to improve access to care and increase patient satisfaction. The effectiveness of this program is supported by level 3 evidence.[7]

Military Health System: The Military Health System offers programs to improve access to care and support the health and well-being of military personnel and their families. The TRICARE Prime program provides beneficiaries access to care through a network of civilian providers. This program has been shown to improve health outcomes by reducing hospitalizations and improving patient satisfaction. The effectiveness of this program is supported by level 2 evidence. The Warrior Care program provides support and resources for wounded, ill, and injured service members. This program has been shown to improve access to care and increase patient satisfaction. The effectiveness of this program is supported by level 3 evidence.[8]

VA Health Care System: The VA Health Care System offers programs to improve access to care and support the health and well-being of veterans. The Patient Aligned Care Teams (PACT) program is designed to provide comprehensive, coordinated care to veterans. This program has been shown to improve health outcomes by reducing hospitalizations and improving patient satisfaction. The effectiveness of this program is supported by level 2 evidence. The Veterans Health Administration (VHA) Telehealth program provides veterans access to care through remote technology. This program has been shown to improve access to care and increase patient satisfaction. The effectiveness of this program is supported by level 2 evidence.[5]

Issues of Concern

The Role of Telehealth and Mobile Health Clinics in Addressing Access to Care in Underserved and Rural Areas

One issue of concern is access to care, particularly in underserved and rural areas. Several studies have found that patients in these areas may have difficulty accessing healthcare services, resulting in poorer health outcomes (Level of Evidence: 3). Programs such as telehealth and mobile health clinics have been implemented to address this issue (Level of Evidence: 2), but further research is needed to determine their effectiveness.[9]

Cost-Related Concerns and Effectiveness of Cost-Sharing Programs in Healthcare Services

Another issue is the cost of healthcare services. While these programs are designed to provide affordable healthcare to eligible individuals, the cost of healthcare services can still be a burden for some patients. Several studies have examined the effectiveness of cost-sharing programs, such as copayments and deductibles, on patient outcomes (Level of Evidence: 2). These programs have been found to have mixed results, with some studies indicating that they may lead to reduced healthcare utilization and poorer health outcomes, while others suggest that they may improve patient outcomes by encouraging more judicious use of healthcare services.[10]

Effectiveness of Patient Safety Initiatives and Clinical Practice Guidelines in Improving Quality of Care in Healthcare Programs

Quality of care is also a concern in these programs. While the quality of care healthcare professionals provides is generally high, there are still medical errors, misdiagnoses, and suboptimal care. Several studies have examined the effectiveness of quality improvement programs, such as patient safety initiatives and clinical practice guidelines, on patient outcomes (Level of Evidence: 1). These programs have been found to improve patient outcomes by reducing medical errors and improving the quality of care.[11] 

Effectiveness of Patient-Centered Care Programs on Patient Satisfaction

Finally, there is the issue of patient satisfaction with the care received. Several studies have examined the effectiveness of patient-centered care programs, which prioritize patient preferences and involve patients in their care (Level of Evidence: 1). These programs have improved patient satisfaction and health outcomes by enhancing communication between healthcare providers and patients.[12]

Pros and Cons of Using Compounded Medications Under Tricare Coverage

Tricare is a healthcare program that provides coverage for active-duty military members, retirees, and their families. Compound pharmacies create customized medications for patients based on individual needs. Several studies have evaluated the relationship between Tricare and compounding pharmacies.

One study published in the American Journal of Health-System Pharmacy in 2019 found that compounded medication use among Tricare beneficiaries had increased over time, particularly for pain management. The study also found that compounded medications were associated with higher healthcare costs and a higher risk of adverse effects compared to commercially available medications.[13] 

Another study published in the Journal of Managed Care & Specialty Pharmacy in 2018 evaluated the use of compounded medications among Tricare beneficiaries with chronic pain. The study found that while the use of compounded medications was associated with higher healthcare costs, it was also associated with lower rates of opioid use and lower rates of opioid-related adverse events.[14] 

A third study published in the Journal of Pharmacy Practice in 2016 evaluated the use of compounded medications among Tricare beneficiaries with dermatological conditions. The study found that while compounded medications were commonly used for dermatological conditions, there was a lack of evidence supporting their effectiveness and safety.[15] 

These studies highlight the need for careful consideration when using compounded medications among Tricare beneficiaries. While compounded medications may have potential benefits for some patients, they also come with higher costs and potential risks compared to commercially available medications. Healthcare practitioners must carefully evaluate the use of compounded drugs and consider the evidence supporting their effectiveness and safety.

Clinical Significance

Varied Effectiveness of Medicare, Medicaid, and VA Programs Based on Level of Evidence and Intended Outcomes

The clinical significance of the programs offered in Medicare, Medicaid, and Military settings and at the VA varies depending on the specific program and its intended outcomes. The effectiveness of each program varies and is often based on the level of evidence supporting its implementation.

For example, programs like the Medicare Diabetes Prevention Program effectively reduce the risk of developing type 2 diabetes among individuals with prediabetes. This program is based on Level 1 evidence from large randomized clinical trials with clear-cut results. Other programs, like the Medicaid Health Homes program, have been implemented to improve care coordination and management for individuals with chronic conditions. While there is limited Level 1 evidence supporting this program's effectiveness, some evidence from cohort and case-control studies suggests that it may lead to improved outcomes, including reduced hospitalizations and emergency department visits. Similarly, the VA's Patient Aligned Care Teams (PACT) program has been implemented to improve care coordination and patient-centeredness among veterans. This program is supported by Level 2 evidence from small RCTs with unclear results, as well as cohort and case-control studies suggesting improved patient outcomes.

Overall, understanding the clinical significance and effectiveness of the various programs offered in Medicare, Medicaid, and Military settings and at the VA requires a comprehensive understanding of the specific outcomes they aim to achieve, the level of evidence supporting their effectiveness, and any issues of concern that could impact their implementation and outcomes.[16][17]

Nurse-led Care Coordination Interventions

Level 1-evidence studies have shown that nurse-led care coordination interventions can significantly improve patient outcomes, such as reduced hospitalizations and emergency department visits, for Medicare beneficiaries with multiple chronic conditions. Patient-centered care programs, which prioritize patient preferences and involve patients in their care, have also improved patient satisfaction and health outcomes.[18] 

Interprofessional Education Programs

Level 2-evidence, interprofessional education programs have significantly improved communication and collaboration among healthcare team members, leading to improved patient outcomes. This is particularly important in delivering high-quality care in VA settings.[19][20]

interprofessional Team-Based Care Coordination

Level 3-evidence, interprofessional-team–based care coordination effectively improves outcomes for Medicare beneficiaries with complex care needs. Effective communication and collaboration among healthcare providers have also been associated with improved patient outcomes, increased patient satisfaction, and improved healthcare provider satisfaction.[18]

Other Issues

Medicare

• Rising healthcare costs may lead to reduced access to healthcare services for older adults and people with disabilities.
• Fraud and abuse can lead to unnecessary costs and reduced quality of care for beneficiaries.
• Limited coverage for long-term care can be a significant financial burden for older adults and their families.

Medicaid

• Limited provider availability can reduce access to healthcare services for low-income individuals and families.
• Rising healthcare costs may lead to reduced access to healthcare services for low-income populations.
• Limited coverage for dental and vision care can lead to unmet healthcare needs for beneficiaries.

Military and VA Programs

• Limited availability of mental health services can lead to unmet healthcare needs for military personnel, veterans, and their families.
• Long wait times for appointments can lead to delayed healthcare services and reduced patient satisfaction.
• Limited access to healthcare services for veterans who live in rural areas.

Issues of Concern Impacting the Effectiveness of Programs in Medicare, Medicaid, and Military and VA Programs

Some programs offered in Medicare, Medicaid, and Military settings and at the VA may have issues of concern that could impact their clinical significance and effectiveness. For example, the VA's Choice Program, which provides veterans access to care outside of the VA system, has been criticized for its complex eligibility criteria and long wait times, which can delay access to care and potentially compromise patient outcomes. Similarly, the Medicaid program has faced challenges in ensuring access to care for individuals with low income or disabilities, particularly in states that have not expanded Medicaid under the Affordable Care Act. This can impact the effectiveness of programs aimed at improving outcomes for these populations, such as Medicaid Health Homes.[17][21]

Ranking the Effectiveness of Medicare, Medicaid and Military and VA Programs: Considering Evidence and Context

In ranking the effectiveness of these programs, it is essential to consider the specific outcomes they aim to achieve and the level of evidence supporting their effectiveness. Programs with Level 1 evidence from large RCTs with clear-cut results, such as the Medicare Diabetes Prevention Program, may be considered more effective than programs with lower levels of evidence. However, it is essential to consider the context in which these programs are implemented and the individual patient needs and preferences they aim to address. Programs with lower levels of evidence, such as the Medicaid Health Homes program, may still be effective in improving outcomes in specific populations, particularly when implemented in a patient-centered and coordinated manner.[22]

Other Considerations

• Cost: One of the main issues of concern for Medicare and Medicaid is the rising cost of healthcare services. As the population ages, healthcare costs continue to increase; these programs struggle to keep up with the demand for services. There is reduced funding for these programs and a strain on the quality of care.[23]

• Quality: Another issue of concern is the quality of healthcare services. While Medicare, Medicaid, and Military and VA Programs aim to provide high-quality healthcare services, gaps in care must be addressed. These gaps include disparities in healthcare access and outcomes based on race, ethnicity, and socioeconomic status.[17]

• Accessibility: For Military and VA Programs, the issue of concern is providing timely and accessible healthcare services to military personnel and veterans, especially those who live in rural areas. There are also concerns about the quality of care provided to veterans, including issues with mental health services appointment wait times.[24]

• Coordination: Additionally, there are concerns about the coordination of care between different healthcare providers. There is a need for better communication and collaboration between physicians, nurses, pharmacists, and other health professionals to ensure that patients receive comprehensive and coordinated care.[25]

Enhancing Healthcare Team Outcomes

Ongoing research focuses on enhancing clinicians' competence in skills, strategies, ethics, responsibilities, interprofessional communication, and care coordination related to Medicare, Medicaid, and Military and VA Programs. Recent studies highlight the need to improve clinicians' understanding and ability to navigate the complexities of these healthcare systems, ensuring optimal care delivery and outcomes for patients within these programs. 

• Skills: A recent study published in the Journal of Interprofessional Education & Practice evaluated the impact of interprofessional education on healthcare professionals' skills in providing patient-centered care in a VA setting. The study found that interprofessional education improved healthcare professionals' communication skills and ability to develop comprehensive care plans collaboratively. [Level 2 study. Small RCTs with unclear results.][26] 

• Strategy: A study published in the Journal of the American Geriatrics Society evaluated the effectiveness of a team-based approach to care coordination for Medicare beneficiaries with complex care needs. The study found that the team-based approach improved patient outcomes and reduced healthcare costs, indicating the importance of a comprehensive strategy in delivering patient-centered care. [Level 3 study. Cohort and case-control studies.][27]

• Ethics: An article published in the Journal of Medical Ethics explored ethical considerations in Medicare and Medicaid programs, highlighting the importance of respecting patients' autonomy, promoting their best interests, and ensuring non-discrimination in healthcare delivery. [Level 5 Study. Case Series, Studies With No Controls and Expert Opinion.][28]

• Responsibilities: A study published in the Journal of General Internal Medicine evaluated the impact of a collaborative care program for Medicaid patients with depression. The study found that the program improved patient outcomes and reduced healthcare costs, indicating the importance of fulfilling responsibilities in providing high-quality, cost-effective care. [Level 1 study. Large randomized clinical trials (RCTs) with clear-cut results.][29]

• Interprofessional Communication: A recent review published in the Journal of Interprofessional Care highlighted the importance of effective interprofessional communication in delivering patient-centered care. The review emphasized the need for healthcare professionals to develop communication skills and strategies that facilitate collaboration and ensure that patients receive comprehensive, coordinated care. [Level 5 study. Case series, studies with no controls, and expert opinion.][30]

• Care Coordination: A study published in the Journal of General Internal Medicine evaluated the impact of a care coordination program for Medicare beneficiaries with multiple chronic conditions. The study found that the program improved patient outcomes and reduced healthcare costs, indicating the importance of care coordination in delivering high-quality, cost-effective care. [Level 1 study (Large randomized clinical trials (RCTs) with clear-cut results.][31]

In conclusion, recent research has emphasized the importance of skills, strategy, ethics, responsibilities, interprofessional communication, and care coordination in delivering patient-centered care in Medicare, Medicaid, and Military and VA Programs. These factors improve patient outcomes, patient safety, and team performance. Healthcare professionals should continue to focus on developing these skills and implementing effective strategies in their practice.

Nursing, Allied Health, and Interprofessional Team Interventions

Nurses, allied health professionals, and other healthcare providers play a critical role in enhancing healthcare team outcomes. Nurses can educate and support patients and their families, manage medications, and monitor patient progress. Allied health professionals can provide specialized services such as physical, occupational, and speech therapy. Interprofessional team interventions include care coordination, case management, and patient-centered care planning.

• Ethical Considerations. To further enhance healthcare team outcomes, it is also essential for healthcare providers to prioritize ethical considerations in their practice. This includes promoting patient autonomy and informed decision-making, respecting patient privacy and confidentiality, and upholding the principles of beneficence and non-maleficence.

• Collaboration and Coordination. Care coordination is also a crucial aspect of healthcare team interventions. By collaborating and communicating effectively, healthcare providers can ensure patients receive seamless care across different healthcare settings and providers. This involves sharing information and keeping accurate and up-to-date medical records.

• Medication Management. Pharmacists also play an essential role in the healthcare team, especially in medication management. They can ensure patients receive the appropriate medication, dosage, and frequency and monitor for potential drug interactions and adverse effects.

• Communication. Interprofessional communication is crucial for effective healthcare team interventions. This involves clear and concise communication among healthcare providers, including physicians, nurses, pharmacists, and other allied health professionals. Communication can occur through various means, including face-to-face discussions, electronic medical records, and telehealth technologies.

In conclusion, Medicare, Medicaid, and Military and VA Programs are vital programs that provide essential healthcare services to vulnerable populations in the United States. Healthcare providers should work together to ensure patients receive high-quality, patient-centered care that meets their unique needs. By prioritizing ethical considerations, promoting care coordination, and improving interprofessional communication, healthcare providers can enhance patient outcomes, improve patient safety, and optimize healthcare team performance.

Nursing, Allied Health, and Interprofessional Team Monitoring

Nurse-Led Care Coordination Intervention Improves Outcomes for Medicare Beneficiaries With Multiple Chronic Conditions

A study published in the Journal of General Internal Medicine in 2020 examined the impact of a nurse-led care coordination intervention on Medicare beneficiaries with multiple chronic conditions. The study found that the intervention improved patient outcomes, including reduced hospitalizations and emergency department visits. This study provides evidence for the effectiveness of nurse-led care coordination in improving patient outcomes in the Medicare population.[19]

Interprofessional Education Improves Patient Outcomes and Collaboration in VA Healthcare Settings

Another study published in the Journal of Interprofessional Education & Practice in 2020 investigated the impact of an interprofessional education program on healthcare professionals' ability to provide patient-centered care in a VA setting. The study found that the program significantly improved communication and collaboration among team members and improved patient outcomes. This study highlights the importance of interprofessional collaboration and communication in delivering high-quality care in VA settings.[32]

Interprofessional Team-Based Care Coordination Improves Outcomes for Medicare Beneficiaries

A 2019 study published in the Journal of Gerontological Nursing examined the impact of an interprofessional team approach to care coordination on Medicare beneficiaries with complex care needs. The study found that the team-based approach improved patient outcomes, including increased patient satisfaction and reduced hospitalizations. This study provides evidence for the effectiveness of interprofessional team-based care coordination in improving outcomes for Medicare beneficiaries with complex care needs.[33] 

Effective Interprofessional Communication Improves Patient Outcomes and Satisfaction

A systematic review published in the Journal of Interprofessional Care in 2021 analyzed the literature on effective interprofessional communication in delivering patient-centered care. The review found that effective communication was associated with improved patient outcomes, increased patient satisfaction, and improved healthcare provider satisfaction. This study highlights the importance of effective communication and collaboration among healthcare providers in delivering high-quality, patient-centered care.[34]

Overall, these studies provide evidence for the effectiveness of nursing, allied health, and interprofessional team monitoring in improving patient outcomes in the context of Medicare, Medicaid, and Military and VA Programs. Effective communication and collaboration among healthcare providers are critical components of successful care coordination and delivery of patient-centered care.