Medicare Research: Impact in Licensure, Certification

Impact in Licensure, Certification, Accreditation Standards

The Medicare system introduced in the United States covers almost every aspect of healthcare. First of all, the rules and recommendations apply to medical institutions and their management. The fact is that the system shares the principles of innovation, accessibility, and high quality of medicine. In order for an institution to obtain a license to carry out medical activities, it is necessary to meet certain criteria (Martien & Nelligan, 2018). Firstly, the organization must have the necessary number of highly specialized professionals with the appropriate education. A detailed list of profiles is indicated in the program itself, but it is worth emphasizing that it affects almost all services.

It should be noted that the process of obtaining a license and accreditation of a doctor is complicated. After receiving a diploma of secondary education, one usually goes to college. After graduation, the student will still have to study at a medical school (Tayor & Dai, 2018). Examinations will be held in basic and special disciplines, and in practice the student will have to correctly diagnose patients and prescribe appropriate treatment (Tayor & Dai, 2018). Having successfully passed all the tests, the future doctor will enter the residency, in which he will have to work in many departments of the hospital for about five years (Martien & Nelligan, 2018). Next comes the last exam, which is exactly what is needed to obtain a medical license (Martien & Nelligan, 2018). The Medicare system aims to provide patients with the most professional and effective care.

Quality Reporting Systems

It is necessary to highlight the fact that Medicare has introduced and modified several new systems for feedback and quality control of services. The main task of all systems is to provide management and payers with up-to-date information in a timely and efficient manner. In turn, this contributes to permanent control and quick response in case of detection of shortcomings or negligence of specialists. It is necessary to take a closer look at all the programs introduced with Medicare:

  1. Polls of public opinion. The essence of the tool is to ask each patient about their thoughts and impressions about the services. These surveys are recorded both on paper and with the help of audio equipment, conducted anonymously and by objective experts. After that, the data is processed and the results are entered into a database designed to collect statistics (Tayor & Dai, 2018).
  2. Professional development of specialists. Once a year or five years, depending on the specialty and relevance, each doctor and nurse takes courses to improve residual knowledge and acquire new ones. Such courses include repetition of highly specialized material, learning how to interact with new technology, as well as working on mistakes. This is to ensure that no doctor or nurse loses their skills and allows them to maintain a high quality of service.
  3. Regular control inspections. This was introduced to check the health of equipment and the general condition of hospitals. According to certain criteria, such employees conduct inspections and identify weaknesses. All comments are recorded and a deadline is set for their elimination. At the same time, with the help of such a mechanism, it maintains the general condition of each institution at a high level.

Patient Access to Care

Original Medicare, sometimes referred to as a fee-for-service plan, has 2 parts:

  • Part A, hospital insurance;
  • Part B, health insurance.
  • Medicare Preferential Coverage (Part C), an alternative to mainstream Medicare, includes managed care plans, plans for preferred provider organizations, and paid private plans.
  • Part D, prescription drugs. People must qualify for Part A and Part B before they can use a Medicare Advantage plan. Each part covers individual medical services. Basic Medicare does not cover intermediate or long-term care, regular eye, foot, or dental exams (Plunkett, 2020). Medicare Advantage plans must meet or exceed coverage for Basic Medicare and usually include Part D coverage.

It is important to note that the Medicare’s payer program has a positive effect on patients’ access to treatment. The fact is that thanks to the program, most of the costs are included in the insurance provided by Medicare. Thus, clients who make regular payments under the program may end up with treatment that is fully or partially covered by insurance (Plunkett, 2020). Based on this, medical care is becoming more accessible, as Medicare provides not only the side of patients, but also doctors and nurses.

Reimbursement for Healthcare Services

The most striking and important innovation for patients is the procedure for partial or even full reimbursement of expenses. The prospective payment system limits the amount and duration of coverage, but annual limits for physical therapy, speech therapy, and occupational therapy have been removed. The supply of medicines is covered if billed at home by the health agency. The federal government pays, on average, about 80% of the costs of Part B, and program participants, after the annual deductible is used, pay 20% (Patrinos & Zgheib, 2020, p. 107). Part B is optional, although beneficiaries are automatically enrolled in Part B at age 65, the government may reduce coverage.

Part B coverage needs to be analyzed in more detail. Part B covers a percentage of the following: Physician fees; outpatient treatment with certain restrictions, and much more, which is listed in detail in the program. If surgery is recommended for the patient, Part B pays for a portion of the doctor’s consultation fee, an additional 2nd opinion, and, if these opinions differ, a 3rd opinion (Tayor & Dai, 2018). Part B covers emergency medical Otherwise, Part B is generally not covered for self-administered outpatient drugs, Part D can cover them.

Support for Professional Goals

Medicare funds are used to support certain parts of graduate medical education and programs that regulate and control the quality of care. Physicians should be familiar with the basic rules of elderly health insurance, provide documents used to determine whether patients are eligible for benefits. Thus, one of the main professional goals of specialists is supported – high-quality knowledge and effective assistance. In addition, the program takes into account the material interests of professionals. Under Part B, physicians may elect to receive payment directly from Medicare, receiving 80% of the eligible payment directly from the program after meeting the deductible (Chiplin & Stein, 2019, p. 536). If doctors accept an appointment, their patients only must pay for the deductible. Physicians who do not agree to receive payments from Medicare may bill patients up to 115% of the allowable fee; the patient is reimbursed by Medicare (Chiplin & Stein, 2019, p. 576). After all, Medicare seeks to meet the needs of both sides of the medical process while increasing its benefits.

Separately, it is necessary to highlight non-clinical services and how they are consistent with the current program. The fact is that the main principle of the program is to provide quality healthcare services. This is an important point because it extends to both pre-clinical and non-clinical services. Thus, Medicare does not interfere with or complicate the implementation of the goals of such organizations, however, it places high demands on specialists. In turn, this is allowed to almost completely eliminate the chance of deception or fraud in areas such as psychology (Tayor & Dai, 2018). Thus, the professional goals of any area related to health are supported by the program by setting a high bar for the quality of services and specialists.


Chiplin, A. J., & Stein, J. A. (2019). Medicare handbook. Wolters Kluwer Law & Business.

Martien, N., & Nelligan, J. (2018). The sourcebook for clinical research. A practical guide for study conduct. Elsevier Science.

Patrinos, G. P., & Zgheib, N. K. (2020). Pharmacogenetics research and clinical applications: An international landscape of the accomplishments, challenges, and opportunities. Frontiers Media SA.

Plunkett, J. W. (2020). Plunkett’s health care industry almanac 2021. Plunkett Research, Limited.

Tayor, S., & Dai, T. (Eds.). (2018). Handbook of healthcare analytics. Wiley.

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