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Failures of the affordable care act
Problems with the Affordable Care Act
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Healthcare practices must contend with many challenges throughout the year, from adopting new technologies to managing health outcomes for any number of patients. Numerous factors can add up to have a dramatic effect on revenue cycle management, creating positive - and negative - changes in providers' bottom lines.
Medical practices are businesses, and funds must be controlled to maintain profitability. According to a survey from TransUnion Healthcare, three-quarters of patients believe that knowing their out-of-pocket costs for treatments would improve their ability to pay for health services.
The poll included more than 700 respondents who were insured healthcare patients. In contrast to the initial 75 percent, the results also showed that 56 percent either rarely or never received a cost estimate before treatment, and 59 percent said they were surprised by the costs they were responsible for.
Inform to collect
One of the biggest revenue cycle challenges providers face is the timely collection of payments. Often, when a large medical bill is issued to a patient, he or she is surpri...
On the basis of the clinic’s previous collections experience, Dough was able to convert billings for medical services into actual cash collections. On average, about 20% of the clinic’s patients pay immediately for services rendered. Third-party payers pay the remaining claims, with 20% of the payments made within 30 days and the 60% remainder (of total billings) paid within 60 days. For monthly budgeting purposes, 20% are assumed to be collected one month after the billing month, and 60% are assumed to be collected two months after the billing month.
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
In addition to this business plan, we must also address the financial issues plaguing this organization. To illustrate some of these issues lets look at some of the trends here at OCB and within our Industry: For example, OCB’s clinic operations profitability in 1990 was 60%, and now in 1996 our profitability is only 37%, which is down 23 percentage points! We can blame some of this on rising costs of overhead, consumables, etc, however this is happening as the industry as a whole is growing 5% annually, and as our customer base, largely senior citizens, population is growing at almost 1% as year. We should be capitalizing on these industry trends, however, as you all know, not all the trends work in our favor. For example, our lifeblood, the Insurance company’s managed care organizations, and government healthcare reimbursement programs shows a downward trend of allowable payments for our services (DRGs) For example in 1995 the DRG price of ...
Without question the cost of medical care in this country has skyrocketed over the last few decades. Walk into an emergency room with an earache or the need for a few stitches and you’re apt to walk out with a bill that is nothing short of shocking.
For decades, one of the many externalities that the government is trying to solve is the rising costs of healthcare. "Rising healthcare costs have hurt American competitiveness, forced too many families into bankruptcy to get their families the care they need, and driven up our nation's long-term deficit" ("Deficit-Reducing Healthcare Reform," 2014). The United States national government plays a major role in organizing, overseeing, financing, and more so than ever delivering health care (Jaffe, 2009). Though the government does not provide healthcare directly, it serves as a financing agent for publicly funded healthcare programs through the taxation of citizens. The total share of the national publicly funded health spending by various governments amounts to 4 percent of the nation's gross domestic product, GDP (Jaffe, 2009). By 2019, government spending on Medicare and Medicaid is expected to rise to 6 percent and 12 percent by 2050 (Jaffe, 2009). The percentages, documented from the Health Policy Brief (2009) by Jaffe, are from Medicare and Medicaid alone. The rapid rates are not due to increase of enrollment but growth in per capita costs for providing healthcare, especially via Medicare.
Since the quality of healthcare would not suffer, the only thing to lose through maximizing efficiency is a bunch of waste. Through its administrative simplification advocacy, the American Medical Association (AMA) claims that up to 14% of a physician’s revenue is taken up by administrative waste. The goal of the administrative simplification is to inspire physician practices to use computerized, instantaneous health plan transactions, minimize manual procedures through the claims revenue cycle, while increasing transparency and reducing vagueness with the payment process involving the insurance company. It is the AMA’s hope to push this movement into high gear, getting more practices on board and to eventually see a decline in wasteful and inefficient administrative
Healthcare has been a topic of discussion with the majority of the country. Issues with insurance coverage, rising costs, limited options to gain coverage, and the quality of healthcare have become concerns for law makers, healthcare providers and the general public. Some of those concerns were alleviated with the passing of the Affordable Care Act, but new concerns have developed with problems that have occurred in the implementation of the new law. The main concerns of the country are if the Affordable Care Act will be able to overcome the issues that plagued the old healthcare system, the cost of the program, and how will the new law affect the quality of the health delivery system.
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
The health of the American people lags behind those from other developed countries. Federal public health agencies have a wide range of responsibilities and functions which includes public health research, funding, and oversight of direct healthcare providers. It has been a long time since changes have been made to the way the federal government structures its health care roles and programs outside of Medicare and Medicaid (Trust, 2013). With healthcare reform on the horizon now is the time to invest time and money in prevention, not medicine, making it a top priority to improve health and prevent disease. Funding efforts at all levels of the public health continuum need to focus on developing programs aimed at such leading initiatives as tobacco cessation, improving nutrition, supplying safe workplaces, and increasing physical activity in all ages of the population. People should have equal access to quality preventative medicine and education.
Competitive advantage matters greatly to those responsible for the management of healthcare institutions. Together with rapidly escalating healthcare costs, increasingly complex medical technologies, and growing regulatory and legal pressures, healthcare organizations face a critical need to improve the quality of care at reduced costs (Cu...
If the United States had unlimited funds, the appropriate response to such a high number of mentally ill Americans should naturally be to provide universal coverage that doesn’t discriminate between healthcare and mental healthcare. The United States doesn’t have unlimited funds to provide universal healthcare at this point, but the country does have the ability to stop coverage discrimination. A quarter of the 15.7 million Americans who received mental health care listed themselves as the main payer for the services, according to one survey that looked at those services from 2005 to 2009. 3 Separate research from the same agency found 45 percent of those not receiving mental health care listing cost as a barrier.3 President Obama and the advisors who helped construct The Affordable Care Act recognized the problem that confronts the mentally ill. Mental healthcare had to be more affordable and different measures had to be taken to help patients recover. Although The Affordable Care Act doesn’t provide mentally ill patients will universal coverage, the act has made substantial changes to the options available to them.
In order to fully understand the uninsured and underinsured problem that hospital administrators face the cause must be examined. The health outcomes of uninsured individuals are generally worse than those who are insured. Uninsured persons are more likely to experience avoidable hospitalizations, diagnosed at later stages of disease, hospitalized on an emergency or urgent basis, and more seriously ill upon hospitalization (Simpson, 2002) Because the uninsured often lack an ongoing relationship with a health-care provider, they are less likely to receive preventive care and diagnostic tests (Kemper, 2002). Many corporations balance their budget through cost cuts and other moves, but have been slammed with an increasing load of uninsured patients, coupled with reduced payments from government and private insurance programs. In 2000, 564,476 uninsured patients came through Health and Hospitals Corporations health care centers, a 30 percent increase from 1996. In the same period, Congress reduced Medicare reimbursements to hospitals, while Medicaid reimbursements to primary care clinics remained basicall...
The chargemaster is an integral element of the revenue cycle. It is used in generating charges for services that are rendered to patients in real time, the absence of functioning chargemaster can result in potential collapse of the revenue cycle. Hence, the process to optimize revenue cycle must include optimizing the chargemaster and all services that is associated with it. The negative consequences of nonfunctioning chargemaster can include excessive payment/overcharging, inaccurate billing to patients; and can result in stiff penalties and fines (Bielby et al,
The revenue cycle is known as the process by which healthcare providers receive reimbursement for care provided. Bringing in revenue is necessary for the efficient operation of any healthcare facility. The revenue cycle consist of all the steps involved in patient care starting from bringing in the patient, meeting their needs, and receiving payments for services provided (Gillikin).