In order to address the issue of rising healthcare expenditures and the increasing cost to Pennsylvania’s Medicaid program, it is imperative that the use of CER be adopted to identify and promote the use of medical practices which are cost-effective and produce the greatest patient outcomes. It is equally important however, that any CER policy is implemented in a manner that will ensure that government directed healthcare rationing cannot occur. There are several possible options which may allow for the adoption of an effective and fair CER policy in Pennsylvania. The first possible option is to simply ensure healthcare providers have access to results of CER and require that they stay abreast of research that specifically effects their area of practice without mandating that recommended practices be followed. This option would result in the greatest amount of autonomous decision making for both patients and healthcare professionals in selecting a treatment method. Unfortunately, it would also likely be largely ineffective in shaping treatment decisions based upon CER results and thus the smallest impact to healthcare expenditures. …show more content…
Doctors and other healthcare providers could be obliged to adhere to CER guidance by offering a reimbursement incentive to doctors who provide treatments that match up with directives produced by CER. The benefit of this type of policy is that CER evidenced treatments would be more likely to be provided and in turn a greater cost-efficiency in medical practice may occur. The possible downside of this option is that it creates the possibility for physicians to abuse the program and attempt to sway the patient’s decision based on the prospect of financial
Healthcare payers agree with the idea of Evidence-Based Medicine (EBM) to advocate for pay-for-performance in provider reimbursement on quality and efficiency. The fundamental system that most payers use to compensate physicians and provider associations embodies enticements for excellence and efficiency. Reimbursement can be affected by the P4P approach and other factors such as the claims process, out-of-network payments, legislation, audits and denials. While the same P4P approaches are attempts to commence incentives and new strategies into the healthcare, the underlying arrangement of the compensation system produces many per...
In December 2011, Texas Health and Human Services Commission (HHSC) received federal approval of a Medicaid Section 1115(a) Demonstration Waiver, entitled “Texas Healthcare Transformation and Quality Improvement Program,” for the period starting with December 12, 2011 through September 20, 2016. The main objective of the 1115 Waiver is to improve access to and quality of health care by expanding Medicaid managed care programs and promoting health care delivery system reforms while containing cost growth. Specifically, the Waiver created two new pools of funding—Uncompensated Care (UC) and Delivery System Redesign and Innovation Payment (DSRIP) pools—by redirecting funds that were available under the old Upper Payment Limit (UPL) payment methodology. DSRIP funding is used to offer financial incentives to health care providers that develop and implement projects aimed at improving how care is delivered to low-income populations. Specifically, the providers (often referred to as the “performing providers” or “performers”) propose and execute projects like programs, strategies, and investments designed to enhance access to health care, quality of health care, cost-effectiveness of services, and health of the patients and families served.
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
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.
The United States (U.S.) has a health care system that is much different than any other health care system in the world (Nies & McEwen, 2015). It is frequently recognized as one with most recent technological inventions, but at the same time is often criticized for being overly expensive (Nies & McEwen, 2015). In 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) (U. S. Department of Health & Human Services, n.d.) This plan was implemented in an attempt to make preventative care more affordable and accessible for all uninsured Americans (U.S. Department of Health & Human Services, n.d.). Under the law, the new Patient’s Bill of Rights gives consumers the power to be in charge of their health care choices. (U.S. Department of Health & Human Services, n.d.).
As more and more people go without any medical insurance, the time for changes in the healthcare industry seems to be now. The government cries for restructuring and the cost coverage of prescription pills should make us step back and question the broad picture. Why would the public benefit from captitation and which segments of the healthcare industry would benefit from which types of capitation? It is important for the public to be educated on our options, healthcare is something that effects us all, old, young, rich, and poor. Why are medical executives determining the directions of cost utilization in the system and not the public? The only thing that seems to be for ceratain is that further research is vitally needed to clarify how capitation truly effects physician-patient relationships, decision making by physicians, and clinical outcomes.
The current health care reimbursement system in the United State is not cost effective, and politicians, along with insurance companies, are searching for a new reimbursement model. A new health care arrangement, value based health care, seems to be gaining momentum with help from the biggest piece of health care legislation within the last decade; the Affordable Care Act is pushing the health care system to adopt this arrangement. However, the community of health care providers is attempting to slow the momentum of the value based health care, because they wish to maintain their autonomy under the current fee-for-service reimbursement system (FFS).
In order to make ones’ health care coverage more affordable, the nation needs to address the continually increasing medical care costs. Approximately more than one-sixth of the United States economy is devoted to health care spending, such as: soaring prices for medical services, costly prescription drugs, newly advanced medical technology, and even unhealthy lifestyles. Our system is spending approximately $2.7 trillion annually on health care. According to experts, it is estimated that approximately 20%-30% of that spending (approx. $800 billion a year) appears to go towards wasteful, redundant, or even inefficient care.
It is no secret that the current healthcare reform is a contentious matter that promises to transform the way Americans view an already complex healthcare system. The newly insured population is expected to increase by an estimated 32 million while facing an expected shortage of up to 44,000 primary care physicians within the next 12 years (Doherty, 2010). Amidst these already overwhelming challenges, healthcare systems are becoming increasingly scrutinized to identify ways to improve cost containment and patient access (Curits & Netten, 2007). “Growing awareness of the importance of health promotion and disease prevention, the increased complexity of community-based care, and the need to use scarce human healthcare resources, especially family physicians, far more efficiently and effectively, have resulted in increased emphasis on primary healthcare renewal.” (Bailey, Jones & Way, 2006, p. 381).
...cern is the need to revise state laws governing NPs. Drafting correct legislation to clarify a NPs scope of practice is absolutely necessary to increase primary care capacity. “In some states, NPs provide care without any involvement from a physician. In other states providing the same care requires that NPs collaborate or even be supervised by a physician”. These are fundamental services that states are restricting NPs from. In addition, twenty-seven states have no restrictions on diagnosing and treating, where twenty states only require writing documentation. The remaining states have requirements but, no written documentation is necessary. It is clear that certain states have taken the correct steps to create a favorable situation for NPs. While these states have taken great steps in helping expand PCPs, other states need to follow suit. Law follows practice.
In today’s healthcare system, there are many characteristics and forces that make up the complex structure. Health care delivery is a complex system that involves many people that navigate it with hopes of a better outcome to the residents of the United States. Many factors affect the system starting from global influences, social values and culture. Further factors include economic conditions, physical environment, technology development, economic conditions, political climate and population characteristics. Furthermore the main characteristics of the Unites States healthcare system includes: no agency governs the whole system, access to healthcare is restricted based on the coverage and third party agencies exist. Unfortunately many people are in power of the healthcare system involving multiple payers. Physicians are pressured to order unnecessary tests to avoid potential legal risks. Quality of care is a major component; therefore it creates a demand for new technology. A more close investigation will review two main characteristics and two external forces that currently affect the healthcare delivery system. Furthermore, what will be the impact of one of the characteristics and one of the external forces in review with the new affordable care act 2010? The review will demonstrate the implications to the healthcare delivery system and the impact on the affordable care act 2010.
Reforming the health care delivery system to progress the quality and value of care is indispensable to addressing the ever-increasing costs, poor quality, and increasing numbers of Americans without health insurance coverage. What is more, reforms should improve access to the right care at the right time in the right setting. They should keep people healthy and prevent common, preventable impediments of illnesses to the greatest extent possible. Thoughtfully assembled reforms would support greater access to health-improving care, in contrast to the current system, which encourages more tests, procedures, and treatments that are either
“At its core evidence based ‘anything’ is concerned with using valid and relevant information in decision making” “high quality research is the most important source of valid information”. Psychological Association (2006, p. 273) defines EBP as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences. " When caring for patients it is fundamentally important to have a good selection of up to date evidence Based Practice clinical articles to support research strategies, this allows professionals to assemble the most recent and accurate information known which enables them to make decisions tailored to the individual’s plan of care. It is essential to have clinical expertise and have the involvement of the individual patient, they must have full engagement and incorporation in order to have the accurate evaluation.... ... middle of paper ...
The idea behind conforming to evidenced based practices is that research is the most likely tool to improve patient
CEA is able to help managed care organizations, insurers, and policy makers make informed decisions. Supporters are optimistic that the increased involvement by the federal government in comparative effectiveness research will eventually lead to increased acceptance and the use of QALYS as a metric. Other Issues Concerning CEA With CEA, one of the main issues is determining what level of evidence is sufficient to approve or deny a treatment. Utilizing comparative analysis to make medical decisions is also difficult since there are biases in almost any test done. To account for differences between patients, it would require randomized, double-blind trials that are notoriously time consuming and expensive.