By addressing some of the negative factors of the current healthcare system, the Affordable Care Act attempts to reform the broken healthcare system. Access The Affordable Care Act promises the public access to health coverage. Many of the people who d... ... middle of paper ... ...nities in Criminal Justice, Homelessness, and Behavioral Health With the Patient Protection and Affordable Care Act. American Journal Of Public Health, 103(S2), e25-e29. doi:10.2105/ AJPH.2013.301497 Fontenot, S. (2013).
Global payment enables providers to reduce unnecessary care and bring down spending under control but creates incentives for providers to restrain the supply of services. The Obama administration recently made some changes to physicians and outpatient method of payment. The five levels clinic and outpatient codes have been replaced by a single code. Physicians will be reimbursed based on the chronic care management fee.
As a way of limiting moral hazard, most insurance companies will include features to contracts such as deductibles, co-payments, co-insurance and other out-of-pocket payments. A deductible is the fixed amount that the insured must pay out of their own pockets each year before the health insurance company starts to pay for the medical benefits. It is calculated yearly and expressed as an annual amount. When the deductible is met, the following out-of-pocket costs are incurred: co-payment and/or coinsurance. A co-payment is a specified amount that the insured must pay the healthcare provider at every visit.
Program Structure The UR Plan Committee includes representatives from Physicians, Nursing, Administration, Quality Management, Admission and Discharge coordinators, and Health Information Management. The UR Plan directs the committee activities and reporting hierarchy. A Utilization Review Coordinator is appointed by the committee and responsible for: Measurement and assessment of • Level of care • Resources • Discharges • Evaluate identified problem cases to identify under and over utilization of resources • Performance measures and improvements o ALOS o Average total charges o Average profit margin o Number of hospital days denied reimbursement (Spath, 2013, p.129) Discharge planning • Track patients from admission to discharge o Ensure effective use of resources • Develop discharge plan o Ensure coordination and continuity of care (Spath, 2013, p.126, p.131) Program Process The UR plan guidelines are used to assess patient care and assure services are necessary, appropriate, and meet regulatory and clinical guidelines (Spath, 2013, p.126). These goals will be met through a monitoring and review process. Review Methodology and Rationale There will be three types of reviews conducted, prospective review of admissions, physicians, and medical records, concurrent review of new admissions for medical necessity and appropriateness, and retrospective review to focus on denied claims and identify cases of under and over utilization of resources.
The use of medical homes would identify one provider to oversee the health care needs of individual patients. Medical homes can help with follow up when patients are in the hospital to decrease readmission rates. Medical homes can assist the patients with multiple diagnoses and improve outcomes related to medication adherence. Collaboration between the federal government and state and local government agencies with AKF and NKF working together on funding can support the use of medical homes. An advocacy campaign to support the use of medical homes can be developed that includes patients, health care professionals, families and
The government plans to accomplish this by controlling the insurance premiums incre... ... middle of paper ... ...p or prolonged illness (pre-existing conditions) to be able to afford the healthcare insurance coverage. One of the priorities in the American healthcare system at the moment is to develop health care initiatives affordable and accessible for the low income earners and the homeless in America (Barton, 2013). There is no doubt a dire need of healthcare reform in America. However, the proposed healthcare has some positive and negative aspects that impact on businesses. This paper has discussed these aspects in detail to set a framework that can receive certain considerations by the policy makers by reviewing those aspects that have dire negative impact on businesses.
The employer mandate will allow large employers to provide health coverage to their full time employees at descent rates and the individual mandate will allow Americans to purchase federal subsidized... ... middle of paper ... ...lthcare system is slowly shifting from volume to value based care for quality purposes. By allowing physicians to receive payments on value over volume, patients receive quality of care and overall healthcare costs are lowered. The patients’ healthcare experience will be measured in terms of quality instead of how many appointments a physician has. Also, Medicare and Medicaid reimbursements are prompting hospitals, physicians and other healthcare organizations to make the value shifts. In response to the evolving healthcare cost, ways to reduce health care cost will be examined.
She explains that we need evidence based on research to provide the best medical care, and then customize care to each person’s values, preferences and needs. She explains that primary care providers will have to inspire, create a vision and a path for the health care team. The Center for Medicare and Medicaid Services has a link to Partnership for Patients, it has explanations of the health care models for the future. Many are functioning now, and having great reductions in hospital readmission rates. “The Independence at Home Demonstration will award incentive payments to healthcare providers who succeed in reducing Medicare expenditures and meet designated quality measures.
This paper discusses how reimbursement can be affected by the pay-for-performance approach and how system cost reductions impact the quality and efficiency of healthcare. In addition, it also addresses how pay-for-performance affects different healthcare providers and their customers. Finally, there will also be a discussion on the effects pay-for-performance will have on the future of healthcare. Discussion How Reimbursement Is Affected By Pay-For-Performance Approach 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.
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs.