Case Study: Accelerator System

The Arkansas Health Care Payment Improvement Initiative (“AHCPII”) is one part of the health care innovations the state has implemented with the aim of “increas[ing] health care quality and reducing the costs of care.” The AHCPII’s intent is to shift Arkansas’s payment system from “one that primarily rewards service volume to one that rewards desired outcomes, particularly with respect to quality and affordability.” Applying to Medicaid, Medicare, and private payers, payment innovation will move away from fee-for-service health care (where quantity all too often trumps quality) to pay for quality. In doing so, the hope is that Arkansas will gain a “new, sustainable model of financing” with the help of a multi-payer leadership and support.

Prior to September 2011, Medicaid Managed Care Organizations (MCOs) paid FQHCs a fee-for-service rate and HHSC reimbursed FQHCs the difference between the rate paid by the MCO and the FQHC PPS rate in quarterly wraparound payments. Pursuant to budget riders starting in the 2012-2013 General Appropriations Act, and continuing through the current appropriations bill, HHSC Rider 62 (HB1, 84nd Regular Session, 2015), MCOs were required to pay the full PPS rates to FQHCs up front. The stated intent of Rider 62 was to reduce HHSC administrative costs. The administrative cost was associated with the Texas Medicaid and Healthcare Partnership (TMHP), an HHSC contractor, calculating and disbursing the wrap payment to each FQHC. By moving responsibility for the wrap payment to the MCO, the administrative cost to HHSC was eliminated. Rider 62 did not contemplate a reduction in appropriate FQHC utilization.

Mr. Williams told us that beginning July 1, 2014 that we were to email him at the beginning of the month with a list of the non-Medicaid, and non-Medicaid rate vendors and the current appointments we had for those vendors. We were also directed to state “subject to change” in the email, and that would cover additional youth appointments that needed to be made with those approved vendors.

According to Sebelius, (2013) article, Affordable Care Act Incudes steps to improve the quality of health care and lower cost for you and the nation as a whole. This means avoiding costly mistakes and readmissions, keeping patients’ healthy, rewarding quality instead quantity, and creating the health information technology infrastructure that enables new payment of models to work. North Carolina foundation for Advance Health Programs is a model to create and maintain a centralized tracking system to monitor and disseminate new model of payments and delivery of reimbursements. This

The federal exchange and the local governments launched their affordable healthcare system on October 1, 2013. Their system crashed, timed out and or froze before consumers could were able to complete their applications. There was one state that outperformed the federal government’s exchange. This state had the only up and running system since the beginning. This was the state of Kentucky. Kentucky, under the advisement of Sparx, their outside contracted IT experts, used a reusable framework which gave them a head start to this large statewide project. This project duration was little over 27 months of constant planning, designing, and development of this state level exchange.

The U.S. Department of Health and Human Services (HHS) is the U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. HHS is responsible for almost a quarter of all federal outlays and administers more grant dollars than all other federal agencies combined. The mission of the U.S. Department of Health and Human Services (HHS) is to enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services. In addition, HHS is also responsible to provide better services to people by adapting to new technologies to keep pace with the advancement in technology. As we compare the health and human services from last ten years to present, it is very clear to analyze how health and human systems have improved over the years. The Department manages programs that cover a vast spectrum of activities that impact health, public health, and human services outcomes throughout the life span.

Accountable Care Organizations – “ ‘National Pilot Program On Payment Bundling’ - The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health

Services provided at IHS/tribal 638 facilities – regardless of plan or AIHP enrollee – are reimbursed with 100% federal funds

The delivery system reform include: Mandates that the Secretary of Health and Human Services adopt value-based purchasing and payment methods for Medicare reimbursements for both physicians and hospitals. Creates incentives to reduce preventable hospital admissions. Creates a new Center for Medicare and Medicaid Innovation that will research, develop, test, and expand innovative payment and delivery arrangements. Encourages the formation of Accountable Care Organizations (ACOs) that allow hospitals and doctors to work together to manage and coordinate care and provides that these ACOs will receive a share of the savings they achieve for Medicare

As previously mentioned, the subspecialties pertain to specialists in child or adolescent mental and behavioral health care. $30,000 was appropriated annually for the fiscal years of 2010 through 2014 for the pediatric workforce, and $20,000 for behavioral health specialists, in this repayment program. Section 5204 continues to amends Part E of Title VII of the Public Health Services Act, with the addition of “Section 776 Public Health Workforce Loan Repayment Program.” Under such amendments, $195,000,000 is sanctioned for the fiscal year of 2010, and amounts through

Establishment - The Secretary establishes the Public Health Workforce Loan Repayment Program to assure an adequate supply of public health professionals in Federal, State, Local, and tribal public health agencies.

As for DHHS they chose to build a new system unlike most states that chose to only integrate their systems so they met HIPAA requirements. By choosing to build a new system they would have no access to the legacy system and all information would now become extinct once the cut over occurred. By DHHS rushing the conversion they in turn were not ready for the cut over and in turn also fell behind on the agreed schedule. By this occurring and the merging of departments the IT department was cut in half and no one discussed what the other was doing. Also, there was no one from HIPAA on the committee to begin with to approve and assist with all programming rules and regulations (Oz, 2009).

However, Packard Health is a Federally Qualified Health Center (FQHC) which means it meets all federal requirements to offer health care services to people who are uninsured, isolated, and medically vulnerable. The Hope Clinic is unique in that all services are free to and they are not funded by nor do they receive reimbursement from government resources. The Hope Clinic does not seek to become a FQHC which would result in direct competition with Packard Health. Since, Hope does not accept insurance payments, co-pays nor deductibles from outside entities they also refer eligible clients to Packard Health for services. Instead, they support clients by assisting them with the application process to receive government provided health care

Health Information Exchange is the electronic movement of healthcare information amongst organizations according to the national standards. HIE as it is widely known, serves the purpose of providing a safe, timely, and efficient way of accessing or retrieving patient clinical data. Health Information Exchange allows for doctors, nurses, pharmacists, and other vital healthcare professionals to have appropriate access and securely share vital medical information regarding patient care. Health Information Exchange has been in efforts of developing for over 20 years in the United States. In 1990 the Community Health Management Information Systems (CHMIS) program was formed by the Hartford Foundation to foster a development of a centralized data repository in seven different geographically defined communities. Many of the communities struggled in securing a cost-effective technology with interoperable data sources and gaining political support. In the mid-1990s a similar initiative began known as the Community Health Information Networks (CHINs) with the intention of sharing data between providers in a more cost-effective manner. In 2004, the Agency for Healthcare Quality and Research Health Information Technology Portfolio was funded $166 million in grants and contracts to improve the quality and safety to support more patient-centered care. This was the beginning of the progress we have seen in HIE today. Health Information Exchange devolvement serves the purpose of improving

Medicare pays for ED services through three payment systems. Beneficiaries of Medicare who receive ED care generate a physician claim and a hospital outpatient ED claim. Physician claims are paid through the Medicare physician fee schedule (PFS) while hospital claims for ED, that don’t result in admission, are paid by the hospital OPPS. Hospital claims for ED that do result in admission are paid through the inpatient prospective payment system.