Cost Containment, And Quality Of Care

Medicare is a federally governed insurance program, primarily serving Americans over the age of 65, younger disabled meeting specific disability criteria, and dialysis

There has been discussion to have universal healthcare system similar to Medicare as a method to have a centralized monitoring system of cost. There have also been other systems tried beginning with HMOs in the 1970s in an effort to streamline access to necessary healthcare services by employing a gatekeeper to their access at the primary care levels. With patient dissatisfaction, PPOs were tried which circumvent the necessity of referrals (Hacker, 1998). Either of these models had substantial effect on healthcare outcomes while the cost of healthcare continued to skyrocket. The US spends more than any other country on healthcare but outcomes are not better (Blackstone, 2016). In 2010, under President Obama’s leadership, Affordable Care Act was passed and one of the promising features is the formation of accountable care

The negative impacts of healthcare reform to health systems are significant in that health systems are preparing their resources on developing Accountable Care Organizations (ACO) for bundled payments and population-based reimbursement. In this economy the impact to health systems may require healthcare systems to figure out ways to continue to keep positive financial performance due to the cost-reduction of healthcare reform. For some time now, health systems have subsidized their losses from the Medicare and Medicaid systems by contracting with commercial payers for their premium rates. As a result of the healthcare reform, cost shifting will shrink. Another negative impact over the next few years will be the large shift in health plan enrollment. Less people will be covered by highly

The Medicare trust fund is a government insurance program that finances medical care for three different groups of individuals: people that are 65 years of age or older, disabled individuals who can receive Social Security benefits, and people who have end-stage renal disease (Shi & Singh, 2015). Individuals in these three categories can enroll regardless of their annual income. In 2015 there were 55.3 million beneficiaries and the expenditures for the year totaled $648 billion ("Trustees report," 2016). Medicare is funded by payroll taxes, general tax revenues, and premiums that are paid by individuals enrolled in the plan.

Medicare is a federal health insurance program for people over the age of 65. It also covers particular people who may have a disability and people who have End-Stage Renal Disease. There are four different parts to the Medicare program. These parts include hospital insurance, medical insurance, Medicare advantage plans, and prescription drug coverage. The program, since being created, has helped to fix many different problems, as well as help the elderly and other persons to receive health insurance.

What is Medicare insurance? Medicare is a federal health program for an individual between the age 65 and older. Medicare has also helped certain younger people who suffer from some type of disability and also help an individual with kidney failure and need to place on a dialysis machine or need an organ transplant. Medicare insurance was created in the year 1965 it was signed by president Lyndon b, Johnson to help those Americans at the age of 65 who was not covered by health insurance received some types of insurance this insurance will be called Medicare. In the year 1972, Medicare starts to expand their program to people with disability and also patient suffering from kidney failure that required dialysis or needed an organ transplant to save their life. Medicare was designed to give the American people a choice how they want to manage their care that why Medicare insurance created two separate insurance called Type A and Type B. The insurance benefit of Type A generalized coverage, hospital care, skills nurse facility care, nursing home, hospice, home health service. The Medicare insurance of type B coverage service for supplies needed for diagnosis or treating a patient and also coverage preventive & screening for a patient that want to check for potential illness, for example, Mammogram & HIV screening. The insurance benefit of Type B cover ambulance service, inpatient and outpatient service, partial hospitalization, laboratory test and limited outpatient

Medicare constitutes a federal health program of the U.S government that is intended to subsidies to individuals who are eligible for the following criteria (Medicare, 2014). Individuals above 65 years with permanent U.S. citizenship or legal residency for five years. Individuals with a disability who has gathered a two year Social Security. Individuals with kidney failure currently receiving dialysis or who requires a kidney transplant. As well as those who are suffering from Lou Gehrig's disease (Medicare, 2014).

The state of California is active in the payment and delivery system reform. Of the 38 million residents in California, more than 15 million receive care through delegated arrangements with provider organizations in the commercial market, or through Medi-Cal (California’s Medicaid program), Healthy Families (California’s implementation of Children’s Health Insurance Program (CHIP)), and Medicare Advantage plans (California Health Care Almanac, 2015). For the past decade, California’s reimbursement has been through shared risk pool, pay-for-performance quality incentive programs, and full and partial capitation (Pegany & Connolly, 2014). Pegany & Connolly (2014) state that under the Accountable Care Collaborative (ACO) programs, providers and hospitals don’t want assume additional risk, and reward does not outweigh the risk and investments costs. To increase the potential and impact of ACA reform, California policymakers should take advantage of the ACA delivery and payment reforms, and do so will require careful attention.

Accountable Care Organization (ACO) model, consist of health professional that form an affordable quality health care to those who have Medicare. These doctors, nurse and other join this team voluntarily, they contribute to this organization by hold relationship with the patient to configure the best care. The organization is designed to given the patient more “say so” into their own health/medical care. There is absolutely no catch to having the support of this organization, those are who have Medicare will remain in control over picking provider and other Medicare services. According to Niles (2018), “ACO’s is purely voluntary, and participating patients will see no change in their original Medicare benefits” (pg. 374). This service beings

Overview: Medicare – passed into law in 1965 – is the federal health insurance program designed for Americans over the age of 65 and certain people with disabilities. Medicare Part A covers inpatient hospital services. Medicare Part B covers physician and outpatient care. Medicare Part D is the prescription drug benefit. Medigap is a supplemental insurance for individuals with Parts A and B, sold through private insurance.

The American health care system has been victim to an escalation in the prices of health care services juxtaposed with inefficiency in delivery of care services. There has even been cases where State spending on the actual health care increased dramatically in the United States and one of the key components of curbing this problem which has been prevalent over the mass media and has been a major discussion among physicians is the advent of Accountable Care Organizations. Accountable Care Organizations (ACOs) is structured with the goal of trying to improve health care delivery and aid in the reduction of the overall cost of services (Weissert & Weissert, 2012). If there is insufficient coordination of high quality care delivery in the health care industry, this will have a negative impact on patient safety and diminish affordable care for patients. Hence, the development of ACOs is envisioned to be the savior of medical practices and can improve the overall fabric of the American society (Bresnick, 2013). ACOs serves as one of the answers for curbing the problem of high costs, low quality care and possible segmented delivery and as much as it serve as the major determinant for improvement in patient satisfaction, there are minor

In my hometown state of Colorado, one of the piloting states who are implementing a new method of delivering and paying for Medicaid beneficiaries’ care to coordinate a broad range of health and social serves by shifting some of the financial risk for the costs and quality of care to providers. Colorado’s Accountable Care Collaborative Program is providing Medicaid beneficiaries care through an accountable care organization (ACO) delivery model. Medicaid contracts with one regional care collaborative organization (RCCO) that works with providers that are part of the Primary Care Medical Providers (PCMP). “Medicaid oversees that the regions get the medical management, admin support, while they seek to ensure care coordination to the Medicaid enrollees and integrate smoothly with the care in hospitals, with social services and specialist” (Ellis, Gifford, & Smith, 2014). Many of the ACA’s provisions affecting Medicaid eligibility and enrollment went into effect during 2014, most significantly the Medicaid expansion implemented as an option for states. All states were required to streamline Medicaid enrollment and renewal processes, transition to a uniform income eligibility standard and coordinate with the new marketplaces (Ellis, Gifford, & Smith, 2014). Colorado has also set out to integrate behavioral and clinical health care through incentives to providers. Colorado’s first annual report indicated progress and success for what the ACO set out to

Based on an article written in the Journal of Health Policy, Politics and Law to increase the value and quality of health care services provided to Medicare patients there is a need for health care professionals to focus more on working as a team to coordinate care. The purpose of establishing an ACO is to achieve high quality outcomes in the most effective manner. By establishing an effective ACO would provide benefits to patients and health care professionals within the community. By accepting the government’s offer will allow patient care to improve, decrease health care expenses and will overall benefit the health care providers within the organization.

Accountable Care Organizations can help curb over s spending with the use of accountability factors that have been put in place. Because of the span of an ACO, the population it will oversee, and the size of the group of healthcare providers overseeing the patients needs there will be an elimination of duplicated and unnecessary healthcare service. This will also flow into their quality model of patient care where they have put in place checks and balances to make sure that a patient medical needs are being looked after to the highest standard, if providers do these effectively they will receive financial incentives.

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.