Health Information Technology : How Can Cms Maintain Regulatory Cost Control?

In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American

The Patient Protection and Affordable Care Act (Obamacare) had mame dramatic changes in the field of the health care system, especially in Medicare, that will seriously take effect in American seniors. Indeed, much of the health law’s new spending is financed by spending reductions in the Medicare program. In addition to the provider payment reductions, Obamacare significantly reduces payments to Medicare Advantage (MA) plans by an estimated $156 billion from 2013 to 2022.( Elmendorf, letter to Speaker Boehner). About 27 percent of all Medicare beneficiaries are enrolled in MA plans, a system of regulated and private plans competing against each other as an alternative to traditional Medicare. MA plans are attractive to beneficiaries because they offer more generous and comprehensive coverage than traditional Medicare by capping out-of-pocket costs and offering drug coverage to a rasonable

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

Medicare and Medicaid information can be overwhelming and confusing to both the consumer and the healthcare professional. The information highway known as the World Wide Web (WWW) can provide the answers to questions about these government benefits, but getting clear, informative and accurate knowledge can be overwhelming. O’Sullivan (2011) identified the WWW as “a primary repository for health information for the medically naïve yet technically savvy healthcare consumer.” One internet website that provides information about Medicare and Medicaid is CMS.gov ("Cms.gov centers for”). The Centers for Medicare & Medicaid Services (CMS) is the United States agency that administers Medicare,

Contrary to this, anecdotal reports stated that other clinicians sometimes spend more times in checking and treating patients with severe illnesses or who are in critical conditions, which made the physicians care for a greater number of patients with lower acuity. Whenever a physician and clinician bill for the same service, it is very difficult to tell if the physician saw a more complex patient. Due to these uncertainties in comparing their services, the Commission is reluctant in altering the payment differential. From that discussion, every provider must be familiar with some fundamentals about Medicare. First and foremost, there is Medicare Part A, which actually covers skilled nursing home, hospital, and home health charges; and then there is Medicare Part B, which then envelops most outpatient services, the care that patients in particular obtain from a doctor’s office (Fishman, 2002).

In an office setting, RBRVS determines overall cost of visit. The Relative Value Unit (RVU) is a created value to measure resource consumption by assigning numeric values. RVUs are divided into three domains, each with different weight. This metric sums the salary of provider, facility/practice expense (inclusive of utilized resources), and malpractice adjustment (exposure level to account for). This determines the overall Relative Value Unit (RVU) which is then multiplied by the GPCI (geographic index specific for each factor) which adjusts for cost differences in different areas. The total RVU is multiplied by conversion factor to equal reimbursement. Doctors working more and producing more RVUs are making more

Medicare payments to hospitals grew annually by 19 percent; the Medicare hospital deductible had expanded, placing a burden on beneficiaries; the solvency of the Medicare Trust Fund was endangered by escalating costs; expenditures for hospital inpatient care jeopardized Medicare's ability to fund other necessary health programs; Medicare's payments for comparable services were vastly different across hospitals nationwide; and the cost-based system imposed burdensome reporting requirements.

In 2009, the American Recovery and Reinvestment Act (ARRA) were passed by the Obama legislation to try and improve healthcare for Americans by reducing costs and improving quality. The ARRA is commonly known as the ‘stimulus package’. The Health Information Technology for Economic and Clinical Health (HITECH) act was part of the ARRA to help improve our country’s infrastructure. HITECH supports electronic health records– meaningful use (EHR-MU) which is led by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC). HITECH allocated over $27 billion in funds to help encourage the healthcare industry in

The Affordable Care Act will adjust Medicare’s annual payment updates to Part A hospitals to account for economy-wide productivity increases for cost savings, which is estimated to reduce Medicare associated with Medicare for 10 years. Under previous laws, the market basket part of the physician update or the Medicare economic index was adjusted to

Hospitals are subject to a 2% reduction in the annual payment if they do not meet certain requirements of the Quality Data Reporting criteria. If the hospital does meet the criteria, there is a financial incentive they can receive. With most of the services, the patient will pay the deductible for that year. Once the patient meets the deductible, Medicare pays the rest of the charges, less the copay or coinsurance the patient must meet. On certain services, such as a screening mammogram, the patient is not liable for a deductible.

UnitedHealthcare, Medicare and Retirement provide health insurance for senior citizens and other Medicare recipients usually through the Medicare’s Advantage program. Under this program, the two organizations were able to provide healthcare coverage in exchange for a fixed monthly premium per client from CMS. The premium amounts for this service varies based on demographic factors such as age, gender and health status as well as where the individual is located geographically. The program uses automated medical record software that allows clinical care teams to track and capture data and clinical encounters for high-risk patients. It also allows the teams to create a comprehensive set of care information which links across hospitals, homes and nursing home care settings. They are patented predictive modeling tools that helps identify members that are at high risk ,and allows their care managers to reach out to those members to create and individualized care plan. By the end of December 2012, approximately 2.6 million individuals enrolled in this program.

After reviewing the Medicare website, I learned a few new things as well as had some previous knowledge clarified. First, I learned that Medicare offers a lot more services that I initially thought such as alcohol misuse screenings, depression screenings, HIV screenings, and sexually transmitted infections screenings and counseling. In addition, prior to reviewing the website, I knew that there were two parts to Medicare, Part A and Part B, however I did not know that difference between the two parts and the different services they provide. I learned that Part A is basically hospital insurance that covers visits to a facility such as a hospital or doctor visit. Alternatively, Part B is medical insurance that covers the actual services and medical equipment such as outpatient care and preventative services.

For many countries such as Europe, care is allocated based on predetermined factors (Knickman & Kovner, 2015). For example, an individual may be meticulously examined from health history to their present state to determine whether they are approved for chemotherapy treatments. Allocating care, familiarly called rationing, allows countries to control expenses of health care (Stein, 2010). Based on numbers, the United States tops Europe by double of the amount of patients they see for dialysis treatments (Knickman & Kovner, 2015, p. 265). Withinn the United States, as long as the services are in the guidelines of policy to provide care, Medicare is going to cover those services no matter the

Health Information Technology (HIT) Medicare databases are valuable tools to extract healthcare data because they store comprehensive sources of health information. Medicare collects information on all its beneficiaries and those providers that receive payments from Medicare. The data that Medicare collects can be used to identify the variations in cost, utilization and quality. Most Medicare beneficiaries are in traditional fee-for-service (FFS), therefore, spending per beneficiary should be the same throughout the country but, it is not. Numerous studies have shown there are differences in cost and the quality of health care with Medicare beneficiaries, with the biggest spending difference being post-acute services. As explained, by the

(Elhauge, 2010). Fragmentation leads to duplication of tests and effort. Often, physicians do not have test results and notes from prior treatments. This results in wasteful duplication of efforts. Fragmentation leads to unplanned hospitalizations. Approximately 20% of discharged Medicare patients are re-hospitalized within thirty days. (Jencks, Williams, Coleman, 2009) It is estimated that only 10% of those readmissions are planned. (Jencks, Williams, Coleman, 2009) Patients can receive better continuation of care if their doctors coordinated better, if there was better discharge planning and incentives for providers to control costs after the patient has been discharged.