Healthcare Cost And Utilization Project Case Study

The Medi-Cal Managed Care system for Shasta County is the COHS Model (County Organized Health System), also known as the Healthy Families Program. This program“administers a capitated, comprehensive, case-managed health care delivery system. This system has responsibilities for utilization control and claims administration and Medi-Cal covered health care services to all Medi-Cal beneficiaries who are legal residents of the county” (Department of Health Care Services, 2009). This model has been shown to be the most efficient Medi-Cal managed care model for improving patient

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

Health Information Technology (HIT) Medicare databases are useful tools to obtain 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 recognize the variations in healthcare cost and the use of services. Spending for Medicare beneficiaries 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

The Camden Coalition of Healthcare Providers is built on a partnership between with active participation from 3 Camden hospitals, 2 Federally Qualified Healthcare centers, private community-based medical practices, social service agencies and the patients and community at large (Miller, Cunningham, & Ali, 2013). The main goals are improving care for “super-utilizers” while bending the cost curve (Miller et al., 2013). A “super-utilizer” is a person who overuses emergency departments and hospital inpatient services, making more visits to those facilities in a month than some people make in a lifetime (Camden Coalition of Healthcare Providers [CCHP], 2015). Also referred to as “frequent users” or “frequent

As the shift for HCOs is made to a PCMH model, the financial aspect also has to make a transition to accommodate to the changes. In recent years, there have been implementations of different payment and reimbursement options, health insurance programs, and the establishment of the Affordable Care Act (ACA). Between May 2009 and April 2012, one of the initial PCMH pilot programs was conducted in Colorado, appropriately named The Colorado Multipayer Patient-Centered Medical Home Pilot. More than 100,000 patients within sixteen internal medicine practices participated in the experimental PCMH model, using six different health plans (Harbrecht & Latts, 2012).

As the continued support grows the PCPCC, the health care sector is recognizing the role of the medical home model, Accountable Care Organizations(ACO), many entities are embracing the model and performing better. According to Center of Medicare and Medicaid, the medical home model shows that there is an improvement cost effectiveness, which helps practitioners deliver quality care and advanced approaches to care coordination, care teams, and chronic disease management. As evaluations of ACOs, integrated health systems, and the medical neighborhood continue, the Patient Center Medical Home will be essential to driving improvements in cost, quality, and outcomes. [3]

Patients in the United States are receiving an elevated level of care that places their needs at the core of each health care visit. As the US adopts the new, patient-centered medical home model (PCMH), the health care system transforms into a community-focused on holistic wellbeing. While making use of existing resources, the addition of technology that enables timely file sharing between practitioners and outreach programs, decreases duplicated processes and creates sustainable improvements to system efficiency (Cliff, 2012). Standardization of data formats and billing practices enables health care providers and insurance companies to make informed decisions that maximize profits (Harbrecht & Latts, 2012), or excess revenues over expenses in nonprofit HCOs. The PCMH establishes an effective, trustful, and

The Medicaid health home state plan option looks promising for the state of California. This expands beyond the traditional medical homes model, that in many states, have developed in their Medicaid programs. It offers home health services to eligible individual with chronic conditions, with flexibility in selecting home providers (Medicaid.gov, n.d.). States participating in this option must require that hospitals who

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

The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and relates to software tools and products recognized through a Federal-State-Industry partnership and supported by the Agency for Healthcare Research and Quality

One of the leading concerns affecting the health care system is the high rates of unplanned hospital readmissions. While some readmissions are an appropriate part of treatment, many patients are admitted back into the hospitals due to avoidable factors that compromised their health. This critical issue, according to the Dartmouth Atlas Project, has now become a measure of the quality of hospital care. As a result, the Center for Medicaid and Medicare Services (CMS) currently penalizes hospitals with high rates of 30-day readmissions for certain conditions (PerryUndem Research & Communications, 2013). Aside from the governmental costs, those most affected are the patients, families, and their providers. Effective programs assessing the discharge plan and care coordination must be enforced to diminish the number of hospital readmissions and potential health complications.

The center set ought to concentrate on patient experience and engagement, results identified with consideration coordination like readmissions, measures of vital well-being confusions, and actions of the populace and preventive wellbeing Situated to a limited extent on the change model confirmed by Massachusetts in 2006, this government arrangement. Endeavor extends access to scope utilizing four mechanisms: an individual. Medicaid qualification; reconfiguring of business. Wellbeing protection market controls; and setting up, state- based medical coverage trades (Exchange) that are scheduled to open for business by 2014. We condensed the Patient Protection and Affordable Care Act of 2010 (PPACA) and inspected four cost regulation and quality-change instruments mechanisms with Medicare installment strategy that will be actualized by this as of late passed law. The PPACA will grow human services scope and advance packaged payment frameworks, responsible consideration associations, and the patient-focused therapeutic home as the vehicles for containing cost and enhancing social insurance quality. The enactment will likewise build up a free commission to order cost-regulation approach, which may have critical ramifications as far as doctor repayment. In spite of the fact that the late

The health care system within the United States is facing numerous problems. Even after the passing of the Affordable Care Act many Americans remain uninsured or underinsured. This results in citizens facing financial blockades in receiving care at a primary level and often waiting till the health issue has escalated to the point of needing hospitalization before seeking care. While each state has had challenges expanding their health care system the board of Access Health Care Initiative (AHCI) has chosen the state of Pennsylvania as a target region for possible expansion. The question posed by the board of directors is would it be possible for AHCI to expand into Pennsylvania and have a positive effect on the state’s health care system. The research has shown that it would be possible for AHCI to expand into Pennsylvania and help the state meet the health care needs of its residents. However this expansion will take careful planning and the ability to overcome some unique problems that Pennsylvania poses.

The cost of healthcare services keeps rising through the years. Statistics show that United States is the country that spends more on healthcare services than any other country. There are many reasons for the higher cost of health care services: the fee-for-service system that pays the medical providers for each procedure or test, the aging of the population with many chronic conditions and obesity, out of control pricing of medical services, the new more expensive treatments implemented as a result of extensive technological research, and more (Blumenthal, 2013).

Healthcare Cost and Utilization Project, abbreviated as “HCUP,” includes the largest collection of longitudinal hospital care data in the United States (HCUP). The HCUP and AHRQ described (HCUP) as, “…Is a family of health care databases and related software tools and products developed through federal-state-industry partnerships…HCUP databases bring together the data collection efforts of state data organizations, hospital associations, private data organizations, and the federal government to create a national information resource of encounter-level information beginning in 1988. Databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health services, medical practice