Healthcare Cost Benefit Analysis

The Improving Medicare Post-Acute Care Transformation Act (IMPACT) standardizes data collection and data sharing among post-acute providers. The IMPACT Act is part of the Centers for Medicare and Medicaid services (CMS) effort on basing reimbursement on quality as it moves from voluntary reporting of quality measures to mandatory reporting, basing reimbursement on the data reported. Presently, post-acute providers are paid on a fee-for-service basis but with the IMPACT act, bundle payment will replace the fee-for-service. The bundle or value based payment pays for outcomes and not for the volume of services. The Act gives post-acute providers an incentive to work on

Describe how the recommended system will impact patient care and documentation. The core of care delivery and documentation is shifting to new technology innovations and developments. Stakeholders are in need of systems that contribute to improved health outcomes. Interoperability between technologies is vital to start the meaningful process change. However, divisive systems add to the complexity of health care management. Therefore, EHRs must have the correct architecture to drive value from all clinical information systems continuously. Strategic interoperability contributes to the systemic improvement of healthcare. Health care organizations can ultimately make fundamental shifts in population health with the use of interoperable technology coupled with meaningful process change.

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,

With the implementation of the ACA, many states have expanded their Medicaid programs to include a larger population of low income individuals and families that were not able to obtain health insurance prior to the law. Some of the issues that state legislators struggle with are the overall cost of providing services for the additional recipients, staying within budget, determining an adequate approach of offering quality care, and providing adequate coverage for each recipient. Even though the cost of Medicaid expansion within each state has increased the budget for the program, new appraisals has shown that Medicaid programs spend less per enrollee than commercial health insurance and much of the increase in Medicaid expenses originate from the increase in enrollment in the programs (Coughlin, Long, Clemens-Cope, & Resnick, 2013).

The Center for Medicare and Medicaid Services (CMS) is the federal agency within the Health and Human Services that runs Medicare and Medicaid. In addition to Medicare and Medicaid CMS oversees the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA), among other services.1 It provides quality healthcare services to the indigent, elderly, and other needs based groups and also has been charged with the implantation of electronic health records program. It drives policy development and analysis, program operations and budget preparation, health care research and demonstrations, data collection and

Centers for Medicare and Medicaid Service (CMS) provides health coverage through Medicare, Medicaid, Children’s Health Insurance Program, and the Health Insurance Marketplace. “The CMS seeks to strengthen and streamline the Nation’s health care system, to provide access to high quality care and improved health at lower costs” (CMS Quality Strategy, 2016). The CMS provides health insurance to those who are uninsured or underinsured to those who are low-income families, adults, seniors, and people with disabilities.

Partnership for Patients (PfP) has made significant progress in decreasing the number of preventable hospital acquired conditions (HACs), hospital readmissions, hospital patient deaths, and health care expenditures. Nonetheless, much work remains to be done so that PfP is more effective in their mission to make and improve care safety and care transitions. The progress made is part of a program that has been in effect since April of 2011, soon after sections 3011 and 3026 of the Patient Protection and Affordable Care Act (PPACA) were signed into law. These sections allowed then Department of Health and Human Services (DHHS) Secretary, Kathleen Sebelius, and Center for Medicaid and Medicare Services (CMS) Administrator, Donald Burwick, to create and provide funding through Medicare for a dual program to reduce hospital readmissions and transition care services.

Policy makers created the Medicare Hospital Readmissions Reduction Program (HRRP) in an attempt to improve quality of patient care and lower costs (James, 2013). In order to avoid these penalties, healthcare leaders must recognize that CMS has identified a correlation between readmissions and a lack of quality care. Therefore, the aim is not to focus solely on hospital readmissions, but to seek clinical excellence by investing in quality improvement (Silow-Carrol, Edwards & Lashbrook, 2011). However, reducing readmissions is a complex undertaking, because not all readmissions can or should be prevented. Indeed, some readmissions are planned as part of sound clinical care. Furthermore, while hospitals work to reduce readmissions caused

The United States health care system has can be assessed for quality measures in many different ways such as mortality rate or infant mortality, but the United States government often judges the efficiency of health care provider or network on the Centers for Medicare & Medicaid (CMS) core measures. The reason the United States gauge health care performance on CMS standards is due to CMS is the federal governing body that operates Medicare and how the hospital will be reimbursed from Medicare patients. Formerly Medicare would reimburse a hospital based all services the hospital provided a patient or fee for service (FFS). The rising

With the law, hospitals have the opportunity to receive increased Medicare payments as long as they increase patient education about care after hospital discharge, provide patients with community healthcare resources, and increase discharge instructions for patients suffering from heart failure (Burton, 2012). The Centers for Medicare and Medicaid Services (CMS) has threatened to reduce hospital payments to one percent if the patient readmission rates of “heart failure, pneumonia, and myocardial infarction” increase past a certain limit (Burton, 2012). State Medicaid agencies will grant providers reimbursement if “comprehensive transitional care” is provided to patients (Burton, 2012). The law also offered $200 million towards projects aimed at increasing the number of advanced practicing nurses in areas including: chronic care, preventive care and primary care (Burton, 2012). Preventive care will allow nurses to reduce the rates of high acuity patients in their hospitals. If the PPACA fails to improve care transitions, the CMS plans to carry out other policies. These policies

On July 30, 1965, Medicare was signed into law by then President Lyndon B. Johnson. The President declared “No longer will older Americans be denied the healing miracle of modern medicine (Johnson, 1965). The Medicare act was implemented to provide the older population of U.S. citizens and those with disabilities and end-stage renal disease with financial security, coverage, and access to healthcare. It’s a federal program that most families will eventually rely on. “As the single largest purchaser of medical services in the United States, Medicare is an important source of income for hospitals, physicians, home health agencies, and other medical care providers” (Oberlander p. 119).

Quality and financial viability being closely tied is an extremely salient point. Furthermore, the Affordable Care Act has influenced the requirement for high-quality, cost-effective care provision by implementing Value Based Purchasing (Aroh, Colella, Douglas, & Eddings, 2015). In addition, there are presently Centers for Medicare and Medicaid (CMS) quality indicators that effect reimbursement for hospitals (Xu, Burgess Jr, Cabral, Soria-Saucedo, & Kazis, 2015). For example, if a facility does not meet the indicator threshold for catheter associated urinary tract infections, central line infections and/or pressure ulcers their reimbursement is affected. Given that the quality of care provided by a hospital is

This savings would be a direct result of decreased overpayment by Medicare to hospitals, physicians and insurance companies (Perez, 2013). As a result, Centers for Medicare and Medicaid is incentivizing increased quality care in hospitals. Consequently, hospitals are not getting reimbursed for hospital acquired conditions. In addition, CMS is penalizing hospitals for readmissions (Bauchner, 2015). Lawmakers are expecting resounding savings related to CMS expectations. The short term savings of more than $200 billion through 2016 (CMS, 2015). As a result, hospitals are in a paradigm shift from volume based care to value based care. The expectation is that hospitals will reduce waste and decrease inappropriate waste which will result in savings that be used for other therapies (Bauchner,

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.

In fact, one of the biggest struggles of DM programs is that they need to ensure that their care model fosters patient provider relationship, and they should clearly define the patient population so that results can be replicated; therefore, avoiding healthcare disparities in the delivery of disease management programs ( Faxon et al, 2004). More so, in an article by Faxon (2004), he states that future challenges for DM programs revolve around reimbursement policy designs and integration of DM in the public. I am not clear whether this has occurred in the past ten years. However, it is obvious that disease management emerged as a potential strategy to enhance the quality of care received by patients suffering from one or more chronic conditions, and to improve the efficiency of the delivery of healthcare services by maintaining or improving quality while reducing costs (Faxon et al, 2004). However, I consider that in order to make this sustainable, disease management companies should try not to make the same marketing mistake than MCOs did. In fact I completely agree with Faxon et al (2004) when they state that evaluations of disease management programs should not be based solely on their ability to reduce healthcare expenditures. More so, the best way to obtain complete buy in for this program is to focus on quality of care and patient outcomes;