Healthcare Delivery: Article Analysis

A mixed payment system combined with physician monitoring, will provide physicians with incentives to consider costs and benefits of different treatment options, which will lead to an efficient level and quality of care. (1,2)

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).

The increase of expenses - As politicians continue their dissension amongst each other, the situation is worsening in our healthcare system. According to the World Health Organization, to achieve universal health coverage, countries need a financial system that enables people access to all types of health services without incurring financial hardship (Carrin, Mathauer, Xu, & Evans, 2011). This idea would be the foundation of innovative ideas that the U.S. could reform its healthcare system, but too many ideas are sabotaging any valid efforts. In the mean time, the U.S. healthcare system continues to deal with issues such as the increasing uninsured Americans (over 49 million), expensive administrative procedures and the inability to measure the accuracy of quality of care, access of care, and the increasing healthcare spending and financing that limit our ability to efficient utilize resources.

When Medicare was first established, Medicare adopted the payment methods of Blue Cross Blue Shield which meant that the program was paid hospitals on the basis of their own costs and physicians were being reimbursed by the fees that they charged which caused hospitals and physicians to provide care without boundaries (Anderson et al., 2015). This method caused Medicare to dissipate the budget that was established for beneficiaries to utilize. Now, with the ACA being implemented, Medicare had done an overhaul of payment reimbursement. Medicare is now moving toward a volume to value payment initiative that links payment to patient outcomes, experience of care, while giving providers an incentive to limit spending

There is a growing trend in the United States called pay-for-performance. Pay-for-performance is a system that is used where providers are compensated by payers for meeting certain pre-established measures for quality and efficiency (What is Pay-for-Performance, n.a.). We are going to be discussing what pay-for-performance is. There are different aspects of pay-for-performance which include; the effects of reimbursement by this approach, the impact cost reductions has on quality and efficiency of health care, the affects to the providers and patients, and the effects on the future of health care.

What is the control mechanism the government uses on Medicare payments to physicians, and how is it applied?

Medicare has instituted policies to help regulate cost on these outliers which includes standardized payments, risk adjustments and bundle payments. CMS uses standardized payment rates to determine its Medicare spending per beneficiary (MSPB) .Medicare standardizes the allowed amount for the MSPB. This method looks at the different Fee for Service (FFS) payments and identifies the factors to adjust. Once you remove the differences this should help even out the variability in payments and give a more accurate picture of how resources

A major change is occurring in the healthcare system as the United States continues to move toward enhancing patient care quality and access while also decreasing cost. This significant transformation is driven by a variety of forces, including changes in managed care, a shift from pay for service to pay for quality, and ever-evolving client characteristics. This paper aims to discuss each of these factors and the ways in which they make this major transformation a difficult one for the nation to undergo.

The Health Affairs published an article in about a proposed Medicare reform regarding the high levels of use of Medicare although there was little impact on individuals. Though this article dates back to 2002, the issue still remains true to this day. In this article, the authors explain that the high level of Medicare spending was mostly due to the increase number of physician visits, specialist consultations, and hospital stays, especially among those that had chronic illnesses. Although the spending is higher among such Medicare patients, this did not mean better effective care or health care outcomes. On the contrary, according to the article, more than 20% of the total

It covers people who are 65 or older, and it will also cover an individual under the age of 65 with certain disabilities or disease. There are four different categories within the Medicare health insurance such as part A, B, C and D. As one goes up the order the services within each category changes based on one’s need. Along with ACA and the programs such as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) and Modernization Act has authorized CMS to pay hospital that report “designated quality measures a higher annual update to their payment rates”3, which engages hospitals to work towards value-based care. For every fiscal year CMS can place new rules and measures to determine the incentive payments for given hospital based on the reporting. Therefore, not obeying the rules of CMS will impact hospital’s incentive payments. The participated hospitals must report data to CMS, the data reported than can be used to put new measures in fiscal year so that enhancements can be made to value-based care.

However, the quality of these services seems to need improvements as better services to patients and proper care for health will impact the revenue cycle and reimbursements. Obama-care supporters are making the false impression that new government rules would promote opposition, control costs, and advance the quality of health care delivered within Medicare. Believing that, implementing this method would concurrently regulate the growth of Medicare costs in a more rational fashion and close the gap of health care we currently have and the health we would have in our future. No matter what department is seeking insurance reimbursement, accurate documentation is required along with proper billing codes to receive timely reimbursement.

From recent studies suggests that Medicare provides health insurance to 48 million Americans. Medicare also plays a significant role in determining the price for most medical treatments and services provided in the U.S. They set what is considered a “fair price” for services renders from routine check-ups to heart transplants. If the calculations were correct, some doctors spend more than 24 hours on average performing medical procedures. With is over-calculation the U.S. healthcare costs are sky rocketing. Medicare updates

Medicare has introduced value based system. It will give reward to those hospitals which are offering quality services and punish which are not.

Another reimbursement is the Pay-for-performance model where the providers are only paid when they are able to achieve a specific goal. “Insurers pay providers an “extra” amount if certain standards, usually related to the quality of care, are met”(Gapenski, 2013, p.69) The

Payments models will continue to change in 2016 and in order to get paid what they deserve, physicians will have to prepare to take on more risk. When Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in April, providers across the country breathed a sigh of relief. It wasn’t long, however, until doctors realized that solution came with a price: incentives to move away from the old fee-for-service payment model toward quality-of-care models for Medicare payments.