Healthcare Reimbursement : The Future Of Healthcare

The policy issue that I have selected to discuss herein is the pay-for-performance payment model. I feel that this impacts a large number of our population and changes in this regard should be made. This type of payment model aims to use reimbursement to incentivize providers to deliver high quality services. Pay-for-performance model steps away from the traditional manner of reimbursement of fee-for-service, in which providers receive payment on the basis of frequency or volume of the services they provide regardless of outcomes. In contrast,

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

The Arkansas Health Care Payment Improvement Initiative (“AHCPII”) is one part of the health care innovations the state has implemented with the aim of “increas[ing] health care quality and reducing the costs of care.” The AHCPII’s intent is to shift Arkansas’s payment system from “one that primarily rewards service volume to one that rewards desired outcomes, particularly with respect to quality and affordability.” Applying to Medicaid, Medicare, and private payers, payment innovation will move away from fee-for-service health care (where quantity all too often trumps quality) to pay for quality. In doing so, the hope is that Arkansas will gain a “new, sustainable model of financing” with the help of a multi-payer leadership and support.

Hospitals should be encouraged to participate because improving hospital care is likely to be essential to success (McClellan et al, 2010). Accountable care organizations can be implemented through different payment models. These could include opportunities to share in demonstrated savings within a fee-for-service environment, in which providers took on no new financial risk. They could also include limited or substantial capitation arrangements, in which payments were unrelated to the volume of services provided, to the intensity of service use, or to the frequency of face-to-face meetings, and in which providers took on some financial risk for poor-quality results or failure to control costs (McClellan et al,

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

The main economic challenge for the healthcare system in the United State will be the rising expenses associated with Medicare and Medicaid. The Governments share of healthcare spending is predicted to rise to 31 percent by the year 2020 (Keehan, Sisko, Truffer, Poisal, Cuckler, Madison, Lizonitz, and Smith, 2011). This may jeopardize the economic stability and financial security of the nation.

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

The Obamacare/ACA, might have helped numerous of individuals in acquiring health care, but the health professionals are facing a shortage of reimbursement difference for their services. As a result, Hospitals and healthcare providers were force to layoff personal and come up with innovative solutions. This point is proven by the renowned author, Amy Anderson by stating as follows: “The American health care framework has had shortages of personnel for quite some time and would not be prepared to give the adequate service to this amount of patients in need of medical attention. Training new professional health services personnel could take years. There is a shortage of graduates from medical and nursing schools. Doctors, nurses and health professional are sharing responsibilities prospective patients will face a longer wait time”. (Anderson, 2014)

The Affordable Care Act (ACA) legislated in 2010, has changed the United States health care industry. In addition to universal healthcare, one of the principles of the ACA is the ideal of accountable care. Specifically, adopting an Accountable Care organization (ACO) for Medicare beneficiaries under the fee for service program. An ACO seeks to hold providers and health organizations accountable for not only the quality of health care they provide to a population, but also keeping the cost of care down (1). This is accomplished by offering financial incentives to the healthcare providers that cooperate in, circumventing avoidable tests and procedures. The ACO model, seeks to remove present obstacles to refining the value of care, including a payment system that rewards the volume and intensity of provided services instead of quality and cost performance and commonly held assumptions that more medical care is equivalent to higher quality care (2) .A successful ACO model, will have developed quality clinical work and continual improvement while effectively managing costs, however this is contingent upon its ability to encourage hospitals, physicians, post-acute care facilities, and other providers involved to form connections that aid in coordination of care delivery throughout different settings and groups, and evaluate data on costs and outcomes(3). This establishes the ACO will need to have organizational aptitude to institute an administrative body to manage patient care,

Review of the literature identifies the issue of fair pay for similar work has been an issue for some time. According to Grey (2013, par. 7) the pay parity for NP and PA became an issue when two insurance carriers dropped reimbursing rates for NP and PA by 50%. On March 1. 2013 NP and Physician Assistants (PA) who run private practices reported they were struggling to maintain their business because of the lower rates paid by insurers (Grey, 2013, par. 8). Mccarger (2017, p. 15) discusses how payment parity is strongly opposed by medicine, and is primarily historical in nature. Advanced practice nurses still need to justify their value in a historically hierarchical framework of health care where the physician is the chief authority

Healthcare reimbursement systems within the United States are a complex structure for obtaining payment for services rendered. The healthcare system officers are required to understand the ordinary principles of the payer system. Understanding the rules, and keeping up with the continuous changes will allow the providers, physicians, and facilities to gain an advantage in this growing healthcare domain. Both private and commercial insurance companies provide a diverse menu of choices to customers. All third-party payers create interest in decreasing healthcare costs and improve control access to the not needed services. This paper will address the complexity of the healthcare reimbursement systems in the United States. Additionally, the research

Rising health care cost currently threaten the sustainability of the Medicare program. Although advances in biomedical knowledge and technological innovation offer cost saving improvements, the differences in spending across regions and health systems highlight the opportunity to improve efficiency by providing better care at lower cost (Fisher, McClellan, Bertko, Lieberman, Lee, Lewis, & Skinner, 2009). On average regions with lower Medicare spending provide higher quality care and achieve better health outcomes. While regions with higher spending, due largely to the over use of “supply-sensitive” services, demonstrate high levels of inefficient use of health care resources. Providing a need to approach payment reform by addressing three barriers to care: lack of accountability, the volume reward system, and the penalties associated with cost saving innovations.

Robbie’s accuracy affect the reimbursements the facility receives from Medicare and Medicaid reimbursement decides by and large give that the correct Medicare bearer to pay doctor cases is the Medicare transporter for the area in which the doctor or work on giving the administration is found as opposed to the Medicare transporter for the district in which the patient accepting the administrations is found. A large number of our associated radiologists are situated in a Medicare area that is unique in relation to the Medicare district in which the patient and treating healing center are found. It might be essential for our clients to enlist with extra Medicare bearers so as to appropriately submit claims for repayment. On the other hand, we

The future and direction of health care has been the topic of discussion amongst politician and U.S citizens today. There are several challenges surrounding the future and strategic direction in which health care should be heading. Accreditation, quality of health care and organization’s compliance; access to health care, maintaining a skilled workforce, information technology and pay for performance are some of the challenges that currently presenting itself in healthcare today. If health care is not dealt with appropriately it will have a significant effect an impact on the strategic direction in the future and direction of care.

The positive outcomes that have resulted due to value base programs have caused the model to gain traction and ignite one of the largest changes in history in the health care marketplace. By linking reimbursements to service quality, insurers such as the Centers for Medicare and Medicaid Services have facilitated a massive leap forward in the performance of United States health care providers. This achievement is a considerable accomplishment in the face of an institution that has received reimbursement from insurers via a fee-for-service model during the last 75 years. Soon, valued based payment models will represent the norm as more insurers support initiatives such as shared savings program, integrated clinical care, and accountable care payment models.