Pros And Cons Of Medical Reimbursement

In my role with Liberty Mutual, I drove adoption of Medicare reimbursement models through public affairs involvement with multiple state workers' compensation committees seeking to update their reimbursement schedules in response to the implementation of ICD-10 coding requirements in October of 2015. With the state workers’ compensation authorities seeking to adopt CMS reimbursement type models, my involvement was directed at securing the inclusion of specific CMS rules governing correct coding and reimbursement practices including National Correct Coding Initiative Guidelines (NCCI), Medical Unlikely Edits (MUE), along with the Resource Based Relative Value System (RBRVS) for reimbursement rate setting.

Since 1992, health cares like Medicare have reimbursed physicians on a fee-for-service basis that weighs their service and expenses and then converts the weights to money (Wilensky, 8). According to Gail Wilensky, “Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy” (Wilensky, 8). Physicians and PAs are having a hard time with health-care reimbursement. It is causing many problems and Congress needs to come up with a solution. ¨This article states several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform

This fundamental transformation of the healthcare industry is led by the Affordable Care Act (ACA). One of the impacts of this legislation was significantly reducing the rate of uninsured – from over 16% at the end of 2013 to under 11% at the start of 2015 (Source: Kaiser Family Foundation) – which has expanded procedure volume, creating a corresponding revenue tailwind for medical devices and Medtronic. To address the increasing costs and inefficiencies, the ACA shifts risk and accountability from payers to providers and other healthcare stakeholders. However, additional policies have also been shifting the way the healthcare industry thinks about reimbursement and cost.

It seems as though the gaps between patient-care and doctor relationships are being pulled apart and further disintegrated by eliminating “patient-care” and substituting it with “reimbursement”. Most physicians working in private practice today are burdened by diminished reimbursement rates and a growing list of administrative tasks required by insurance companies. In response, many primary care physicians are exploring alternative practice options other than the traditional fee for service. A fee for service is a delivery system where health care providers are paid for each service like an office visit, test, or procedure. A new health care trend which seems to be the growing

Professionally, we acknowledge that hospitals have a general mission to provide a level of service for patients, but we also understand that they also require capital for a wide-range of business operations. (research, expansion of services, equipment modernization, new

Health care systems are refining their strategies in line with the changing market dynamics. These dynamics range from competitions to a change in the technological developments. It is worth noting that other than changes happening in the markets, the health care facilities have been highly impacted by changing legislations, such as the passing of the Affordable Care Act. Constantly evolving health care system calls for reevaluation of current strategies that have an impact on the quality of performance, as well as the value of the services offered to the clients. Historically, the reimbursement was driven by the volume rather than the value. Utilization of efficient transition of care, as a value-based care, will allow for overall cost savings, lower rate of readmission, and continuity of care. The purpose of this paper is to examine the utilization of strategies to enhance the transition of care, as a value-based care.

Healthcare has been an every changing service as different leaders have tried to find better ways to streamline the system as costs continue to increase on an annual basis. One thing is becoming clear as Healthcare continues to evolve in that Healthcare is moving to a performance based system in which higher performing plans will get financed a lot quicker than low performing plans.

Three general hospitals and two other cardiac hospitals serve the metropolitan area’s 620,000 people from a ten-county area. One of the main issues continuing to consider include factors that influence costs including outputs, input costs, technology, efficiency, and variable and fixed costs. Cost management’s important in healthcare, as organizations start to adopt the cost-reducing technology, substitute high cost for low-cost production techniques, purchase goods and services more conservatively, and rethink what they

Various elements influence how resources within a Patient-Centered Medical Home (PCMH) are managed. PCMHs veer away from traditional episodic and often fragmented care to offer patients higher quality care that is accessible, comprehensive, coordinated and more cost-effective. PCMH demonstration projects have shown that the model enhances health outcomes, reduces waste, and improves patient and employee satisfaction alike. This transition, however presents significant challenges and necessitates the restructuring of financial, material, and personnel resources within primary care structures. Effective implementation of this model is contingent upon the procurement of specialized staff, health information technology (HIT) systems, and possibly workspace reconfiguration all of which can impact an organization’s operating budget. Unfortunately, primary care payment reforms as well as complex billing and coding guidelines pose a significant threat to the financial viability of PCMHs and remain highly important factors to consider prior to undergoing this transition. Despite many of these challenges, PCMH continues to be a leading model in primary care. This paper presents a hypothetical PCMH implementation project and discusses some important considerations related to the management of financial, material, and personal resources.

Alternatively, health care organizations need to continue to improve operating performance to decrease reimbursements; arrival of new covered patients under the Affordable Care Act (ACA) (Molinari, 2014), and increasing patient outcomes and satisfaction. The demographic shift of those retiring is moving from commercial insurance coverage to enrollees for Medicare, by the way, pays lower reimbursement rates. With the arrival of new patients using the health care system under the coverage from state and federal insurance exchanges, lower reimbursement rates are expected as well (D Piro, 2014, February 11).

This article is about today’s healthcare marketplace have broad demand for greater value in healthcare face two obligations according to HFMA survey. Those obligations consist of reducing costs for existing services, optimizing the efficiency with which those services are delivered and develop the infrastructure and capabilities required to thrive in the emerging value-based payment and care delivery environment (HFMA 2015). HFMA research seeks to understand the challenge organizations face today is not simply to contain costs, but rather to reconfigure cost structure so that spending reductions in one area can free up resources needed for new investments in another (HFMA 2015). Dan Piro, president of MedAssets Advisory Solutions, notes:

In 2001, Consumer-Driven Heathcare plans were introduced (wall street journal ref) Consumer-Driven Healthcare plans (CDHP) can be combined with Health Savings Account (HSA), Health Reimbursement Acocunt (HRA) or Flexible Spending Accounts (FSA). The idea of conjoining the two assists the consumer with paying for their deductibles, by using their HRA, FSA and HRA’s. The idea of utilizing Consumer Driven plans is to help decrease unnecessary claims and allow for more health consensus individuals. CDHPs were develop to assist in the rising health care costs and provide individuals with control over their health care endeavors.

Change can be devastating and not always everyone agree with it. The biggest transformation in healthcare is the implementation of the Affordable Care Act. With the new health care system the government mandated U.S. citizens and legal residents to have health insurance that resulted in the rise of insured individuals. Due to the new policy more people have access to health care that means more primary physician needed to accommodate the rise of new patients. Shortages of physicians not only in the primary care area but also in specialty care area are projected between 46,000-90,000 by 2025 ("The Physician Shortage," n.d.). The pay-for-performance focuses on quality that will eventually decrease the costs (James, 2012, p. 1). This system will give a reward or a bonus to the health care providers whenever they meet or exceed quality standard that are being set (James, 2012, p. 1). In contrary the system can also penalized those providers that are unsuccessful in providing the indicated goals or cost savings (James, 2012, p. 1-2). There are 2,225 hospitals in 2013 that were fined under the Hospital Readmissions Reduction Program (HRRP) which is part of the ACA regulation (Anderson, 2014, p. 11). For the institutions to survive with the new system a lot of hospitals are merging that a year after the ACA implementation there were already

The financial challenges facing hospitals are daunting. The cost of updating aging IT infrastructures, staffing shortages that trigger more overtime, and a switch to pay-for-performance paradigm for federal reimbursement all contribute to budgetary stress.

Background: Hospitals are under unprecedented pressure to control costs; and thus, have been challenged with examining their escalating budgets for employee healthcare benefits, which have been rising at a substantially higher rate than in other industries. It is more critical than ever for hospitals to reduce these costs through strategic implementation of increasing use of the organizations own healthcare facilities and systems (referred to as “domestic resources”). Hospital organizations need to do more to encourage employees to use their domestic resources, including utilization of their doctors, pharmacies, laboratories and outpatient clinics. Furthermore, it’s imperative for hospitals and healthcare systems to design