Roaring Fork Valley Physicians Case Study

Financial incentives play a significant role in how care is provided. The North Ohio Heart Center was found to perform more angioplasties compared to the Cleveland Clinic performing bypass surgeries resulting in different incentive rates (McLaughlin & McLaughlin, 2015). These non-invasive procedures (angioplasties) generated highly profitable incomes for the physicians involved at the North Ohio Heart Center. The physicians perceived these procedures to be a safer option of treatment as opposed to drug treatment or bypass surgery. These decisions impacted patient care by causing more patient visits and more tests being performed generating a cumulative higher reimbursement. These incentives are moving us away from what is best for the patient. Robert Doherty, ACP senior vice president, stated, “we need to move away from the piecemeal approach: how many visits you can generate, how many tests

The ethical committee should intervene to determine the ethical responsibilities of the medical and administrative staff. The people involved should be held accountable and give them the opportunity to communicate the patients about the medical

Melnick, G., & Fonkycj, K. (2013). Fair pricing law prompts most California hospitals to adopt policies to protect uninsured patients from high charges. Health Affairs, 32(6), 1101-1108. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com/docview/1372932073?accountid=2532

Failure to satisfy the safe harbor does not mean that the ASC joint venture is necessarily illegal, but rather that it may be subject to scrutiny and prosecution. It is important to recognize that many ASCs with physician investors do not meet the safe Ambulatory surgery centers: While there is no immunity for “substantial compliance” (i.e., operating as close to the safe harbor as reasonable and practical), it is widely believed that ASC joint ventures that are appropriately structured and operated should have reasonably low risk under the Anti-kickback Statute, even if they do not come squarely within the safe harbor. This view is based, in part, on the only federal court case4 that analyzes the application of the Anti-kickback Statute to joint ventures. That court concluded that a physician’s ownership interest in a health care provider does not violate the Anti-kickback Statute so long as: n the return on investment is based on each physician’s ownership interest and not their referrals, n eligibility to invest does not depend on an agreement to refer, n the size of the investment is not based on referrals, and n physicians who do not refer are not required or pressured to

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.

Thank you for your response regards to "Rolling Meadows Community Hospital". John did not act in a fairly manner by not giving the intern the position. Even though John did confess his truly feelings it still ended up being an altercation not only for him but the hospital as well. I agree where you stated "This provide an understanding that just because one doesn’t physically touch or ask for physical contact doesn’t mean you can’t get in trouble for comment." I believe John felt like he could get away with this case just because he was the CEO of the hospital but it obviously does not matter what type of position you hold in a work environment; this should not be tolerated at any work environment.

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.

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

Through the history of health care, the standard of care changed from protecting our patient from injury and illness to a systemic entity to make money for insurance companies. Access to services and clinical outcomes are dependent on what health insurance providers will “pay” for in a clinical or community setting; as a result, patient safety, care and satisfaction has been negatively impacted.

The Roaring Fork Valley Physicians, IPA, Inc., a Corporation adopted the unfair method of competition by determining fixing price agreement for the healthcare services provided by the doctors who are the members of

There had been previous research that displayed that managed care contracting added to physician dissatisfaction and also their administrative expense. It was determined that physicians had the option to choose to contract and also the number of contracts to have. The results of this survey suggested that physicians who contract with more health plans worked more hours and earned more money.

Jones Regional Medical Center is a huge academic health center with 900 beds and are known for its research and teaching hospitals. Additionally, the IT staff at Jones supports 300 applications and 12,000 workstations. The center uses Technology Med (TechMed) for their admitting system. The system includes registration, inpatient charge, payment entry, master patient index, admission, hospital billing, and more. The TechMed system has been accessible since 1998; Jones is beginning to plan a replacement of this systems because of the fragility of the software (Wager, 2013).

In 2014, the North Texas Division (the “Hospitals”) initiated an arbitration against Aetna arising out of approximately $2.7M in alleged underpayments for items billed by the Hospitals as “Other Implants” under Revenue Code 278. The applicable Hospital Services Agreement (“HSA”) required Aetna to pay the Hospitals a specified rate “in addition to other negotiated rates” for items properly billed under Revenue Code 278 (Other Implants). The Hospitals claimed that the HSA required Aetna to use the National Uniform Billing Committee’s (“NUBC”)

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

Although Express Scripts is the nation’s largest pharmacy benefit manager (PBM), CVS Healthcare comes in as second place. From 2010 to 2015 both pharmaceutical benefit managers have increased revenues from year to year. Express Scripts Holding Company comes in as number one because they are the leaders in their industry, with the highest market share. The difference between the two’s market share is a small 1.6%. Due to its retail pharmacies, CVS is able to possess such a high market share – but Express Scripts is able to slide by as the leader in its industry only when pharmaceutical benefit managers count. When searching complaints from Express Scripts and CVS Healthcare, you’ll find that Express Scripts has multiple websites that show thousands