Small Area Studies Based On Large Medicare Databases

Looking forward, another interesting option for Canada would be the Group-based profit sharing programs. However their applicability in the short to medium term is unlikely because profit-sharing programs allow hospitals to provide bonuses to physicians based on hospital savings created when physicians coordinate their use of drugs and devices (quantity and market share discounts). That is, the more that a hospital purchases of a particular drug or device from a particular vendor/manufacturer, the more they benefit from quantity and market share discounts. Therefore, adding profit sharing programs to the current FFS system may provide a powerful way to align physician incentives with those of the hospital and of policy-makers. However, little is known about the effect of these programs on patient outcomes, as current regulation in Canada does not allow hospitals to pay physicians in such a manner. (1,2)

These proposals often focus on using hospital DSH payments to expand coverage rather than using these sums to make payments to hospitals, using savings from reductions in other programs, or proposing new revenues (Holahan et al., 1995). The goal is to expand coverage at small new costs to the government (Holahan et al., 1995). The key features of

The advantage of VBPS program is that it promotes and reimburses for all treatments that are planned to help to bring better health outcomes for Medicare patients. This program also plays a part in reducing the rate of unnecessary tests and referrals that are unrelated to treating of patients’ conditions. The program gives incentive rewards to healthcare facilities that are successful in reporting the high quality of cares and better patients’ health outcomes. It also serves as supports and guidelines for healthcare facilities to build needed infrastructures to improve their quality of services (Minemyer, 2016).

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).

What is your opinion of detecting small variations via HIT Medicare databases? How can CMS maintain regulatory cost control to manage these outliers?

Overall, there are still inequalities on the spending of the same condition between different regions. For example, mammograms, which were used to measure effective care, were done by 21 to 77% of individuals. The authors suggested to improve the quality of care through a series of goals that the Medicare program should complete. Through these guidelines and goals, the Medicare program would be restructured to make high quality health care to all Medicare enrollees and to reduce the costs of Medicare.

Constance, evidenced based practice (EBP) and quality are important and they are becoming a focus of healthcare payment models that reward for better quality and outcomes. With the repeal of the Sustainable Growth Rate (SGR) legislature and the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the United States has changed the rules around what determines how much health care providers are paid for services. Starting in 2019, providers including physicians and advanced practice nurses (APNs), will receive payments that are adjusted by the cost associated with, and the quality outcomes of the care provided to their patients for services rendered during 2017 (MACRA, 2015). It is important that all care providers

For anyone who has kept up with the news, the US healthcare system has undergone major changes in recent years. Insurance providers are no longer able to deny someone coverage based on pre-existing conditions. The advent of healthcare marketplaces has changed the way people purchase health insurance. Children can stay on their parents' health insurance plans until 26. Leading the healthcare revolution is InnovaCare Health. This organization is a leading provider of Medicaid and Medicare Advantage plans. InnovaCare Health recently announced it would partner with the Health Care Payment Learning and Action Network. This is a significant private-public partnership that seeks to change compensation models to reflect the quality of care instead of quantity. This new partnership reflects InnovaCare Health's to affect change in compensation sooner rather than later. The current healthcare model focuses on reimbursing physicians based on the number of patients seen or procedures performed. This encourages "treadmill medicine," or a model that focuses on rapid turnover. This can often lead to detrimental effects on patient health. The new quality model would reward physicians based on practice targets. Potential goals include HbA1c goals for patients with diabetes, the percentage of patients who smoke, and hospital stay after surgical procedures.

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

The concept is built on trade-offs meaning that one aspect cannot be affected without affecting the other two. The most common view of this problem is that each aspect is in direct competition with the others. Analyzing Medicare in relation to The Iron Triangle, consumers who participate in the healthcare system through Medicare must still pay deductibles, fees and other costs not covered by the program. Additionally, enrollees who choose non-hospital coverage or Part B will have to pay a premium. In 1993, up to 11% of Medicare participants were also enrolled in Medicaid programs which pay expenses for the poor who may qualify for the benefits. Approximately 75% of Medicare enrollees have some form of health insurance coverage (Gok & Rubin p.1520). Younger participants don’t seem to fare as well within Medicare since the program focuses predominantly on people 65 and over. Too often, the role that Medicare plays in the younger population with disabilities is overlooked. A Kaiser Family Foundation survey drawn from administrative data provided by Centers for Medicare and Medicaid Services (CMS) found that non-elderly disabled beneficiaries reported problems with healthcare access and cost. Opinions have varied on the success and failures of Medicare in relation to overall access and cost. “According to (CMM) Centers for Medicare and Medicaid Services, total healthcare expenditures exceeded $2.1 trillion or more than $7000 for every American man, woman, and child” (Kuttner p.549). Total healthcare spending in 2006 was 16% of the GDP and was projected to reach 20% by 2013. The phenomenon known as “medical inflation” is believed to have contributed to rising costs of healthcare. An aging population, technology advancement, litigation, defensive medicine and insurance coverage that favors high taxes. The most common

A strength of medicare is that it provides coverage to millions of people whom cannot afford insurance. Additionally, Medicaid expansion allowed more individuals to receive coverage. However, due to the U.S. Supreme Court ruling that, “States cannot be forced to expand their Medicaid coverage,” only 29 states have chosen to participate in the expansion (Patel & Rushefsky, 2014, p.88). As a result, residents of non-participating states are not eligible for medicaid nor tax credits to purchase insurance in the private market (Medicaid, 2015). There are approximately four-million people that fall into this category (Medicaid, 2015). Because Medicaid expansion is optional, states like Oregon choose to “stop financing most organ transplants for Medicaid patients and to use the money instead for prenatal care for pregnant women” (Patel & Rushefsky, 2014, p.104). In my opinion, failure to have a nationwide standard for this program is a great

In recent years, emphasis has been placed on improving the quality of health care services and the overall patient experience. Innovative measures are needed to meet these expectations, while also containing the rising costs of health care. The government has enacted new laws in attempts to provide incentives that base Medicare payments in part on quality. In fact, the Patient Protection and Affordable Care Act of 2010, requires the implementation of value-based purchasing (VBP), which bases Medicare reimbursement rates on the quality of care (Kennedy, Wetzel & Wright, 2013). Hospitals may experience a decrease in revenue initially, however, it is theorized that the increase of transparency and accountability will serve as an incentive for improvements in the overall quality of care provided in the United States.

The real problem as pertains to the reimbursement of managed care organizations is that these managed care has had an effect on slowing the rates of growth concerning the costs of hospitals and specialist physicians. For both the hospitals and practitioners, the sources of revenue have been shifted with over 20 percent of the charges being paid from the pocket, others coming from third parties who demand for complex accounting of the charges, lack a pre-authorization process and they can review in a retrospective manner and deny the reimbursement (Furrow et al., 2013). The

One of the major goals of the ACA is to improve quality of care by using a value-based system. Nationwide, nearly 3,500 short-term acute-care hospitals are reimbursed under the Inpatient Prospective Payment System (IPPS). Within the IPPS is the Hospital Value-Based Purchasing Program is (VBP). This program “rewards acute care

The imposed cuts to Medicare’s fees schedule for physicians, known as Medicare Sustainable Growth Rate (SGR) formula, were permanently ended as part of new legislation called the Medicare Access and CHIP Reauthorization Act of 201, aka the “doc fix” bill, was signed on April 16, 2015. The new bill would replace the current reimbursement schedule with a five year plan to provide automatic pay increases to physicians. The focus of the new payment system is value, accountability and quality and would become a Merit-Based Payment Incentive System (MIPS). A physician’s assessment for reimbursement would be based on four core metrics; quality, clinical practice improvements, resource use, and meaningful use of EHR. The lowest performing physicians would have their reimbursements cut by nine percent. (Wynne, 2015)