The Health Care System Within The United States

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)

H. (04/2015). Comprehensive Health Insurance: Billing, Coding & Reimbursement, VitalSource for Allen School of Health Sciences, 1st Edition. [Bookshelf Online]. Retrieved from https://online.vitalsource.com/#/books/9781323131503/

Accountable Care Organizations – “ ‘National Pilot Program On Payment Bundling’ - The Secretary shall establish a pilot program for integrated care during an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health

The goal of the initiative is to increase efficiency of care, improve quality of care, and lower costs. This initiative consists of four different bundled payment models. The first three bundled payment models are retrospective payment arrangements based on patients’ historical data. However, the fourth model is proposed for the future. Centers for Medicare & Medicaid Services (CMS) make a single bundled payment to the hospital for all services during inpatient stays for hospitals, physicians, and other medical professional specialists.

The aim of this paper is to provide a brief description of the bundle payment initiative will be addressed in relationship to the Affordable Care Act (ACA). Additional focuses will be placed on comparisons of the bundle strategy with traditional Medicare fee-for-service (FFS) payments. The purpose of the analysis is to implement and design a bundle payment program for community acquired pneumonia (CAP) patients utilizing the bundle program. The analysis will address health care providers and service vendors needed to successfully implement the program. Additionally, AONE nurse executive competencies will be discussed in relation to skills needed by nurse leaders in collaboration with the programs implementation.

CMS has launched many new bundled payment plans which extend the hospital’s responsibility for care and cost outside of the inpatient stay itself. However, hospitals have been reluctant to sign on for down-side risk. They are risk-averse due to their lack of experience, knowledge, and capabilities that would enable them to successfully own the cost of their population, and this is a gap that Medtronic can address.

Bundled payments create financial incentives for providers and benefits patients. Providers will be influenced to coordinate care for the entire service provided, pre-operation, during, and post-operation. This program will benefit the patients in eliminating costs that do not benefit them or relate to their care. For example, patients can be directed to use home care as opposed to institutional care if suitable.

The United States health care system is problematic. On average the U.S. has 440,000 deaths a year from care in hospitals due to accidents and hospital acquired infections; harming patients and the pocket books of families and insurance companies with unnecessary cost and procedures (Allen). With the Affordable Care Act (ACA) the government is hoping to decrease these unnecessary cost; cutting down on medication administration, providing more preventive care, and merging many different healthcare members’ jobs into one position in order to cut cost on staff. There has been great strives with the new reform of health care, but there has also been downfalls and uncertainty. Preventive care has come to the forefront; this will help save patients and money for all those in the market for healthcare, so everyone. While preventive care is great, it is leaving many health care members are questioning what is next for them. The ACA is moving into the general public, but with immunizations already being taken over by drug stores, people are worried about the stability of job opportunities outside the hospital. As a nursing student myself I have concern of what the job market will be when I graduate; because when I started it was in high demand and now many student are struggling to find jobs. Therefore, I have concerns with the ACA and that some provisions will need to be reevaluated.

These new models aim to transform traditional fee-for-service (FFS) payments that reward episodic care into models that reward the delivery of comprehensive primary care (Edwards et al., 2014). The Belvoir Primary Clinic will seek to take advantage of all potential reimbursement methods such as the Enhanced Fee-for-service (EFFS) model which will allow the clinic to receive augmented payments due to its PCMH status (Edwards et al., 2014). The practice can also qualify for additional payments by using PCMH specific codes to bill for non-visit related care such as care coordination and transition support (Edwards et al., 2014; Gray & Aronvich, 2016). Furthermore, the practice can also receive incentives through value-based and pay-for-performance (P4P) programs by meeting performance measures and utilization goals (Edwards et al., 2014).

The U.S. health care system faces challenges and it is urgent that the American people become aware of these challenges. There are approximately 46 million Americans who are uninsured, and many insured Americans who face rapid increases in premiums have to pay out-of-pocket costs. As Congress and the Obama administration consider ways to invest new funds to reduce the number of Americans without insurance coverage, people must address shortfalls in the quality and efficiency of care that lead to higher costs and to poor health outcomes. If something is not done soon, there will be many more who will not have health care coverage that is affordable or they will be without coverage altogether.

These payments include cost and markups for the services provided, and are used in conjunction with per case constraints (Murray, 2009). Revenue constraints, such as case constraints allow the system to control hospital revenue through control encounter utilization, adjust for case-mix, and align incentives across payers and hospitals (Murray, 2009). Annual adjustments for inflation and uncompensated care markups ensure the systems’ ability to equalize the markup for

Bundled Pricing: As quoted by Zezza, Guterman and Smith in 2012, “In this type of payment system, a single payment is made for an episode of care—a defined set of services delivered by designated providers in specified health care settings, usually delivered within a certain period of time, related to treating a patient’s medical condition or performing a major surgical procedure.” Encouraging the physicians, hospitals to work together and coordinate the care of patients, to decrease re-hospitalizations, to improve the transition of care and to ensure proper care delivery after discharge is the ultimate goal of this payment plan (Zezza et. al., 2012).

here are many benefits to bundled payments, however, there are some possible drawbacks to this payment approach that should be considered. According to Blumenthal and Squires (2016) there are four major drawbacks of bundle payments. The first one is that it's difficult to define what type of care should be included in these payments, especially in patients with mutlple chronic illnesses that interact with each other. These type of circumstances require fair observation which, increases administrative cost. Secondly, it encourages providers to look at patients as single diseases and disregards responsiblity for the cost and care of other illnesses. Next, bundle payments may encourage competiiton in regards to which patients have more profitable

Bundled payment facilitates prospective budgeting, encourages care providers to adopt team-based management, and increases the uptake of innovative strategies in chronic disease diagnosis and management. Funding from Medicaid for certain programs has also encouraged team-based care in the primary care setting. The limited availability of internet and use of sophisticated gadgets in rural communities influence the amount/quantity of innovative services provided in these

These approaches give the patient a broad choice of providers and some financial incentive – in the form of lower cost-sharing – to seek care from a provider participating in the bundled payment program. However, to create enough “steerage” to these providers, the incentives will have to be significant; providers may think twice about participating in bundled payment if patients still have a broad choice of providers.