Category: Medicine
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Provision and Reimbursement of Health Care Services


Innovations and improvements in the health care sector are not only about inventing new technologies and methods but also the development of payment methods. Accountable care organizations were introduced together with the affordable care act. The two networks involve medical practitioners that agree to Medicare patients. ACOs receive financial rewards for reducing health care costs while improving the quality of care. This is in addition to the customary fee for service repayment from Medicare.

Bundled Payment Structure versus Fee for Service Payments

The bundled payment structure is a method that repays a health care provider or a health organization for a given period of care provided under one reimbursement. This is different from the popular fee-for-service method where a health care provider is reimbursed for every service provided. The bundled payment method has enabled health organizations to move from reimbursement methods that are not value-oriented to value-based processes. The bundled payment structure emphasizes high-quality service and is result-oriented (Cutler & McClellan, 2001). On the other hand, the fee-for-service structure emphasizes the number of treatments and tests performed.

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Although the payment structure dominates the health care reimbursement system, it has not yet succeeded in completely replacing fees for service. Moreover, the bundled payment system may not be applicable everywhere since some communities are unable to create the necessary infrastructure to facilitate it. Research has shown that health care providers who are reimbursed under the bundled payment structure utilize fewer care services. Practitioners under bundled payments used considerably fewer health care services than those under fee-for-service payments. Research also suggests that bundled payment has led to a significant decrease in hospitalization (Hillman, Pauly & Kerstein, 1989). Other researchers have found that providers operating under bundled payments were less likely to carry out cataract extractions. Shafrin (2009) found that the rates of outpatient surgery among providers under fee-for-service payments were greater than those under bundled payments. According to Chernew, Mechanic, Landon & Safran (2011), the amount of money spent on drugs reduced significantly after the implementation of the bundled payment structure.

Medicare Advantage Plans

Medicare Advantage plans are a type of Medicare health plan that is provided by private companies with the approval of Medicare. They are also referred to as part C or MA plans." Special needs plans, private fee-for-service plans, Medicare medical savings account plans, preferred provider organizations, and health maintenance organizations are all part of Medicare Advantage plans. Prescription drug coverage is commonly offered by a majority of Medicare benefits plans (Shafrin, 2009).

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Individuals who can join the Medicare benefits program must meet certain conditions. First, they must live in the service location of the program they wish to enter. Secondly, they must have Medicare part A and part B. Finally, they should not be suffering from end-stage renal disease. People, who have end-stage renal disease, can receive their health care through original Medicare. Medicare part A is the hospital insurance, and Medicare part B is the medical insurance coverage. Medicare Advantage plans cover the entire Medicare services.

Population Health Management Strategies

Population health management involves the organization and management strategies of the systems of health care delivery. It makes the health care delivery system more effective clinically and in terms of costs and safety. Population health management, therefore, is the practical implementation of strategies and involvement of health care providers to particular groups of persons across the scale of health care in an attempt to advance the health status of the people at the lowest possible costs (Lynch, Forman, Graff, et al., 2000).

Many challenges have been encountered in the implementation of the Population health management system. The improper collection and usage of information are what have made it difficult to tackle population health management. The current reform period of pay for value has made it difficult for healthcare organizations to handle the large quantities of information that are necessary for the system to succeed. Although the electronic health records in various health organizations provide the raw clinical data, ways to access and use the information have proven difficult to understand.

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Three important schemes are required for the effective implementation of population health management. They include the content system, the deployment system, and the measurement system. These three methods are needed to improve and sustain systemic population health. If one of the three systems is weak or nonfunctional, the result produced will be substandard.

Identified Health Care Trends Already Impacting Organization

Cost-saving versus quality care is one of the emerging trends affecting organizations. Health care providers will be required to reduce the cost of treatment while improving the quality of health. Health care providers are taking health care providers outside the hospitals; more care is shifting to outpatient as opposed to inpatient. There is also increased consumer participation as opposed to the old times; more people are becoming more educated and accountable to themselves. There is also a shift in medical provisions and delivery of the health care system to patient locations. The bundled payment structure is a new trend that is already affecting my organization. Although the adoption of this payment system is slow, it has more advantages than the traditional payment system. This new payment system has proven to be effective in improving the quality of health provision while lowering the cost of treatment. Physicians under this payment system manage the hospital resources and reduce the misuse of medical services. For the bundled payment system to be efficient, a reduction in costs and the rates of spending should be realized. The issues associated with spending growth, for instance, development and installment of modern medical technology are different from the issues that result in high spending e.g. overuse of health care services (Chernew, Mechanic, Landon, et al., 2011).

Emerging Trends With Positive and Negative Impacts

The new payment structure has negatively impacted my role as the group of physicians who perform a particular procedure share payments. Unlike in the former fee for service arrangement where an individual was paid for the number of services one provided for patients. Therefore, the wages are less than before. The medical advantage plan has had a positive impact on the health care system because it provides health care coverage for patients whose medical fees are much higher than they can afford. The population health management strategies have both, negative and positive impacts. The positive effect is that it has enabled health care providers to improve the health status of many people (Cutler & McClellan, 2001). The negative effect is on my personal role since most providers lack the necessary skill to extract information using the technology of electronic health care records.

How the Trends Will Impact Safety, Risk Management, and Quality Improvement Policies

Bundled payment system, enables health care providers to improve the quality of care they provide for the patients because their wages no longer depend on the number of procedures they perform. Population health management enables the health practitioners to prevent exposure of populations to risks that will predispose them to diseases (Lynch, Forman, Graff, et al., 2000). Therefore, this has had a positive impact because the health status and safety of the individuals in various populations are enhanced. The Medicare Advantage plans improve the safety and reduce the risks of patients because the insurance caters to all their medical bills hence they can receive prompt treatment when they need it.

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Improvements in the healthcare sector are not only about inventing new and improved techniques to treat patients and handle healthcare problems. It is about introducing positive changes in the entire system, for instance, the payment structures, the health insurance cover, and the disease prevention techniques. These new systems have come with many challenges, for example, adequate knowledge is required to implement successfully them. Restructuring the healthcare delivery system will affect the working environment.

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