20 May Identify the effect of expanding state Medicaid roles and the impact it has upon cost and non-reimbursable care
There is great controversy over whether a patient will be able to retain or choose his or her doctors with the advent of the PPACA. In addition, many existing plans are being ruled as incompatible with the requirements of the PPACA and discontinued or canceled as a result. Explore and explain whether the patients will be able to continue with their physicians and the rationale behind the plan cancelation. Additionally, identify the effect of expanding state Medicaid roles and the impact it has upon cost and non-reimbursable care.
To support your work, use your course and textbook readings As in all assignments, cite your sources in your work and provide references for the citations in APA format.
respond to 2 classmates on their response to discussion
Your initial posting should be addressed at 300-500 words. Submit your document to this Discussion Area by the due date assigned. Be sure to cite your sources using APA format.
Discussion 5
Rose Cates posted May 14, 2023 5:05 AM
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Patient-Physician Continuity: Analyzing Plan Cancellations and Rationale
According to Brown et al. (2021), the Patient Protection and Affordable Care Act (PPACA), also known as Obamacare, lacks a direct provision mandating patients to switch their medical practitioners. Nonetheless, certain insurance schemes may become incompatible with the edicts of the fresh legislation, inducing insurance firms to terminate or discontinue such policies. As a result, insurance contracts that fail to adhere to the provisions of the PPACA may not offer commensurate benefits and coverage as those that comply with the statute. If a patient's present healthcare provider is not associated with the novel scheme, conformance with the PPACA may require them to switch to an alternative plan, which could force them to change their medical practitioner (Koku, 2020). Ultimately, the decision to retain their doctor hinges on the availability of insurance schemes featuring the patient's preferred medical experts within their network. In other words, patients can only preserve their current physicians if they select an insurance plan that includes their favored healthcare professionals within their network. The discontinuation of incompatible insurance plans represents a concerted attempt to ensure that all Americans have access to high-quality healthcare policies that meet certain minimum standards (Koku, 2020).
The state Medicaid enrollments expansion can have both positive and negative outcomes. It may enhance the availability of healthcare services for low-income individuals and families who otherwise lack the necessary financial means to access such care (Zhang & Zhu, 2021). This could translate into a decrease in the utilization of costly emergency department visits, resulting in an overall reduction in healthcare expenses. Conversely, the expansion of Medicaid may lead to an increase in healthcare costs due to heightened usage of healthcare amenities by recently registered individuals (Zhang and Zhu, 2021). Additionally, healthcare providers often receive lower reimbursement rates for treating Medicaid patients in contrast to those insured by private insurance plans. This may dissuade healthcare providers from accepting Medicaid patients, ultimately reducing healthcare accessibility. In addition, the expansion of Medicaid may have implications for non-reimbursable care, as healthcare providers may feel compelled to prioritize Medicaid patients over those with private insurance who can provide more substantial reimbursement rates (Zhang & Zhu, 2021). The potential outcome of this situation could be prolonged waiting periods and a reduced capacity to obtain non-compensable healthcare services, including discretionary medical procedures or non-urgent surgical interventions.
References
Brown, E. A., White, B. M., Jones, W. J., Gebregziabher, M., & Simpson, K. N. (2021). Measuring the impact of the Affordable Care Act Medicaid expansion on access to primary care using an interrupted time series approach. Health Research Policy and Systems, 19(1), 1-10.
Koku, P. S. (2020). Effect of the Patient Protection and Affordable Care Act on for-profit hospitals in the USA. International Journal of Pharmaceutical and Healthcare Marketing.
Zhang, P., & Zhu, L. (2021). Does the ACA Medicaid Expansion Affect Hospitals’ Financial Performance? Public Finance Review, 49(6), 779-814.
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WEEK 5 DISCUSSINO
Gina Lugo posted May 12, 2023 1:19 PM
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Despite the great controversy of a patient being able to keep their original Doctor due to the PPACA (Patient Protection and Affordable Care Act). Due to many inconsistencies and interrelated requirements. Would they be able to continue with the policy if any cancelations of the policy, and the rationale behind the plan cancelation? Additionally, identify the effect of expanding state Medicaid roles and the impact it has on cost and non-reimbursable care.
First, (n.d.) the right to choose any Doctor whether it be in or out of network is always an option. However, it’s up to the provider in some cases and at their discretion if they choose to see you. So many rights today have been taken away that I’m unsure if today the patient has too many rights left with the ever-changing bills proposed and potentially passing into law. In my opinion with so many barriers to care today, I’m not sure if insurance is worth having really.
Second, (BEUTLER, 2013) anyone can cancel their policy at any time. However, thankfully with the PPACA, the government has grandfathered in many policies to provide those especially the elderly with continuity of care which is important to their well-being. Patients can cancel their plan, not the service that’s ultimately up to the healthcare facility, and the provider at the time of the visit.
Third, (n.d.-b) the link with identifying the effect of expanding state Medicaid roles and expansion is interrelated with the increase to access to care which is a good thing. Also, improvements in healthcare outcomes and the reduction of the minority population that can’t afford or does not have access to health coverage insurance. Typically, policy cancellations have an advisory of thirty days prior. So this gives the patient time to seek a new Primary care doctor if needed for continuity of care purposes. I have answered these questions to the best of my ability.
References
BEUTLER, B. (2013). GOP About to Hurt Itself Again: New Ploy to Kill Obamacare Will Blow Up. Progressive Populist, 19(22), 8.
Doctor Choice & Emergency Room Access. (n.d.-b). HealthCare.gov. https://www.healthcare.gov/health-care-law-protections/doctor-choice-emergency-room-access/
The Affordable Care Act’s New Patient’s Bill of Rights | CMS. (n.d.). https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca-new-patients-bill-of-rights
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Managed Care and Insurance Companies.html
Managed Care and Insurance Companies
True access to patient care is controlled by corporations—namely, managed care organizations and indemnifiers, corporations that conduct business based on profit margins and cost reduction without knowledge of medical practice.
As a result, the healthcare consumer must select from a panel of approved doctors, hospitals, outpatient facilities, allied health professionals, and pharmaceutical programs. If the consumer does not accept these restrictions, they must pay large out-of-pocket expenses.
While we are spending more and more of our income on healthcare products, we continue to give up more and more control over its quality and management. More concerning is the trend of nonmedical personnel making critical day-to-day decisions regarding access to care.
As we wait and see the final outcome of the Affordable Care Act legal challenge, which would move most people into a managed care system, we may give up even more access as new layers of government bureaucracy are put into place.
This last video lecture leads you to a deeper understanding of managed care. This topic is complex and takes many facets in the healthcare systems. Read the following resource for a deeper understanding of this material.
Resource:
Baldor, R. A., & NetLibrary, I. (1998). Managed care made simple (2nd ed.). Malden, Mass: Blackwell Science. Retrieved from: http://web.a.ebscohost.com.southuniversity.libproxy.edmc.edu/ehost/detail/detail?sid=78109f3e-3659-4151-a0a6-2fae3b518578%40sessionmgr4010&vid=0&hid=4104&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=52327&db=nlebk .
Additional Materials
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Managing Access to Patient Care.html
Managing Access to Patient Care
The conceptual and practical role of the patient has evolved over time due to environmental factors such as economics, technology, and sociopolitical pressures. The autonomy of the patient has eroded in the sense that patients are directed to access care rather than having the choice to access the desired health services. Today, physician selection is defined by plan participation, medical services and testing are directed by care protocols, and access to specialty care is regulated by a referral process or precertification.
It is important to understand that research pertaining to patient-physician relationships has proven paramount in the ability to achieve positive health outcomes. The understanding of the process of acceptance, concordance, and adherence is fundamental to a new patient-centered care paradigm defining a new-era of patient-physician relationship.
In today's healthcare environment, the new-era patient is far more dynamic fueled by telehealth and telemedicine. The patient is far more knowledgeable and understanding of health issues. Conversely, the patient's ability to decipher factual, credible information from rhetoric and marketing hyperbole might be challenging and potentially disruptive to the patient-physician relationship.
Managing Healthcare Organizations
The US Department of Labor, Bureau of Labor Statistics, reports that "Employment of medical and health services managers is expected to grow faster than the average for all occupations through 2012 as the health services industry continues to expand and diversify" (2014).
Nevertheless, there is a nationwide concern about the ability of the healthcare leadership to efficiently manage and expand the US healthcare system.
Middle management plays a key role in healthcare organizations. How can middle management help to both improve organizational efficiency and benefit the healthcare industry as a whole?
So far in this unit you have learned about managing access to care, a most important function of the healthcare manager. Next you will lean about managed care companies. Reflect on your experience and how managed care has impacted healthcare. Review the following resources to add to your know edge of the managed care business approach. Review the following resources for a deeper understanding of this material.
Resources:
Berenson, R. A., Sunshine, J. H., Helms, D., & Lawton, E. (2015). Why medicare advantage plans pay hospitals traditional medicare prices. Health Affairs, 34(8), 1289-1295. doi:http://dx.doi.org.southuniversity.libproxy.edmc.edu/10.1377/hlthaff.2014.142
Afendulis CC, Landrum MB, Chernew ME. The Impact of the Affordable Care Act on Medicare Advantage Plan Availability and Enrollment. Health services research. 2012;47(6):2339-2352. doi:10.1111/j.1475-6773.2012.01426.x.
Additional Materials
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media/transcripts/Metrics_Second_Curve_4_13.pdf
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Metrics for the Second Curve of Health Care
April 2013
1 Metrics for the Second Curve of Health Care
Metrics for the Second Curve of Health Care
Resources: For information related to health care delivery transformation, visit www.hpoe.org.
Suggested Citation: Metrics for the Second Curve of Health Care. Health Research & Educational Trust, Chicago: April 2013. Accessed at www.hpoe.org
Contact: [email protected] (877) 243-0027
Accessible at: www.hpoe.org/future-metrics-1to4
© 2013 American Hospital Association. All rights reserved. All materials contained in this publication are available to anyone for download on www.hpoe.org for personal, noncommercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publisher, or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please email [email protected]
2 Metrics for the Second Curve of Health Care
Table of Contents Executive Summary………………………………………………………………………………………………………………………………………..3
Introduction……………………………………………………………………………………………………………………………………………………4
Strategy One: Aligning Hospitals, Physicians and Other Providers Across the Continuum of Care………….8
Strategy Two: Utilizing Evidence-Based Practices to Improve Quality and Patient Safety………………………..10
Strategy Three: Improving Efficiency through Productivity and Financial Management…………………………….12
Strategy Four: Developing Integrated Information Systems……………………………………………………………………….14
Measuring the Six Other Must-Do Strategies……………………………………………………………………………………………..16
Conclusion……………………………………………………………………………………………………………………………………………………17
Endnotes……………………………………………………………………………………………………………………………………………………….18
Table of Contents
3 Metrics for the Second Curve of Health Care
Executive Summary In 2011, the AHA Board Committee on Performance Improvement (CPI) identified ten must-do strategies for the hospital field to implement in order to survive and thrive in the transforming health care system. These strategies were identified in the groundbreaking report, Hospitals and Care Systems of the Future, found at http://www.aha.org/about/org/hospitals-care-systems-future.shtml.
Building off of health care futurist Ian Morrison’s first curve to second curve shift, CPI identified characteristics of the first curve (the volume-based curve) and the second curve (the value-based curve). Of the ten must-do strategies, four were identified as major priorities for health care leaders. “Metrics for the Second Curve of Health Care” expands on those strategies, focusing on the four imperative strategies:
1. Aligning hospitals, physicians and other clinical providers across the continuum of care 2. Utilizing evidence-based practices to improve quality and patient safety 3. Improving efficiency through productivity and financial management 4. Developing integrated information systems
In addition, there is another report hospitals and health care systems can use to self-assess and provide a road map on the first curve to second curve transition at http://www.hpoe.org/future-roadmap-1to4.
Table 1: Second Curve Evaluation Metrics (applicable to the hospital or the health care system)
Strategy One: Aligning Hospitals, Physicians and Other Clinical Providers Across the Continuum of Care
Percentage of aligned and engaged physicians Percentage of physician and other clinical provider contracts containing performance and efficiency incentives aligned with ACO-type incentives Availability of non-acute services Distribution of shared savings/performance bonuses/gains to aligned physicians and clinicians Number of covered lives accountable for population health (e.g., ACO/patient-centered medical homes) Percentage of clinicians in leadership
Strategy Two: Utilizing Evidence-Based Practices to Improve Quality and Patient Safety Effective measurement and management of care transitions Management of utilization variation Reducing preventable admissions, readmissions, ED visits, complications and mortality Active patient engagement in design and improvement
Strategy Three: Improving Efficiency through Productivity and Financial Management Expense-per-episode of care Shared savings, financial gains or risk-bearing arrangements from performance-based contracts Targeted cost-reduction and risk-management goals Management to Medicare payment levels
Strategy Four: Developing Integrated Information Systems Integrated data warehouse Lag time between analysis and availability of results Understanding of population disease patterns Use of electronic health information across the continuum of care and community Real-time information exchange
Source: AHA, 2013.
Executive Summary
4 Metrics for the Second Curve of Health Care
Introduction Hospitals and health care systems face common challenges in transitioning to a health care delivery system characterized by value-based payment focused on outcomes, population health management and a patient-centered, coordinated care-delivery approach. As hospitals and health care systems shift from the volume-based first curve to the value-based second curve, they must transform their business and health care delivery models to balance quality, cost, patient preferences and health status to achieve real value and outcomes.1 Hospitals and health care systems that are moving to the second curve use performance metrics to identify clinical, financial, cultural and process improvements; incorporate appropriate incentives; and evaluate results. The AHA Hospitals and Care Systems of the Future report from 2011 (found at http://www.aha.org/about/org/hospitals-care-systems-future.shtml) outlined 10 must-do strategies, with four high-priority strategies required to be successful in the transformation from the first curve to the second curve.
Figure 1: First Curve to Second Curve
Source: Adapted from Ian Morrison, 2011.
This guide builds on the first report further detailing each of the four high-priority strategies and creating specific metrics to evaluate progress toward the next generation of essential hospital management competencies. Table 2 outlines the second curve evaluation metrics for the four high-priority strategies. The four high-priority strategies detailed in this report (bolded) and the addi- tional six must-do strategies are:
1. Aligning hospitals, physicians and other clinical providers across the continuum of care
2. Utilizing evidence-based practices to improve quality and patient safety 3. Improving efficiency through productivity and financial management 4. Developing integrated information systems 5. Joining and growing integrated provider networks and care systems 6. Educating and engaging employees and physicians to create leaders 7. Strengthening finances to facilitate reinvestment and innovation 8. Partnering with payers 9. Advancing an organization through scenario-based strategic, financial and operational
planning 10. Seeking population health improvement through pursuit of the “Triple Aim”
Introduction
5 Metrics for the Second Curve of Health Care
Table 2: Second Curve Evaluation Metrics (applicable to the hospital or the health care system)
Strategy One: Aligning Hospitals, Physicians and Other Clinical Providers Across the Continuum of Care
Percentage of aligned and engaged physicians All affiliated physicians are aligned across all dimensions (structural relationships, financial interdependence, culture, strategic collaboration). All affiliated and employed physicians are engaged, collaborative and participative in all major strategic initiatives. Physician engagement survey data has been analyzed and improvement actions have been implemented with positive results. Recruiting and contracting include an assessment of cultural fit as well as a formalized “compact” or code of conduct with mutually agreed on behaviors, values and mission for all physicians. Percentage of physician and other clinical provider contracts containing performance and efficiency incentives aligned with ACO-type incentives Significant level of reimbursement risk associated with new payment models (bundled payments, two-sided shared savings with both upside and downside risk, or capitation payments). Participating in an ACO or PCMH model across a significant population, utilizing value-based incentives. All payment contracts, payment and compensation models are linked to performance results. Availability of non-acute services Full spectrum of ownership, partnership or affiliation of health care services available to patients. Distribution of shared savings/performance bonuses/gains to aligned physicians and clinicians All clinicians’ performance is measured and they receive benchmark data on performance against peers. Most clinicians share financial risk and rewards linked to performance, and many have received distributions of shared savings or performance bonuses. Number of covered lives accountable for population health (e.g., ACO/patient-centered medical homes) Active participation in a population health management initiative (e.g., chronic disease management, prevention) for a defined population. Able to measure the attributable population for health management initiatives and a sizable population is enrolled. Percentage of clinicians in leadership Active clinical representation at the leadership or governance level (30 percent or above). Physicians and nurse executives are leading development of strategic transformation initiatives.
Strategy Two: Utilizing Evidence-Based Practices to Improve Quality and Patient Safety Effective measurement and management of care transitions Fully implemented clinical integration strategy across the entire continuum of care to ensure seamless transitions and clear handoffs. Fully implemented use of multidisciplinary teams, case managers, health coaches and nurse care coordinators for chronic disease cases and follow-up care after transitions. Measurement of all care transition data elements. Data is used to implement and evaluate interventions that improve transitions. Management of utilization variation Regular measurement and analysis of utilization variances, steps employed to address variation and intervention effectiveness analyzed on a regular basis. Providing completely transparent, physician-specific reports on utilization variation. Regular use of evidence-based care pathways and/or standardized clinical protocols on a systemwide basis for at least 60 percent of patients.
Introduction
6 Metrics for the Second Curve of Health Care
Reducing preventable admissions, readmissions, ED visits, complications and mortality Regular tracking and reporting on all relevant patient safety and quality measures. Data commonly used to improve patient safety and quality, with positive results observed. Active patient engagement in design and improvement Regular use of patient-engagement strategies such as shared decision-making aids, shift-change reports at the bedside, patient and family advisory councils and health and wellness programs. Regular measurement or reporting on patient and family engagement, with positive results.
Strategy Three: Improving Efficiency through Productivity and Financial Management Expense-per-episode of care Tracking expense-per-episode data across every care setting and a broad range of episodes to understand the true cost of care for each episode of care. Shared savings, financial gains or risk-bearing arrangements from performance-based contracts Measuring, managing, modeling and predicting risk using a broad set of historical data across multiple data sources (e.g., clinical and cost metrics, acute and non-acute settings). Implementing a financial risk-bearing arrangement for a specific population (either as a payer or in partnership with a payer). Targeted cost-reduction and risk-management goals Implemented targeted cost-reduction or risk-management goals for the organization. Instituted process re-engineering and/or continuous quality-improvement initiatives broadly across the organization and demonstrated measurable results. Management to Medicare payment levels Projected financial impact of managing to future Medicare payment levels for the entire organization; cost cuts to successfully manage at that payment level for all patients.
Strategy Four: Developing Integrated Information Systems Integra
