The health care delivery system of U.S. reformed in order to improve on their quality and value of care. By so doing, they managed to address issues related to escalating costs, poor quality, and the increasing numbers of American people without health insurance coverage. As such, targeting treatment is viewed as an initiative promoting quality and value as it targets specific patient populations and clinical areas. Hence, cost is contained using such second-curve business models. The change in reimbursement structure helps incentivize hospitals and clinicians through providing quality care. As such, value-based payment methodology is implemented in an attempt to rewards quality through incentives and transparency. Having such payment reforms that include pay-for-performance, value-based purchasing, bundled payments, capitation and others align incentives in providing care that is timely, necessary, cost-effective, and appropriate. The Affordable Care Act (ACA) is an acceleration of value-based payment programs that helps in the application of VBP to both Medicare and Medicaid structures of reimbursement. Moreover, funding is also provided that supports research work in the private sector that is related to VBP (Joshi et al., 2016, pp. 6-7).
The ACA is an expansion of health insurance coverage that was signed into law by President Obama in 2010. Medicare and Medicaid were created in 1965 and the ACA is an expansion initiative that looked into two mechanisms: (1) states are provided with an option to expand on their Medicaid to all their individuals who are under the 138% poverty line and (2) supporting the creation and implementation of insurance exchanges of federal- or state-based health ( Joshi, Erb, Zhang & Sikka, 2016, p. 8 ). Under the ACA, there are numerous provisions promoting a shift towards value-based reimbursement; the creation of new care models such as accountable care organizations and patient-centered medical homes; and funding that tests new strategies geared towards improving quality, reducing costs and improving patient’s experience of care (Joshi et al., 2016).
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The initiative is a model for improvement that has been embraced by many organizations such as the IHI because the questions established by the program help guide teams in establishing measurable and time-specific aims. In addition, the improvement teams will be able to define the impacts laid on their patient population, progress is monitored using established quantitative measures, and change concepts are implemented to bring about evidence-based results. Plan-Do-Study-Act (PDSA) is an example of a framework that helps in the planning and execution of efforts geared towards performance improvement in the health care organization.
The existing initiative also looks at accommodating lean thinking methodology to help the health care organization create and deliver to their customers more value. At the same time, be efficient by consuming fewer resources and fully utilizing the knowledge and skills of their employees. The lean methodology has principles if applied help the health care system reach their organizational ideal (Chapter 6). In the end, lean comprises of a management system, a tool set, a method for continuous improvement, and an employee engagement philosophy. Through lean, waste is reduced and this translates down to reducing the efficiency gap.
The development of the ACA was done by President Obama in 2010. This was due to the rising costs associated to health care and was passed into law to necessitate the accommodation of health care needs of people from low-income families including the aging population. In essence, ACA meets the minimum essential coverage requirements and gives an employer control of their plan in terms of it offering to meet affordability threshold. The ACA has managed to create three safe harbors for its members and this as incorporated the health needs of many people in America.
Medicare Prescription Drug Coverage is the part of Medicare designed to lower prescription costs of medication for beneficiaries of the program. The coverage gap is known as “doughnut hole” meant for individuals not covered under the dual-eligible status (Chapter 5). Activities such as answering patient emails or calls, implementing systems that coordinate care in an attempt to avoid duplication or inappropriate services, lifestyle changes, spending more time with complex patients to improve medication adherence, among other care management steps. In conjunction with using quality measures, Medicaid and Medicare have managed to undertake a range of payment reforms that provide better support of stated activities in the organization.
The existing initiative is not meeting its intended purpose because the ACA leaves substantial numbers of Americans without access to insurance. As such, their intended goal of universal health coverage has not been met fully. Evidence shows that more people are moving to high-deductible health insurance policies as they are affordable and are found under the Affordable Care Act. By high deductibles, health insurance profession assert that healthcare spending is under control. The ACA was intended to bring to the population a relatively low deductible and low co-pay health insurance policy to enable cover majority of their expenses. The out-of-pocket is a hefty amount that has resulted in very high-deductible policies ( Goldsteen, Goldsteen, & Goldsteen, 2016 ). Such issues have sparked concern with regard to the sustainability of the current insurance ecosystem. For patients, the ACA is a positive development, but for payers it presents a problem because they are not allowed to charge higher premium for their patients especially those with medical conditions. Moreover, those with complex needs are not charged higher premium and for companies, loses are incurred because they pay for the care of their employees. It is important for solutions to be minimized that look into such financial problems.
References
Chapter 5: Financing the health care system.
Chapter 6: Health care system performance.
Goldsteen, R. L., Goldsteen, K., & Goldsteen, B. Z. (2016). Jonas’ introduction to the U.S.
health care system (8th ed.). New York, NY: Springer Publishing Company.
Joshi, M., Erb, N., Zhang, S., & Sikka, R. (2016). Leading health care transformation: A primer
for clinical leaders. Boca Raton, FL: CRC Press.
