How Healthcare Is Purchased and Funded Through the Insurance Model

Describe how healthcare is purchased and funded through the insurance model. 

  Healthcare providers are usually paid, not by the patients, but by private or government health insurance. The providers of medical services do not receive direct payments from patients. Instead, patients pay money to their preferred insurers in the form of premiums (private companies) or taxes (the government) (Fredrickson, 2020). The insurers then use this money for the compensation of the providers who then provide medical services to patients. 

Describe the types of reimbursement in the healthcare market and provide an example of each. 

  There are three main types of reimbursement in the healthcare market. The first type of payment is Fee for Service (FFS) or 'volume-based' reimbursements in which the revenue of a physician is entirely based on the procedures they conduct. For example, 20-minute office consults and metabolic panels have different prices linked to them. The second type of capitation, which is a form of payment providers receives to cover all services for a particular population over a specific period. For example, a doctor’s office has 150 patients, and they get paid 30 dollars a month per patient for all costs associated with those patients. 

Bundled payments are the payment of healthcare providers based on expected costs for episodes of care that are clinically defined (Fredrickson, 2020). For example, if hip replacements are 22,000 dollars, then a provider will receive 22,000 dollars for each replacement, despite the specifics involved in every individual surgery. Lastly, value-based reimbursement consists of the payment of healthcare providers based on the quality of healthcare provided and not the number of procedures conducted. 

How does Value-Based Purchasing impact the revenue for healthcare organizations? What is the advantage to Value-Based Purchasing for the provider, the payer, and the patient? 

By improving patient outcomes, the value-based purchasing model has been found to enhance the revenue of these organizations. This is by increasing the payments received by providers and the patients willing to visit the healthcare organizations (Cms.gov, 2020). For providers, the model helps in the reduction of medical errors while patients receive higher quality care while being more informed of proactive measures to enhance their health. Due to the proactive approach associated with this model, payers benefit from reduced costs. 

Healthcare organizations must establish pricing to remain competitive in the market. What information must healthcare leaders use to set costs for services?  Is pricing directly relate to reimbursement? 

To set costs for services, healthcare leaders have to consider costs associated with labor, the costs of employed physicians, the unintended costs of new technology, the cost burden of risk, and reimbursement. Pricing is directly related to reimbursement as the payment plans of a patient determine the healthcare procedures that they can access. 

References 

Cms.gov. (2020).  CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2019 | CMS . [online] Available at: https://www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2019 

Fredrickson, J. (2020). Billing and Review Perspectives in Healthcare. In  Theory and Practice of Business Intelligence in Healthcare  (pp. 18-67). IGI Global. 

Module Four Discussion 

Consider the role of the physician/NP as agent for the patient. How should they best use their power of their knowledge to benefit the patient.  If providers induce patients to receive certain care, how to they assure the inducement is positive for the patient. 

Physicians have the training to diagnose medical issues and make recommendations for treatment. Hence, they use the knowledge they have for the interpretation of clinical evidence and identifying proper treatment ( The patient- and caregiver-centered experience of care/care coordination domain scores, 2020) . Physicians ensure that inducement is positive for the patient through the assessment of whether the patient possesses the information they require about the effectiveness of healthcare choices. 

Consider the pay for performance methods and metrics for healthcare organizations. Have they had a positive impact to improve quality and reduce the cost of care?  How can providers be similarly incentivized to improve healthcare. 

Pay for performance methods have had a positive impact on the quality and costs of care through the improvement of patient outcomes (Linking quality to payment, 2020). Providers can be similarly incentivized by creating a direct link between quality and pricing. This way, providers will be motivated to emphasize the provision of high-quality care. 

Consider the challenges in the healthcare workforce for primary care providers. You are a healthcare leader who must secure primary care providers for a community ambulatory service.  What tactics will you consider to recruit the required primary care providers? 

To recruit the required primary care providers, one strategy I would use was the provision of a detailed idea of the service to ensure that the values of the provider align with the service (2020). The second tactic would be offering benefits as part of the compensation package. This would act as an incentive for potential providers. 

References 

Linking quality to payment. (2020). Retrieved 31 January 2020, from https://www.medicare.gov/hospitalcompare/linking-quality-to-payment.html 

The patient- and caregiver-centered experience of care/care coordination domain scores. (2020). Retrieved 31 January 2020, from https://www.medicare.gov/HospitalCompare/Data/patient-and-caregiver-centered-experience-of-care-care-coordination-domain-scores.html 

(2020). Retrieved 31 January 2020, from https://www.qualityreportingcenter.com/globalassets/iqr_resources/11_vbp_fy2019_ppsrrelease_scoring_qrg_vfinal508.pdf 

Module Five Discussion 

Describe the goals of the Triple Aim. Provide examples of methodologies designed to implement the goals of the Triple Aim. 

There are three goals to the triple aim framework; enhance the satisfaction of patients with care provided, the improvement of the health of communities, and the reduction of costs associated with healthcare ( The IHI Triple Aim | IHI - Institute for Healthcare Improvement, 2020) . An example of a method used to implement the triple aim goals is the value-based payment goals. 

Describe the aspects of the Patient Protection and Affordable Care Act that have worked to improve quality, decrease cost of care. (answer) 

The act increases the support for Medicare through the expansion of benefits associated with prescription drugs. Another aspect is the business tax credits, where small businesses are provided with the capability of providing employees with health insurance through the use of federal tax credits (About the ACA, 2020). The act has also increased accountability for insurance companies through the introduction of rate reviews. 

What are the threats to repeal or reform of the act? (answer) 

The threats associated with the repeal or reform of the act include the increased resistance of states to repeal actions and the challenges faced by individual and small-group insurance plans (Health Reform, 2020). Some of these challenges include the enrollment of a smaller groups to the insurance firms. 

Describe why healthcare providers need work to improve the quality of healthcare and decrease the cost. Use specific examples of activities influenced by the healthcare leaders in your organization to achieve these aims. 

Healthcare providers need to work to improve the quality of healthcare and decrease associated costs as this will provide them will reliable and sustained healthcare procedures. In turn, healthcare providers will be able to achieve their goals for the improvement of care delivery. For example, healthcare leaders can enable the utilization of electronic health record systems to enhance information dissemination within the hospital. 

References 

The IHI Triple Aim | IHI - Institute for Healthcare Improvement. (2020). Retrieved 31 January 2020, from http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx 

About the ACA. (2020). Retrieved 31 January 2020, from https://www.hhs.gov/healthcare/about-the-aca/index.html 

Health Reform. (2020). Retrieved 31 January 2020, from https://www.kff.org/health-reform/