Discussion 2
Reimbursement incentives can impact the use of technology in healthcare. In your
initial thread, discuss the impact of value-based care criteria on
healthcare reimbursement. Integrate a discussion of biblical worldview in relation to
healthcare reimbursement and the role of the advanced practice nurse.
Replies: For your replies, respond to two classmates. Incorporate thoughtful analysis
which compares/contrasts key concepts.
The initial thread for this discussion is due by 11:59 p.m. (ET) on Thursday of
Module/Week 6. Replies are due by 11:50 p.m. (ET) on Sunday of the same
module/week.
Healthcare reimbursement is defined as the process by which private health
insurance programs or government agencies pay healthcare providers’ for their
services. When a patient receives medical treatment, the provider bills for the cost
of the treatment. The amount billed is based on a prior agreement with the
government and/or the private insurance companies. Technology has a role in
improving the claims management and reimbursement rates. It also has a role in
the digitization of health records, mobile apps, electronic medical records, value
based criteria and telehealth to name a few. These listed help the healthcare
facilities gain the most reimbursement through government based programs such
as the Meaningful Use, Managed Care, or ACO Contracts (Nelson & Staggers, 2018).
In the Meaningful Use program there are five initiatives. “1) Improve quality,
safety, and efficiencies, and reduce health disparities. 2) Engage patients and
families. 3) Improve care coordination. 4) Improve population and public health. 5)
Ensure adequate privacy and security protections for personal health information”
(Nelson & Staggers, 2018). By developing more technological advanced programs,
the government based programs can put in rules and regulations to achieve these
five initiatives. Meaningful Use initiative is pushing for technology to create a better
system that patients and professionals can use. If used correctly and efficiently on
both parties, hospitals and hospital providers will be reimbursed by the state or
federal government. These reimbursements help motivate the hospitals to create a
more user-friendly system for both the providers and patients. The other motivating
factor is if the hospital or hospital provider is non-compliant to the meaningful use
initiative, there are penalties to both the facility and the provider (Jain et al., 2019).
Reimbursement under managed care usually features value-based payment
models. These are tied to achieving certain health outcomes. Value based care is
here to stay, and nursing must be the facilitator for this change (Huffman, 2021).
Centers for Medicare & Medicaid Services (CMS) put in three reimbursement
programs based on value. These include value-base purchasing, hospital
readmission reduction program, and hospital-acquired conditions reduction
program. All of these programs focus on the value of services provided rather than
the volume completed. Value-based programs were developed in response to the
escalation in health care costs and the increase in poor quality outcomes (Rambur,
2017). Each month at the facility I work for, we do what is called responsibility
reporting. Each metric has an executive leader and that leader is responsible for
stating the metrics to the board and provide actionable items if you are not meeting
your specific metric. Offset groups are formed for each of these metrics to make
sure the actionable items are being disseminated to the nursing staff and proper
policy and procedures are being developed.
Another value-based program involves patient experience, nursing plays a
huge part in this aspect of reimbursement. The hospital is required to send out
surveys known as Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS). These surveys include questions on discharge planning,
communication, responsiveness of staff, and cleanliness of the environment
(Huffman, 2021). There has been a lot of focus in my hospital to help increase
these scores. We have started what is called Leadership Rounding. Every leader in
the hospital is assigned a group of rooms and that leader must round on those
patients daily. We ask a series of staged questions that coincide with the HCAHPS
questions that the patient will receive in the survey. We also attempt to deal with
issues on the spot that way the patient is feeling like they are being taken care of
right away. Nursing is pivotal to the success of this value-based care metric.
Overall, reimbursement incentives are here to stay and will probably continue
to be the focus for healthcare. Each facility must react to get the most
reimbursement for the care that they provide. Both nursing and technology must
be used to help with this process.
References
Huffman, M. (2021). Value-based care. Nurse Leader, 19(1). 82-86.
https://doi.com/10.1016/j.mnl.2020.014
Jain, S., Thorpe, K. E., Hockenberry, J. M., & Saitman, R. B. (2019). Strategies for
delivering value-based care: Do care management practices improve hospital
performance? Journal of Healthcare Management, 64(6), 430-444.
https://doi.org/10.1097/JHM-D-18-00049
Nelson, R. & Staggers, N. (2018). Health informatics: an interprofessional approach
(2nd ed.). St. Louis, MO: Elsevier.
Rambur, B. A. (2017). What’s at stake in U.S. health reform: A guide to the
affordable care act and value-based care. Policy, Politics, & Nursing Practice,
18(2), 61-71. https://doi.org/10.1177/1527154417720935
Response to Michelle Lemke:
Michelle-
Thank you for your post. It was very insightful on the topic of value-based
care. Both reimbursement and technology play a huge part in today’s healthcare
environment. With the shift to value-based care comes a lot of changes for each
facility and the staff who work in it. Implementing value-based care was in
response to the escalation in health care costs and the increase in poor quality
outcomes (Rambur, 2017). If the value-based programs are used correctly and
efficiently, hospitals and providers can both benefit economically from the
reimbursement packages that the government provides. Like the textbook stated,
there were five initiatives developed behind the Meaningful Use concept. Those
include, “1) Improve quality, safety, and efficiencies, and reduce health disparities.
2) Engage patients and families. 3) Improve care coordination. 4) Improve
population and public health. 5) Ensure adequate privacy and security protections
for personal health information” (Nelson & Staggers, 2018). All of these initiatives
help ensure that the patient is the number one priority when receiving care at a
healthcare facility. What it doesn’t encompass is the patient’s ability to make their
own choices. The hospital at times gets penalized for readmissions when the
patient chooses to go home and not take their medications or go to their follow up
appointments.
Overall, reimbursement incentives are here to stay and will probably continue
to be the focus for healthcare. Each facility must react to get the most
reimbursement for the care that they provide. Both nursing and technology must
be used to help with this process.
References
Nelson, R. & Staggers, N. (2018). Health informatics: an interprofessional approach
(2nd ed.). St. Louis, MO: Elsevier.
Rambur, B. A. (2017). What’s at stake in U.S. health reform: A guide to the
affordable care act and value-based care. Policy, Politics, & Nursing Practice,
18(2), 61-71. https://doi.org/10.1177/1527154417720935
Response to Abigail Truschel:
Abigail-
Thank you for your post. Both reimbursement and technology play a huge part
in today’s healthcare environment involving both nursing and physicians. With the
shift to value-based care comes a lot of changes for each facility and the staff who
work in it (Rambur, 2017). A lot of hospitals were reluctant to switch to the
electronic medical records (EMR) due to the cost of the product and the IT
bandwidth that was needed. I know from experience, making that shift took a lot of
time, energy, and education to the nurses and physicians. Implementing the value-
based care for reimbursement was in response to the escalation in health care costs
and the increase in poor quality outcomes (Rambur, 2017).
By developing more technological advanced programs, such as the EMR, the
government based programs can put in rules and regulations. These include value-
base purchasing, hospital readmission reduction program, and hospital-acquired
conditions reduction program. All of these programs focus on the value of services
provided rather than the volume completed (Huffman, 2021). Many hospitals are
putting forth great effort to get as much reimbursement as they can so they are
developing groups to help with readmissions. One thing that is not taken into
consideration when putting these rules and regulations in place in the patient’s
choices. They get discharges from the hospital and make the choice to not take
their medication or go to their follow-up appointment. Because of this, the hospital
gets penalized.
Reimbursement is obviously here to stay, the initiatives put forth from the
hospital facilities need to be well thought out and involve frontline staff to make the
efforts substantial. We must do the best work we can in order for our facility and
patients to succeed.
References
Huffman, M. (2021). Value-based care. Nurse Leader, 19(1). 82-86.
https://doi.com/10.1016/j.mnl.2020.014
