P4P Payment Model

The University of Pittsburg Medical Center (UPMC) has taken a unique approach to improving revenue and reducing bad debt. By taking “a proactive, patient-friendly approach to communicating with patients about their financial responsibility through an integrated revenue cycle model,” UPMC has increased patient payments from an average of $16 million per month in 2012 to an average of $20 million per month since March 2013 (Langford, 2013, p. 88). Additionally, UPMC has been able to “significantly reduced bad debt and enhanced patient relationships through greater financial advocacy” (Langford, 2013, p. 88). In the fiscal year of 2009, UPMC’s bad debt accounted for 52% of UPMC’s uncompensated care, and as of 2013, the bad debt accounts for 24%

In U.S., spending on health care has been growing at a faster pace than spending in rest of economy since 1960s. The government was spending 4.7% of the gross domestic product (GDP) at that time, which grew to 16.2% in 2007, and is expected to rise to 20% of GDP by 2017(1). Without any drastic measures, according to the Congressional Budget Office (CBO), these numbers will project to 25% of GDP in 2025, 30% by 2035, and 49% in 2082 (2). The major components of U.S. health care spending are hospitals (31%), physician and clinical services (21%), pharmaceuticals (10%), and other spending (25%) (3).

In the film Escape Fire the Fight to Rescue American Healthcare, there were many insightful examples of why our Unites States healthcare revolves around paying more and getting less. The system is designed to treat diseases rather than preventing them and promoting wellness. In our healthcare industry, there are many different contributors that provide and make up our system. These intermediaries include suppliers, manufacturers, consumers, patients, providers, policy and regulations. All these members have a key role in the functionality of the health care industry; however, each role has its positives and negatives. Each person with an occupation in the healthcare industry is doing their designated job as assigned, but it’s evident that the system’s design is flawed to its core.

Physicians and Hospitals go hand in hand when it comes to the medical care of patients, and it is this relationship that allows the patients to receive the care they need and deserve. It is also this relationship that we as health care administrators need to understand. In order to fully understand this relationship we need to define the concept of the integrated physician model. We also need to explain the importance of clinical integration in the strategic planning process, and the dynamics of and controversies surrounding accountable care organizations and alternative approaches to the current health system. I will also explain the advantages and disadvantages for hospitals and physician’s models. All of these things are important for health care administrators to understand about the relationship between a physician and the facility they work at.

As an integral part of the healthcare team, nursing has evolved tremendously. In Nurse of the Future Nursing Core Competencies a picture was painted of what the future of nursing looks like. From my own opinion I do feel that a reform or evolution in nursing education is required to create competent nurses of the future. Current nursing school programs are academic heavy with an emphasis on skills. While growing competency in clinical skills is necessary, there is much more to the future of nursing than being highly skilled. It is time to distinguish not just skills, but characteristics of a successful nurse of the future. This is a nurse who will be well rounded with the tools and resources to help guide healthcare and the patient experience

A Medicare Severity-Diagnosis Related Group (MS-DRG) is a system of sorting a Medicare patient’s hospital stay into many groups in order to expedite payment of services for Medicare patients (CMS, "Acute Inpatient PPS") . The MS-DRG is the most-widely used system today as a result of the rising number of Medicare patients. Payments are calculated using wage variants, geographic locations, and the percentage of Medicare patients that a hospital treats (CMS, "Acute Inpatient PPS"). In short, the Medicare Severity-Diagnosis Related Group (MS-DRG) system enables the Centers for Medicare and Medicaid Services (CMS) to provide improved reimbursements to hospitals serving more severely ill patients. Hospitals treating less severely ill patients will receive less reimbursement. (CMS, "Acute Inpatient

Why is Accountability so important in the health care industry? Even though a situation may be positive or negative, every aspect of health care needs to be credited to something or someone, with accountability, errors can be fixed and then prevented and helps keep costs down. An employee accountability is measured by customer satisfaction, results of performance, and the cost and impacts of the employee over time, and affects an organization’s working culture by their values, integrity and work ethics. A successful organization follows the checks and balance process, maintains a positive working culture, and stays clear from blame.

One being the need for a digitized information system in which the data is used to assess what’s working and what’s not more intelligently. This would allow for there to be an assessment of quality or quantity of treatment. (Health care reform debate in the United States, n.d.). Mayo Clinic President and CEO, Denis Cortese describes the four “pillars” of success in reforming the United States health care system by: Focus on value; Pay for and align incentives with value; Cover everyone; Establish mechanisms for improving the healthcare service delivery system over the long-term, which is the primary means through which value would be improved (Health care reform debate in the United States, n.d.). David Leonhardt of the New York Times describes another assessment in which many ailments are treated differently, however have the same outcome. The point in his article is that different treatments cost different amounts, sometimes very significantly different, yet both get the same result. By doing comparative effectiveness research, patients can get the quality care they deserve but at a much cheaper cost. (Health care reform debate in the United States,

Your discussion presents an interesting perspective on business principles. Managing financial needs of a hospital and patient’s satisfaction goes hand and hand in the hospital field. This also can create a negative impact when it comes to prescribing pain medication. An ethical dilemma arises for emergency room providers who in relation to new reimbursement tactics centered upon patient satisfaction scores (Kelly, Johnson, & Harbison, 2016) I feel that these doctors are feeling pressure to prescribe pain medications in order to increase patients scores and in return improve reimbursement for their units. This is contributing to the increase of opioid abuse that is already prevalent in this nation. This needs to be taken into consideration

Millions of Americans are constantly reminded of the horrible effects of the Affordable Care Act anytime medical care is required. I have witnessed many families and individuals struggle to cover the extra financial responsibility imposed upon them: Susan Gardiner, a fellow Kroger employee, states her health insurance costs have significantly increased following the approval of the Affordable Care Act; consequently, Ms. Gardiner routinely experiences financial hardships as she requires frequent medical care. Americans simply cannot cope with the Affordable Care Act’s inherent attribute of exorbitant insurance premiums and deductibles.

Panning (2014) offers an overview of how the new legislation and its goals are both effective and flawed. Goals of the ACA include: universality, financing, cost reduction, quality improvement, and prevention and wellness (Panning, 2014). Within the context of the ACA is the expectation that the majority of Americans will be covered by health insurance. Furthermore, there should be a more reasonable distribution of cost amongst Americans, with younger and healthier Americans assuming some of the financial burden for those less healthy. Another goal of the ACA is to stabilize the skyrocketing cost of health care. One way to stabilize cost can be accomplished by reforming the way payment and reimbursement of services occurs—outcomes versus volume. A final goal of the Affordable Care Act is to provide incentives that reward wellness and preventative medicine (Panning,

Some variability differs with the capability of providing out-of-network health providers and the services in which can be provided. By having a broad range of choices that can be provided, will cause a higher the cost for the individual that is paying. Most Medicare patients have received the managed care plans due to promises of a lower copayment amount and often medication benefits. Medicare post-acute spending has grown rapidly with the number of users between 1999 and 2007. The growth in Medicare short-term post-acute service use, in part, reflects short hospital stays and a growing demand for rehabilitation services. In my experience I have noticed that medicare long-term facilities are usually less costly than home health or even

Prior to the implementation of the Affordable Care Act (ACA), few people anticipated employer-provided health care would disappear as a major player in the United State healthcare arena. However, ACA adoption and has put more than 169 million employees at risk for losing their workplace coverage. Several studies indicate employer-based coverage will decline rapidly over the next decade as the traditional US system is displaced by the healthcare exchange system. While consumers grapple with finding affordable coverage options and providers adjust to the new norms, there is another wrinkle in the mix. In January, Health and Human Services (HHS) Secretary Sylvia M. Burwell announced the agency's push toward value-based and alternative reimbursement models. HHS expects 90% of Medicare payments to be directly tied to quality measures by 2018. It is imperative that hospitals, urgent care clinics and frontline providers align their

As the healthcare landscape continues to shift, medical providers and hospitals are continuously being challenged to develop clear and concise visions and redesign care delivery in ways that will usher proper transitions to value-based care. As value-based healthcare continues to take root, more and more hospitals and providers are finding themselves with little option but to join the movement. However, the jump from previously utilized fee-for-service models to value-based healthcare is not an easy one, and many healthcare organizations are finding it difficult to do so. The greatest challenge lies in successfully making the transition from volume to value-based healthcare in ways that are financially stable. Such inherent difficulties faced by those within the healthcare system are what have necessitated strategic

The Medicare Physician Fee Schedule (MPFS) uses a resource-based relative value system (RBRVS) that assigns a relative value to current procedural terminology (CPT) codes that are developed and copyrighted by the American Medical Association (AMA) with input from representatives of health care professional associations and societies, including ASHA. The relative weighting factor (relative value unit or RVU) is derived from a resource-based relative value scale. The components of the RBRVS for each procedure are the (a) professional component (i.e., work as expressed in the amount of time, technical skill, physical effort, stress, and judgment for the procedure required of physicians and certain other practitioners); (b) technical component