Assignment: Healthcare Condition Discussion

-One reform factor mentioned by Grand Canyon University (2019), is the reimbursements for hospitals when a patient is re-admitted to the hospital within 30 days for the same condition. Due to the hospital negligence and or not being effectively educated patients are constantly being readmitted with the same condition. Readmissions are of concern because of their impact on cost and patient outcomes. The circumstances surrounding hospital readmissions are not fully known; poor care coordination after discharge and poor follow-up care are considered two primary factors (Felix, 2015).

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Another factor that is mentioned is the number of uninsured people in America. Before The Affordable Care Act the number of individuals that was uninsured in the states was unbelievable. Taken from the CDC report an estimated 9.6% of U.S. residents, or 31.1 million people, lacked health insurance when surveyed in the first six months of 2021, according to preliminary estimates from the National Health Interview Survey which is said to not being too different from the 2020 report (CDC, 2021). With so many people being uninsured in a time when it seems as though everybody is being admitted with COVID having insurance would be very wise. Jennifer Mead-Stewart

– It is a significant step that reforms are emphasizing making care as safe and quality as possible. Patients or users of care are dependent on healthcare providers to maintain a high or optimal level of health and wellness (GCU Academics, 2013). Therefore, aligning payment with quality of care helps protect the patients and ensure they are served in the best way that is also cost-effective. However, thinking of this reform raises the issue of staff shortages and patient education.

A prerequisite of quality care is the availability of adequate skilled professionals to serve healthcare consumers. However, in the current healthcare system, the number of qualified professionals is deficient. So, who will be part of the managed care organizations and the network of professionals required for proper and effective care coordination? Who teaches the patient about their role in health care delivery? Therefore, having the right staffing plans to ensure that every organization has adequate skilled professionals is an essential reform factor. Healthcare professionals are an integral part of improving the quality of care, promoting the delivery of primary and preventive care, and containing health costs.

Patients will be active participants in the care delivery process. They will be part of the care team and the decision-making process to increase their self-efficacy once they are out of the facilities. This level of engagement plays a role in patient experience, a metric in the value-based payments. However, looking into the current health care system, patients are very passive participants, coupled with high 30-day readmission rates that CMS works to prevent. According to Warchol et al. (2019), patient education is a critical issue affecting hospital readmissions. Despite hospital leaders taking the initiative to empower patients to be champions of their health, some fail to understand their conditions, treatment, and symptom management. This level of health illiteracy leads to high 30-day readmissions because patients do not follow discharge plans. So, despite the objective to increase patient engagement, patient education is more crucial to improve their health outcomes and reduce the costs of health. Ibrahim Bangura

–Health Insurance Issues

One healthcare reform that needs to be addressed by future leaders is health insurance. Healthcare is so expensive. The cost of healthcare often prevents people from getting needed care or filling prescriptions (Kearney et al., 2021). There are times when insurances deny certain life-saving medications, home health care, and needed medical equipment. Adults in households with incomes under $40,000, those without health insurance coverage, and those in households where someone has a chronic condition are more likely than their counterparts to report negative impacts from their inability to pay for medical bills (Kearney et al., 2021). This leaves individuals in a huge amount of debt. Often, I come across patients that do not have health insurance or their insurance are giving them issues. It is frustrating to see these patients being denied of certain medical costs. This has to change, in order for people to receive proper medical care, have necessary medical equipment at home, and able to afford prescriptions.

Nurse-to-Patient Ratios

Another healthcare reform factor is the problem with nurse-to-patient ratios. Nurses are being assigned to a more patients than the recommendation. Currently, 14 U.S. states have passed some form of safe staffing laws (American Nurses Association, n.d.). A balanced nurse-to-patient ratio can lead to many positive outcomes. Nurses, patients, and even healthcare facilities have experienced success when using a safe nurse staffing method. With unsafe ratios, there is a chance for medical errors and increase mortality rate of patients.

Managed Care Organizations (MCO)

Managed care organization influence healthcare in all aspect of delivery. MCO helps to reduce healthcare expenditures costs (Heaton & Tadi, 2021). Additionally, they are essential for providers to understand as their policies can dictate many aspects of healthcare delivery (Heaton & Tadi, 2021). This could be provider networks, medical formularies, utilization management, and financial incentives. These factors influence how and where a patient receives their medical care. Furthermore, healthcare providers are able to receive financial reimbursement based on their safe delivery of care. Danielle Conol

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– The Affordable Care Act (ACA) fraud and abuse control programs play a crucial role in consumer/taxpayer protection through fraud prevention in healthcare. The Center for Medicare and Medicaid Services (CMS) (2016) details that these programs’ focused efforts have succeeded over the years leading to $2.4 billion recovered from healthcare judgments, settlements, and imposition in 2015 alone. According to the CMS, in 2015, the Medicare Strike Fraud charged over 243 individuals with fraud for $712 million in false Medicare and Medicaid billings (Center for Medicare and Medicaid Services, 2016).

One of the ACA fraud, waste, and abuse laws requirements is the focus from detection to prevention. The regulations impose heavy penalties on Medicare beneficiaries/CHIP/Medicaid recipients who knowingly participate in healthcare fraud schemes. According to Clemente et al. (2018), this shift leads to more fraud reduction as the approach is more proactive than reactive. The laws require that less be paid out upfront to providers. Detection rather than prevention push the goal to develop integrity policies in healthcare organizations that lead to a culture of transparency. Our organization has enforced heavy penalties and zero-tolerance policies for fraud, waste, and abuse based on these requirements. These policies foster a culture of accountability and professionalism.

Another requirement of the laws is increased disclosure requirements for medical suppliers/providers. Based on this provision, our facility should implement data mining systems integrated with the electronic health record system. This system will provide an effective auditing system where data patterns are assessed and fraud/abuse detected in due time. The systems will check for incorrect codes and errors suspicious of fraud, waste, and abuse. Loopholes or system vulnerabilities are significant in fostering fraud; hence such a system will minimize these occurrences. The audit process must be transparent, timely, and cost-effective, focusing on the integrity of the facility. Joudaki et al. (2016) emphasize using data mining to help third-party payers like health insurance providers extract relevant information from the thousands of claims that can indicate fraud or abuse. Ibrahim Bangura

–Combating fraud, waste and abuse in health care and in other federal programs remains a popular refrain for reducing federal expenditures which is why in March 2010, The affordable care act that addresses fraud, waste and abuse was passed in senate ( Andrulis, 2010).

In combating fraud: the Secretary of the Department of Health and Human Services (the Secretary) must establish screening procedures for medical providers and suppliers of medical equipment. Licensure checks, criminal background checks, fingerprinting, unscheduled and unannounced site visits, and database checks may be conducted. Screening procedures may vary by category of provider (Combating fraud, waste and abuse in health care, 2021).

In the organization I worked to combat fraud administration make sure that all license is up to date. If your license has been expired, then the individual is placed on suspension until their license is in good standing. Upon returning the nurse is counsel and an agreement is signed between administration and the nurse that states that they will keep their license in good standing or be terminated. Another way they combat fraud is by cross checking every narcotic administration documentation and progress note. There is a surprise inspection carried out every 3 months which entails inspecting the equipment on the crash cart, the equipment in the patients room to and all the medication carts (Combating fraud, waste and abuse in health care, 2021).

In combating waste and abuse : Physicians must provide documentation on referrals to programs which contain a high risk of waste and abuse. The Secretary may revoke a physician’s enrollment, for no more than one year, if a physician or supplier fails to maintain or allow the Secretary to access written orders or requests for payments for certifications for home health services, durable medical equipment, or other items (Combating fraud, waste and abuse in health care, 2021). The Act requires a person who has received an overpayment to report and return the overpayment to the Secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address, and to notify the Secretary, state, intermediary, carrier or contractor to whom the overpayment was returned in writing of the reason for the overpayment. Section 1128J(d)(2) of the Act requires that an overpayment be reported and returned by the later of— (A) the date which is 60 days after the date on which the overpayment was identified (Centers for Medicare & Medicaid Service, 2016). Assignment: Healthcare Condition Discussion

In the organization I worked to combat waste and abuse all orders must be approve by the NP or physician. Documentation of referrals are attached for every resident all with the documentation of the nurse (If applicable). States are allowed to engage in stricter provider and supplier screening and oversight activities than those followed by the Secretary (Combating fraud, waste and abuse in health care, 2021). The DON goes through all medications that is returnable and make a note of them in the system with detail documentation followed by return to the pharmacy. After an audit is done, if a resident was overcharged, or a overpayment was sent in by the insurance company. The overcharge or overpayment is reported immediately to the insurance company and resident. Jennifer Mead-Stewart

–ACA is the largest healthcare renovation in the US since the onset of Medicare and Medicaid. ACA’s prime directive, numerous provisions within the bill aim to control costs and improve healthcare quality for patients in the US (Adkinson et al., 2014). ACA is a major transition from fee-based practices to performance based but many organizations have been successful in doing so. Of the 3 requirements I feel my organization has initiated value-based purchasing program way. “hospitals are assessed by means of 12 clinical quality measures in 6 domains (patient and family in an efficient engagement, patient safety, care coordination, population and public health, efficient use of healthcare resources, and clinical processes/effectiveness) and a composite measure of patient experience” (Adkinson et al., 2014). VBPP improves decision making and accountability for an organization. Because of this it also drives improved quality care for the patient by lowering the cost for the patient, providers are rewarded for positive outcomes and patient care becomes more coordinated with a team approach to care. My organization has been able to achieve this goal by providing appropriate support for the providers and the care teams, they are committed t long-term quality improvement, and our mission and goals are aligned to improve value-based care. Adiel Fabregas

Assignment: Healthcare Condition Discussion