NUR 4327 Nursing Action Plan

NUR4327 Reimbursement Methodology Financial Realities The federal government (whose insurance plans cover 41% of healthcare expenses) had attempted numerous efforts to control healthcare spending starting in the early 1980s when it became clear that rising Medicare expenses would cause the Medicare Trust Fund to run out of money at some point. Since hospital and physician expenses have represented a majority of costs through Parts A and B, a great many of these initiatives have looked at hospital and physician reimbursement strategies. Value-Based Purchasing The one that most impacts nursing now is a part of the Affordable Care Act, which changed the emphasis on hospital reimbursement to include considering the quality of care provided. Started in 2012, Value-based Purchasing (VBP) is a program which rewards acute care hospitals with incentive payments for the quality of care they give to people with Medicare. The program adjusts payments to hospitals under the Inpatient Prospective Payment System (IPPS) based on the quality of care that they deliver. Each federal fiscal year (Oct 1- Sept 30), Medicare withholds a percentage of the hospital’s prior year Medicare payments. The percentage changes periodically as specified by Centers for Medicare & Medicaid Services (CMS). The hospital can earn back the money that is withheld by achieving acceptable performance scores compared to other hospitals on the defined outcome measures. There is also an incentive to improve performance from a prior year. In 2018, Centers for Medicare & Medicaid Services (CMS) reported having approximately $1.9 billion available in incentives for highperforming hospitals. Of the 2808 hospitals participating, 34% were penalized up to 1.7 percent of Medicare revenue, and 57% were awarded break-even amounts or bonuses up to 3.01% of Medicare revenue. NUR 4327 Nursing Action Plan

Consider if your hospital’s revenue from Medicare was $50 million; a loss of 1.7% would be $850,000 less revenue to cover costs already incurred. That is conservatively the salaries of 10 nurses (CMS, 2018). Measurement for VBP There are specific health measures in each of the four domains. Each domain accounts for 25% of the total score. The results are publicly available on the Hospital Compare website. Consider those areas where nursing care directly impacts the overall score. Hospital Readmission Reduction Program An additional part of the Affordable Care Act requires the Secretary of Health and Human Services to reduce payments through the IPPS (Inpatient Prospective Payment System) for excess readmissions. CMS evaluates the rates of readmissions for the same condition, particularly those that occur within 30 days of the discharge as evidence of ineffective hospital care. The six key areas for prevention of readmission are: • • • • • • Acute Myocardial Infarction (AMI) Chronic Obstructive Pulmonary Disease (COPD) Heart Failure (HF) Pneumonia Coronary Artery Bypass Graft (CABG) Surgery Elective Primary Total Hip Arthroplasty and/ or Total Knee Arthroplasty (THA/TKA) Thus, there is increased involvement of nursing in improving discharge care and in working as case managers, transitional care coordinators, and as population managers for those with heart failure and chronic obstructive pulmonary disease. Public health nurses are an essential provider of education for seniors regarding the flu and pneumonia vaccines. NUR 4327 Nursing Action Plan

Nursing care has a direct impact on the financial well-being of an acute care facility. Excellence in communication, use of evidence-based policies and procedures, careful discharge education and planning, and risk assessment and safety precautions all contribute to whether a hospital will receive a financial penalty or bonus. Remember that improvement in scores year over year is an essential measure in the decision regarding financial incentives. Nurses need to take ownership in monitoring their quality of care and continually improving both the quality of nursing care and the financial status of the healthcare organization. Resources • The 2019 Joint Commission Patient Safety Goals Source(s) Centers for Medicare and Medicaid Services. (2018, August 2). Hospital value-based purchasing.

Retrieved from https://www.cms.gov/medicare/quality-initiatives-patient-assessmentinstruments/value-based-programs/hvbp/hospital-value-basedpurchasing.html Centers for Medicare and Medicaid. (2019, January 16). Readmissionsreduction program. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-servicepayment/acuteinpatientpps/readmissions-reduction-program.html Press Ganey. (n.d.) Nursing quality (NDNQI). Retrieved from http://www.pressganey.com/solutions/clinical-excellence/nursing-quality Maximizing Economic Resources Accountable Care Organizations One of the hurdles to addressing the Triple Aim has been the lack of integration and alignment of the various elements involved in both individual and population health. The concept of accountable care organizations (ACOs) is still evolving, with groups of physicians, hospital, and other health providers who come together to give coordinating care across artificial boundaries.

This coordinated care, especially with the chronically ill, is an attempt to get the right care at the right time and avoiding duplication of services and the high costs of fragmented care. The ACO serves like an insurance company with Medicare to share the risk and the cost of care for patients. Medicare offers several ACO programs, with different incentives for care coordination. As ACOs have proven their efficiency with Medicare patients, private insurance companies are also partnering with ACOs to align the financial incentives to provide the right care with the right provider at the right time. ACOs are accountable to the patients they serve and to the thirdparty payers for the quality, appropriateness, efficiency, and safety of healthcare services. They may use a range of payment models, including a fee for service, capitation for specifically defined populations (CHF, diabetes, and renal failure), or capitation, which is based on a payment per person rather than payment per service. As ACOs have evolved, there seem to be two critical capabilities – population health management with a strong administration and risk management / financial management.

Being a coordinated system is not easy, with differing professional cultures and changing roles and incentives. An effective ACO has strong clinical leadership and is patientcentric in its approach to care. One of the cornerstones of the ACO is a robust primary care practice, which is becoming harder to achieve with a shortage of primary care physicians. This emphasis on a strong primary care practice is where family nurse practitioners, as well as pediatric, adult, and geriatric practitioners are working on rounding out this essential base, particularly in rural areas linked to an ACO. Size of the system is critical, as the ideal is to have all specialties and a range of services (long-term acute care, dialysis, hospice, home care, and rehabilitation therapies integrated through the referral network). The linking of the electronic health records is another vital component to exchanging information in real time throughout the system and for gathering and analyzing quality metrics as well as financial ones. Nurses have begun to expand their roles in information technology into data analytics and quality improvement based upon data. Data analytics and quality improvement is an emerging field for graduates with a Doctorate in Nursing Practice. Right Provider, Right Place Another critical element in reigning healthcare costs is the management of patients and populations to access the right provider in the right place. NUR 4327 Nursing Action Plan

Access to the right provider is a significant issue for those who live in rural areas, where providers are scarce, and access is limited by distance. There are several new initiatives where local providers connect via telemedicine for consultation with specialists. The consulting clinical specialist works with the primary provider on the plan of care and clinical guidelines for follow-up care. Mental health professionals have recently added their services to electronic consultation and treatment, with very positive results. There is still a significant stigma surrounding mental health issues, and patients may be more comfortable having their consultation sessions over Skype or similar technology from the comfort and privacy of their own home. Technology also expands the capabilities of the ACO in integrating physical and mental health care. Another emerging service is Palliative Care programs for those with chronic fatal diseases, such as congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease. Palliative care is providing comfort care and treatment in a variety of settings for patients at the end of life. Unlike hospice, which requires imminent death and the termination of treatment, palliative care looks at the end of life wishes associated with quality of life. Palliative care models are mainly well developed for oncology patients. This type of patient-centered approach to the end of life saves costly and invasive procedures that are not desired by patients. Emerging Role for Nurses Nurses play a vital role in addressing healthcare costs by innovating the systems of care and in improving the care management of the highdollar, high-risk population. The introduction of transitional care nursing is one such example at the University of Pennsylvania School of Nursing. Big data repositories that house data collected from millions of patients will need nurses who are sophisticated in technology and able to use data analytics to advise improvement in practice. Geriatric nurse practitioners are assuming a more pivotal role in long term care facilities. NUR 4327 Nursing Action Plan

Above all, every nurse can observe and provide suggestions for improvement and for achieving the results of the Triple Aim. Source(s) Gold, J. (2015, September 14). Accountable care organizations. Retrieved from https://khn.org/news/aco-accountable-care-organizationfaq/ Healthcare clinic examination. [Photograph]. Retrieved from Encyclopedia Britannica Image Quest. NUR 4327 Nursing Action Plan

https://quest.eb.com/search/132_1477827/1/132_1477827/cite Klein, S., Hostetter, M., & McCarthy, D. (2016, August 22). The hospital at home model: Brining hospital-level care to the patient. Retrieved from https://www.commonwealthfund.org/publications/casestudy/2016/aug/hospital-home-model-bringing-hospital-level-care-patient Udeh, C., Udeh, B., Rahman, N., Canfield, C., Campbell, J., & Hata, S. (2018). Telemedicine/virtual ICU: Where are we and where are we going? Methodist DeBakey Cardiovascular Journal, 14(2), 126-133. https://search.ebscohost.com/login.aspx?scope=site&authtype=ip,shib&c ustid=s9076023&direct=true&db=a9h&AN=130572504&site=eds-live … NUR 4327 Nursing Action Plan