24 Jun List three ways the doctor of nursing (DNP)-prepared nurse could provide leadership in helping a health care entity optimize reimbursement from insurers.
I need the attached discussion questions answered in 600 words.
Please use the study materials and other outside resources to answer the questions.
Please use references only within the last 5 years. Older years are not acceptable
Detailed Instructions are attached.
DNP-804-ECONOMICS & FIN. ASPECTS OF HEALTHCARE
Module 1: Discussion – Leading to Promote Financial Quality.
Prompt:
· List three ways the doctor of nursing (DNP)-prepared nurse could provide leadership in helping a health care entity optimize reimbursement from insurers.
· Describe a new insight or perspective gained after reviewing this weeks' review of the IHI ACA video as it relates to quality and finance. How do you foresee this perspective impacting your practice?
STUDY MATERIALS
Download the PowerPoint presentations below and use them to take notes on the assigned readings from the Wasman and Knighten 3rd Ed. text for Chapters 1 and 2. Then review the additional readings and IHI video before your discussion board post! POWERPOINTS ARE ATTACHED
Insurance coverage, Medicaid expansion, and payment reform have been rigorously debated since the ACA became law in 2010. This video (March 2017) overview, Dr. Don Berwick, IHI President Emeritus and Senior Fellow, explains the changing health care landscape. What’s the future of the Affordable Care Act (ACA)? What will change if it’s “repealed and replaced” by the American Health Care Act (AHC A)? What's the difference between the two? Much has changed and will continue to change with the ACA; this illuminates the initial insurance and care delivery reforms.
Kaiser Family Foundation: Texas v. US Provisions of the ACA December 2018
President Donald Trump and Republicans in Congress pursued several major efforts to repeal and replace the Affordable Care Act (ACA). Still, they were unable to get a bill through the U.S. Senate in 2017. In 2018, Congress did pass a tax bill that eliminated the ACA’s tax penalty for not obtaining health coverage beginning in 2019. The Trump Administration’s actions and decisions also have affected the ACA marketplaces and will continue to reshape how Americans get health insurance into 2019 and beyond.
http://files.kff.org/attachment/Issue-Brief-Potential-Impact-of-Texas-v-US-Decision-on-Key-Provisions-of-the-Affordable-Care-Act
“As you may know, a health reform bill was signed into law in 2010. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it?”
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Financial and Business Management for the Doctor of Nursing Practice Third Edition
© Springer Publishing Company, LLC.
1
Benjamin J. McMichael and Joanne Spetz
Chapter 1: The Economic Context of Nursing Practice in the United States
POWERPOINTS TO ACCOMPANY
Principles of Economics
Resources are limited.
You must make choices.
Substitutability
Resources can be dedicated to many uses.
What is the value of alternate uses of a resource?
Heterogeneous preferences
One person’s pleasure is another’s poison.
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How Much Will You Consume?
People compare the marginal cost with the marginal utility.
Utility is sometimes called “benefit.”
Marginal cost = change in cost for one-unit increase in quantity
Marginal utility = change in utility for one-unit increase in quantity
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Marginal Utility and Marginal Costs
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Marginal Benefit Versus Marginal Cost Applies to Production Decisions as Well
If you are a producer:
The marginal cost of making one more cup of coffee is US$0.17.
The marginal revenue of that cup is US$5.00.
you will produce one more cup.
To sell more cups of coffee, you have to drop the price.
To increase production, you might have to increase marginal cost of production.
Build a new store (or roasting plant) or pay overtime.
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Producers Too
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How Much Do You Choose to Produce?
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Demand for Nurses: As Wage Rises, Demand Is Lower
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Demand Curve
The quantity demanded at alternative prices.
If price changes, you move along the curve.
The entire curve will shift if there are changes in:
Income (insurance reimbursement increase)
Price of related goods (licensed practical nurse [LPN]/ licensed vocational nurse [LVN] wages)
Preferences (chief nursing officer [CNO] prefers RNs)
In fact, the demand curve measures your marginal benefit—which is what you would be willing to pay for something.
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Supply of Nursing Personnel: As Wage Rises, Supply Increases
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Supply Curve
The quantity supplied at alternative prices.
If price changes, you move along the curve.
The entire curve will shift if there are changes in:
Size of the workforce (more RN graduates)
Input prices
The supply curve measures the marginal cost for workers: how much it “costs them” to supply an additional hour of work.
You also can think of this as the amount you have to pay to ensure that the worker gets enough “utility” from work to supply the extra hour.
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Demand and Supply for Nursing Personnel in a Typical Market
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Normally, There Is a Point Where the Margins Balance
To recruit more RNs, you have to raise the wage.
If there are too many RNs compared to jobs, then the wage will drop.
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If Wages Adjust to Make a Market Balance, Why Do We See Shortages?
Limited number of employers
Delays in wage increases
Delays in producing new nurses
Licensing regulations
Minimum staffing requirements
Minimum wages
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Slow Wage Response, Limited Employers
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Slow Production of New RNs
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Are There Many Buyers in the Healthcare Sector?
Who are the buyers here?
If you are selling your labor as a nurse, who are the buyers?
Do they have any control over price (i.e., negotiating power)?
How do we ensure that they will not abuse this power?
State regulations
Department of insurance
Federal regulations—Medicare (we do not let them negotiate for the lowest drug prices!), Medicaid
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Are There Many Sellers in the Healthcare Sector?
Who are the sellers?
Hospitals
Nursing homes
Healthcare professionals, clinics
Typically limited, especially in a geographical area
Sometimes, there is only one!
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Is There Perfect Information in the Healthcare Sector?
You are all future and very likely current healthcare professionals.
Do you know everything about any illness that you might contract?
Do you know all the treatment options, risks, benefits, so forth?
Or do you rely on others to advise you?
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The Fundamental Problem of Healthcare Policy
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How Much Do We Spend on Healthcare?
$3,795,000,000,000 (trillion) in 2019
17.7% of the nation’s gross domestic product
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National Healthcare Expenditures 2000–2019
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Financing Healthcare
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What does the Affordable Care Act (ACA) Do?
Quality and value improvement
Center for Medicare and Medicaid Innovation
Integrated health systems (accountable care organizations)
Value-based purchasing (VBP) program
Bundled payment program for Medicare
Review of insurance plan rate increases
Independent Payment Advisory Board aimed to extend life of Medicare Trust Fund
85% of insurance premiums must be used for care
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Federal Regulatory Cost Containment
Value Based Purchasing (VBP) accelerated by the ACA
Establishment of Center for Medicare and Medicaid Innovation
Accountable Care Organizations (ACOs)
Organizations of healthcare providers that are accountable for the quality, cost, and overall care of patients
Medicare Access and CHIP Reauthorization Act (MACRA)
Changed how Medicare pays providers and created two payment tracks within the Quality Payment Program
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State Regulation
More extensive than federal regulation
Licensing of individual providers (including physicians, nurses, etc.)
Certificate of Need Laws require permission from the state to add services
State tort liability
Medical malpractice lawsuits indirectly regulate healthcare
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A Return to Markets?
Bureau of Labor Statistics estimated that, in 2018, 45% of workers were covered by a high deductible health plan (up from 24% in 2010).
Prior to meeting their deductibles, these individuals are effectively cash-paying patients and may shop accordingly.
New services have emerged to facilitate shopping for services.
MDsave.com
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Financial and Business Management for the Doctor of Nursing Practice Third Edition
© Springer Publishing Company, LLC.
1
Todd B. Smith and Teresa D. Welch
Chapter 2: Health Insurance and Reimbursement
POWERPOINTS TO ACCOMPANY
Quotes: Health Insurance and Reimbursement
“Everybody should have health care (insurance), on the one hand. But on the other hand, if you ask Americans, "Are you willing to pay for it?," they say no. So, I've never been able to understand this contradiction.”
“The manner in which we finance health care in this country, in particular, is bewildering and inefficient.”
“Compared to national health systems in the rest of the developed world, American health care and the American health system are exceedingly complex and almost beyond human comprehension. As America faces such a crossroads where we must decide how we should proceed with our health care and health reform going forward, the need to understand both is great, especially now.”
– Uwe Reinhardt, Princeton healthcare economist
© Springer Publishing Company, LLC.
2
Background Information
The Affordable Care Act has arguably led to the biggest changes in healthcare reimbursement since the 1960s with the introduction of Medicare and Medicaid
The United States spends more money on healthcare than any other country in the world
However, on many measures, health outcomes in the United States are lower than other industrialized countries
The funding and reimbursement systems in the United States are very different from most other countries
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Introductory Concepts
Health Insurance
Definition: prepayment for health services
Main sources
Federal—Medicare, Medicaid, TRICARE (Military), and Veterans Affairs (VA)
State—Medicaid
Commercial insurers
Self-insurance
Reimbursement
Definition: how entities get paid for providing a health care service
Payment is often made by a third party for health services received
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DNP Essentials
Domain 7: Systems-Based Practice
Pertains to organizational and systems leadership for quality improvement and systems thinking
Knowledge of business and finance principles, including those related to health insurance and reimbursement, are critical for the DNP, especially those working in managerial and leadership roles
Knowledge of payers, documentation, billing and coding processes, and the prospective payment system (PPS) complement the clinical and scientific knowledge base the DNP has developed
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Health Insurance
A health insurance policy is an agreement between a person (payer) and an insurance company that provides certain medical benefits per the policy
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Individual (and/or employer, as often is the case) pays a premium
Insurance company agrees to provide certain services, typically with co-pays and deductibles
Economic Market
Healthcare occurs in an imperfect economic market
Why?
Uncertainty
Asymmetry of information—providers and patients have different levels of information
Nonmarketability of risks inherent in medical practice
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Health Insurance
“. . . health insurance is not insurance in the conventional sense. Rather, it is a system for the collective, long-term prepayment for the costs of health services that each member of the group of people covered will, on average, use during the time period for which he or she is covered. Further, the term is a misnomer in the sense that not much “health insurance” money actually pays for the maintenance and promotion of health. Rather, most of it goes to cover the costs of care during sickness.”
Goldsteen, R. L., Goldsteen, K., & Goldsteen, B. Z. (2017). Jonas’ introduction to the U.S. health care system (8th ed.). New York, NY: Springer Publishing.
© Springer Publishing Company, LLC.
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Main Sources of Health Insurance
Federal government
Medicare, VA, Indian Health System, and so forth.
Federal/State government
Medicaid
Commercial insurance
Often offered through an employer
Self-insurance
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The Uninsured
The uninsured—approximately 10.9% of the U.S. population
Down from ~18% pre-ACA
Three groups make up the bulk of those uninsured
Foreign-born residents who are not U.S. citizens
Young adults aged 19 to 25
Low-income families with an annual household income less than US$25,000
An especially vulnerable group within the uninsured is the group of children younger than 18
CHIP—a Medicaid program for children/youth
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Main Sources of Health Insurance
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Medicare
Coverage for individuals 65+
Also, those with disabilities and/or ESRD
Often the largest payer source for hospitals
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Medicare
Hospital insurance (Part A)
hospital care
limited care in a skilled nursing facility (SNF)
funded mostly from social security taxes.
Supplementary medical insurance (Part B)
physician and certain other health professional services
hospital outpatient care and certain other services
funded from general revenues and enrollee premium payments.
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Medicare + Choice (Part C)
Services funded by a managed care organization
Medicare Prescription Drug Coverage (Part D)
funded primarily through individual premiums
Reimbursement
Healthcare Dollars—Where Do They Go?
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Healthcare Reimbursement
US$3.8 trillion in 2019
18% of the national gross domestic product
Majority of spending
31% for hospitals
20% for physicians
10% for prescription drugs
75% provides care for individuals with chronic conditions
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Federal Government is the Biggest Spender on Healthcare Services
Source: Office of Management and Budget. Congressional Budget Office. Retrieved from
https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
Historical and Projected Federal Healthcare Spending (Percentage of GDP)
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Provider Payment (Reimbursement Models)
Degree of care provider integration and accountability
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Five Basic Types of Payments to Providers
Cost/cost plus
Fee for service
Fixed price
Capitation
Value
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Types of Payment Models
Diagnosis Related Group (DRG)-Based Reimbursement
The Prospective Payment System (PPS) operates based on DRGs
In recent history, this has been the most prominent payment model in health care
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Value-Based Reimbursement Options
Hospital Value-Based Purchasing (HVBP) Program for Reimbursement
Hospital Readmissions Reduction Program
Hospital Acquired Conditions Program
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Optimizing and Calculating Reimbursements (Payments)
The Inpatient Prospective Payment System (IPPS)
CMS program that manages in-patient hospital reimbursements based on FY discharged patients
Total Performance Scores
Clinical outcomes (25%)
Mortality and complications
Patient Safety (PSI) (25%)
Healthcare-associated infections
Person and Community Engagement (PCE) (25%)
Patients perception of the experience
Measured through HCAHPS survey
Efficiency and Cost (25%),
Medicare spending per beneficiary
© Springer Publishing Company, LLC.
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Other Value-Based Payment Models
Bundled Payment
Accountable Care Organizations
Shared Savings
Shared Risk
Provider-Sponsored Health Plans (PSHPs)
Alternative Payment Model
Merit-Based Incentive Program
© Springer Publishing Company, LLC.
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Health Insurance and Reimbursement in Nonacute Care Settings
Long-term care
Skilled nursing, intermediate care, and subacute services
Assisted living
Community service agencies
Dialysis
Rehabilitation
Physician offices
Primary care
Specialty care
Owned/managed care
Self-operated
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