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The simplest way to define managed care is: an insurance contract between payors and providers. The providers agree to accept a certain dollar amount per person who receives care. Managed care was created because people were not able to afford healthcare.
Two different kinds of managed care are: Health Maintenance Organizations, also known as HMOs, and Preferred Provider Organizations, also known as PPOs. In an HMO, the cost of the care is covered ONLY if you receive care within the contracted network. A patient is generally not allowed to receive care outside of the network unless there is an extenuating circumstance. In a PPO, a patient is not limited to receive care within the network, but the insurance reimburses at a higher rate if the care is received within the network. This means that the patient would have a higher percentage to cover “out of pocket” than if their care was “in network.”
Managed care has good points and bad. An advantage of an HMO is that if care is received within the network, care is provided at little to no cost to the patient. A disadvantage could be that the patient does not have carte blanche to any and all providers. There will be a limited selection available to pick from. An advantage of a PPO is that you aren’t limited to providers only in the network. If you want a second opinion from a specialist who is not in your network, the visit will be covered (but at a smaller percentage than if they were in network.) The disadvantage could also be the same reason: the reimbursement for out-of-network could be much smaller than if the patient was seen in network.
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Before we discuss the benefits of using attached vs freestanding emergency rooms, its important to point out that there are two different kinds. Off Campus Emergency Departments (OCED) are still part of a larger health system while Free Standing Emergency Departments (also known as FSEDs) are private and run as their own business. Each type has many advantages and many disadvantages. OCEDs can include access to care, built in referrals of patients for In Patient status if needed, as well as an additional revenue source . If patients know that they can receive the same standard of care at a OC ED that they would if they travel all the way downtown to the hospital, they can remain confident about their care in their neighborhood.
Some of the advantages of the FSED are: competition as well as faster care. Competition is always great in almost any space. If a company knows they are competing for a patient’s business, they will strive to do better and that is always a win for the patient. If an ambulance company knows that a patient can receive the care they need at a FSED, it could shorten the ambulance ride, thus the patient arriving at the ED quicker which could potentially save a life. (Guiterrez, “State Regulation Of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided”, 2016)
Disadvantages to having a FSED/OCED can include not being able to treat advanced cases. Things like myocardial infarction, stroke or trauma are generally not treated at FSED. (Johnson, “Free-standing ERs offer care without the wait. But patients can still pay $6,800 to treat a cut.”, 2017) If a patient somehow has an event like this and arrives at a FSED/OCED, it would potentially DELAY care because the patient went to the wrong place and now needs to be transferred to the right place. A really good marketing campaign would need to be established for public education. Training the public in advance for what to do in an emergency would be a great idea so they know which place to pick should they have an emergency. Another disadvantage is that Medicare and Medicaid will not pay for services at a FSED/OCED so that marketing campaign would really need to drive these education points. The elderly population (for example) are the primary users of Medicare and if you try to locate a FSED/OCED right in the middle of a senior living community, you might not do very well financially with your new business venture.
While a FSED or OCED is not ideal for all patient populations, it can be a real asset in affluent neighborhoods where most patients are covered with private health insurance. If someone has an Emergency Room Copay, and they can use it close to home, they will probably choose to do so. If we can find the right location for our new ED, I recommend that we break ground immediately.
Emergency Room Facilities: Free Standing or Off Campus?
In recent years, healthcare has continued to grow and change to keep up with the demand for both convenience and profitability. Healthcare organizations and private facilities have taken advantage of these opportunities to establish two new types of emergency departments: free standing emergency departments, and off campus emergency departments (Kenny, 2016). While both facilities specialize in the treatment and care of life-threatening illness or injury, there are some significant differences in profitability, access, benefits and their drawbacks.
Off campus emergency departments, or OCEDs, are unique in the respect that they are still associated with a healthcare organization, but are located within the community (Kenny, 2016). These types of facilities have the ability provide emergency care within the community, in addition to emergency services located within the main healthcare facility (Kenny, 2016). These emergency departments offer the same co-pays and deductibles that the patient would have at the main campus, as well as a majority of services. In the event that the OCED did not have the specialist or equipment needed for a patient, they would be transported via ambulance to the main facility for immediate care (Boulton, 2014). This type of facility helps reduce wait times to be seen while providing more revenue for the organization (Kenny, 2016). Services provided are reimbursed via private insurance, or through Medicare/Medicaid. These profits, along with income from the main facility, help provide growth for the organization and financial wellness (Davis, FACHE, & Zacchigna, 2018).
While this facility offers many benefits, a free standing emergency department, or FSED, is becoming for popular in some states. These types of facilities differ from OCEDs in regard to their involvement with healthcare organizations- for FSEDs, they have no association with them (Boulton, 2014). As a result of their independent ownership, these facilities may or may not be in network for patients, depending on their association with the healthcare plans available. If the FSED is not a part of their healthcare plan, the patient could potentially be billed for a much larger deductible and out of pocket expense (Kenny, 2016). These emergency departments are expertly built in financially secure areas- a tactic to ensure the facility will collect in full on services rendered (Center for Improving Value in Health Care, 2016). While FSEDs are also made available in the community and provide transportation, they do have some limitations. FSEDs are becoming more popular in states such as Texas, Ohio, and Colorado due to the limitations and bans from other surrounding states (Sutherly, 2014). One of the many reasons for these restrictions is because a large number of patients mistake these FSEDs for urgent care facilities, which have much lower co-pays and deductibles. The high cost of convenience may be one of the many reasons behind these regulations (Davis, FACHE, & Zacchigna, 2018). The driving force behind FSEDs growth can be largely attributed to the potential profits from financially secure communities as well as the absence of regulations that limit them in these states (Boulton, 2014).
While these two types of remote emergency departments have many benefits, the most effective type of facility to build would be the OFED. While this hospital may not get as much initial revenue as a FSED, they would be preferable to the patient for the lower deductibles and co-pays (Kenny, 2016). These facilities would also not have restrictions to which states they could be expanded to, and have the ability to transport patients in serious condition to the nearest hospital facility. In remote areas, these emergency departments could be critical for locals to receive emergency care and help provide vital resources to people who are in need of them. FSEDs may stand to make more revenue in the short-term, but if this new trend for satellite emergency departments continues, OCEDs could help many healthcare organizations expand beyond their community and provide services beyond state lines to patients in need. Despite the fact that they would not generate as much income at first, this growth in their organization would be beneficial to the communities who need it, and could continue to be cost-effective in building a profitable and successful future for the healthcare organizations that provided resources to people in need.
- Describe two reimbursement models and the role of the physician in each model.
- Fee-for-Service . A system of provision of care where the health provider is paid a fee for each service or supply provided. Fees are billed at rates established by the provider. Fee for Service is not a form of managed care. Patients may receive reimbursement for health care services under a fee schedule. Fees and reimbursements from any applicable insurance arrangement based on a complex variety of factors, including the number and type of services provided, standardized coding system, the geographic area of service, and certain office and training expenses of the provider. physicians and healthcare providers are paid by government agencies and insurance companies (third-party payers), or individuals, based on the number of services provided, or the number of procedures ordered.
- Health Maintenance Organization . A managed care arrangement consisting of a health care organization that acts as both insurer and provider of comprehensive but specified medical services. Most services are financed through prospective per capita (capitation) payments. The organization has responsibility for managing the provision of comprehensive health care services and typically provides preventive care. Depending on whether the services are organized under a staff or group model versus being contracted with clinicians separately, services are provided at organization’s own facility or those hospitals, clinicians, and clinics with which it has a network agreement for the provision of care. Typically, primary care clinicians coordinate and refer patients for treatment while acting as the gatekeeper through whom the patient has to go to obtain other health services such as specialty medical care, surgery or physical therapy.The growing presence of managed care, particularly HMOs, has influenced the geographical distribution of physicians. The greatest influence of HMO presence in these areas appears to be on the practice location decisions of new physicians and on the decisions of older physicians to retire. Although the analyses did not include rural areas, HMO growth has been slower in those areas than in metropolitan areas. As a result, an increasing proportion of physicians may be locating their practices in areas with lower population densities.
- How do government and private insurers influence how physicians practice today?
- The federal government’s role as both regulator and payer of the insurance industry has resulted in several key insurance mergers over the past year, which has reshaped the country’s health insurance market, The government’s dominant payer role shapes the face of innovation adoption. For example, when it comes to telehealth, Medicare reimbursement models are determining how new technology will be integrated in the practice of medicine.
- Why is accurate and complete documentation in the EHR important to reimbursement and quality of care?
- What other members of the healthcare team who do not provide direct care to patients contribute to cost containment and delivery of healthcare services?
- Describe two reimbursement models and the role of the physician in each model.
Fee-For-Service- system of provision of care where the health provider is paid a fee for each service or supply provided. Fees are billed at the rates established by the provider. Fee for Service is not a form of managed care. Retrospectively, patients may receive reimbursement for health care services under a fee schedule. Fees and reimbursements from any applicable insurance arrangement based on a complex variety of factors, including the number and type of services provided, standardized coding system, the geographic area of service, and certain office and training expenses of the provider.
Health Maintenance Organization (HMO). The most common of healthcare Reimbursement. A managed care arrangement consisting of a healthcare organization that acts as both insurer and provider of comprehensive but specified medical services. Most services are financed through prospective per capita (capitation) payments. The organization has responsibility for managing the provision of comprehensive health care services and typically provides preventive care. Depending on whether the services are organized under a staff or group model versus being contracted with clinicians separately, services are provided at the organization’s own facility or those hospitals, clinicians, and clinics with which it has a network agreement for the provision of care. Typically, primary care clinicians coordinate and refer patients for treatment while acting as a gatekeeper through whom the patient has to go to obtain other health services such as specialty medical care, surgery or physical therapy.
- How do government and private insurers influence how physicians practice today?
Both government and private insurers influence how physicians practice today in many ways the biggest one I have found is that it all comes down to money. Meaning the government and private insurers set the prices on the healthcare system. Where at times it makes it harder for people to afford even with health insurance. And when this happens physicians lose patience and business.
- Why is accurate and complete documentation in the electronic health record important to reimbursement and quality of care?
Accurate and complete documentation in the electronic health record also known as Documentation integrity is important to the reimbursement and quality of care for many reasons. The biggest one is the safety and HIPPA if the patients if accurate documentation is not done correctly it can result in lawsuits
- What other members of the healthcare team who do not provide direct care to patients contribute to cost containment and delivery of healthcare services
The healthcare system is made up of many people in the world, ranging from individuals who work in corporate offices to the people who in the billing department, even down to jantorios of hospitals and so far all of these people are members that contribute to the services in the healthcare.
One of the biggest challenges we see in the U.S health care system today is the rising costs. In recent years, “healthcare spending per capita in the USA expanded roughly eight times in terms of purchasing power, compared to a five-fold increase for most Western European countries” (Walker & Lodha 2013). The biggest impact this has on the healthcare industry is towards the private insurance companies. More and more patients are turning to government funded insurance, such as Medi-Cal, which has “grown from 13 to 20 percent” (Walker & Lodha 2013) in California alone. Since most private healthcare companies do not accept Medi-Cal, they are taking a big loss on their patient volume.
As previously stated, Medi-Cal is playing a major role in trying to accommodate people with their insurance coverage. As Medi-Cal expands, through the Federal Affordable Care Act, it targets patients who are young and/or middle class, in hopes of raising the number of uninsured people. Even though these patients do not have preexisting conditions, there is still a great potential for financial disaster due to patients neglecting their health or developing a chronic illness. Medi-Cal allows for regular check-ups in the hopes of preventing a potential disaster.
As of now, my role does not play a major role in this disaster because we are on the backend of things. However, since my team can play a role in cutting costs with the usage of technology. I am a site specialist, which means that I assist in the troubleshooting of the Electronic Medical Records (EMR) system, Epic. With Epic, everything is found and completed in one area, leaving us more room to cut costs for our patients. With the role I plan on playing in the future, I hope to be able to find other ways of cutting costs as our technological skills advance. Our computers have allowed us to get the job done, with less staff members, allowing us to allocate monies towards better care for our patients.
What I learned most in this course, which surprised me, was the potential on how big of a role I can play in the efficiency of patient care. In the past, I have always seen my job as a means to an end; however, our department plays a pivotal role in the future development of patient care. We may be simply troubleshooters in some eyes, but because of us, the job is able to be completed more quickly and efficiently, leaving more time for our providers to focus on their patients. I look forward to growing in this industry and am excited to see just how far my career can make a difference.
The U.S healthcare system has different challenges; one is the healthcare regulatory changes. The affordable care act extended the access to care for so many patients. There have been some talks about repealing and replacing the affordable care act (ACA) and if that eventually takes place the Center for Medicare and Medicaid Service is going to be impacted and the physician that provides care for CMS patients. The CMS suggest the importance of information sharing to keep providers informed with changes of healthcare regulation
As an administrator of the facility, I would ensure that the database for the healthcare regulations records are accurate and complete and accessible to authorized personnel. I would ensure that all staff are regularly trained and updated with the changes of healthcare regulation. Training session would be offer via interactive video to ensure every employee is compliance with the changes of healthcare regulation. I would also have strategy in place for all staff to be able to address patient concerns with changes pertaining to the healthcare regulations.
Prior to taking this class, I had very little knowledge about the U.S healthcare system even thought I work for a healthcare company. I learned how much of an influence the government has on the U.S healthcare system. The government implemented programs such as CMS for patient to seek quality healthcare at an affordable rate and added preventative screening for Medicare beneficiaries.
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