AMBULATORY SURGERY CENTER CASE STUDY- Reimbursement Issue and Role of U.S. HealthCare Sector
Speaker notes
ØThe significant players in the United States health care platform includes:
üProviders; consist of those groups that provide services like clinics, hospitals, nursing homes etc.
üPurchases; it involves governments, employers and the group of private Purchasers.
üSuppliers; comprises medical, pharmacy, and other related industries.
üInsurers; comprises of agencies that deal with insurance such as Medicare, Medicaid and Medicare.
ØThe governments, employers, and individuals are the group of Purchasers who supply funds to private and public Insurers.
Ø Insurers then play the role of reimbursing providers and suppliers by disbursing a percentage of the funds collected from Purchasers.
ØThis system considers both purchasers and Insurers as the key “payers”, and there is a fundamental conflict existing between them and the Suppliers and providers who get the payments made(Fiscella, 2011).
ØTherefore, Insurers and purchasers usually have a preference of reducing the health care payments, whereas suppliers and providers are keen on maximizing their receipts. So, health care costs “represents an intense battlefield among the competing interests”.
ØThe governments, employers, and individuals are the group of Purchasers who supply funds to private and public Insurers.
Ø Insurers then play the role of reimbursing providers and suppliers by disbursing a percentage of the funds collected from Purchasers.
ØThis system considers both purchasers and Insurers as the key “payers”, and there is a fundamental conflict existing between them and the Suppliers and providers who get the payments they make.
ØTherefore, Insurers and purchasers usually have a preference of reducing the health care payments, whereas suppliers and providers are keen on maximizing their receipts. So, health care costs “represents an intense battlefield among the competing interests”.
ØBefore taking any health insurance cover, millions of Americans expect to see the health cover benefits
ØACA was initiated with a view of overcoming the shortcomings that arise due inadequate supply and implant costs. Salaries, rent, utilities, taxes, and other operating costs are going up and more regulatory requirements are being introduces;
ØCollectively, all these contribute to decreased satisfaction by those seeking health care.
ØIt is then required of ACA to increase their access to deliver adequate healthcare to the citizens
ØHealth care system is still facing serious problems of health professionals on the issue of reimbursement deteriorating system that requires a lot more to meet the current demand that has gone up (Rosenbaum, 2011).
ØThe present system is mainly facing the problem of growing volume, and load of the health care system, escalating costs, increased accreditation standards,and the system of reimbursement as well as well-trained healthcare practitioners.
ØManagers who are regarded as health care leaders and policy makers have made trials of totally modifying healthcare system in order to reduce the present errors and realize better health care outcomes in the country.
ØMajor reforms are therefore expected in the health care system and the ACA. They should focus on key standard strategies for professionals regarding the system of reimbursement that is has been recently on a decline (Rodwin, 2003).
ØManagers however need to realize that ACA and the entire healthcare system require a lot more to address the current demand that has escalated.
ØThe fee-for-service plan requires patients to typically search for a doctor they prefer and want to get the reimbursement for “covered” health expenses from.
ØACA faces a number of key drawbacks on issue of reimbursement, and these challenges involve:
üA stagnant transition to the current updated ASC payment system,
üSeparate remittance for certain devices, drugs, and biologicals,
üThe gap present between ASCs and the remittance to outpatient departments in hospitals and
üSite of service issues.
ØA revised methodology of Payment should be initiated
ØThe Current Payment Methodology should completely replace the traditional ASC Payment System
ØStandard overhead amount for any medical procedure should be derived from an estimation of incurred costs by ASCs in providing the services related with the procedure on condition that the remittance will be significantly less than it would have been if the procedure was performed on the basis of inpatient (Ash, Berg & Coiera, 2004).
ØThis should lead to a single payment system to be launched to address issues that reduce the complex and lower cost group and reduce complexity level.
ØNevertheless the inflation rate along with covered surgical procedures should be adjusted.
ØThe old methodology of payment was covered under the Payment Medicare Physician Fee Schedule (MPFS) to healthcare providers that may as well be billed the CPT codes for the brachytherapy sources application in the ASCs.
ØHowever, a revision of brachytherapy payment system which was not recognized in the old ASC payment system was introduced. This new system of payment is separately payable.
ØInitially, drugs and biologicals were incorporated into the ASC payment under the old ASC payment system. But the revised policy demands that the drugs and biologicals should be separately paid for (Watkins et al., 2015)
ØACA will bring about the improvement of the health care reimbursement problem with the aid of Health Information Technology (HIT).
ØIn conclusion, the policymakers must aim at revising the range of the issues associated to healthcare policies to improve several opportunities that can ensure enhancement of patient care services and health care opportunities.
ØIt is evident that reimbursement rates are deteriorating constantly along with the supply and implant costs, salaries, rent, utilities, and salaries.
ØThe healthcare system as it stands today is facing numerous emerging challenges. Americans taking benefit of health policies are continually rising; however, foreclosure and bankruptcy are presently threatening the stability of health care system in the US with respect to financial system. This must be amended generally to improve the health care in the country.
vAsh, J. S., Berg, M., & Coiera, E. (2004). Some Unintended Consequences of Information Technology in Health Care: The Nature of Patient Care Information System-related Errors. Journal of the American Medical Informatics Association : JAMIA, 11(2), 104–112. http://doi.org/10.1197/jamia.M1471
vFiscella, K. (2011). Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions. Annals of Family Medicine, 9(1), 78–84. http://doi.org/10.1370/afm.1213
vRosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports,126(1), 130–135.
vWatkins, K. E., Farmer, C. M., Vries, D. D., & Hepner, K. A. (2015). The Affordable Care Act: An Opportunity for Improving Care for Substance Use Disorders? Psychiatric Services (Washington, D.C.), 66(3), 310–312. http://doi.org/10.1176/appi.ps.201400159
vRodwin, V. G. (2003). The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States. American Journal of Public Health, 93(1), 31–37. Barlas, S. (2014). Hospitals Struggle With ACA Challenges: More Regulatory Changes Are in the Offing in 2015. Pharmacy and Therapeutics, 39(9), 627–645.
