Student 1-Demario Stackhouse
Prospective payment system (PPS) refers to a reimbursement method that is based on a fixed and predetermined amount used in payments for medical care services; the value of the payment is based on the rates applied for services in a particular classification of Medicare services. Whereas, Retrospective payment refers to a Medicare payment technique that is based on the rates estimated by the provider of the service; this cost is determined after the services have been offered to the patient or beneficiary (Makary & Daniel, 2016)
The Patient Protection and Affordable Act outline various payment reform initiatives. First, The Global payment Initiative; this method involves individual monthly payments by a beneficiary for services expected upon the person falling sick, the patient’s risk level and the efficiency of the method is used to determine the expected pay.
Secondly, The Medical home payment initiative allows health providers or physicians to receive additional pay to cater for the special performance level and associated costs; this is based on the expected impact on the resources used and quality of the service, also the cost of supporting activities needed to improve the service.
Thirdly, The Bundle Payment Initiative refers to reimbursements made to cater for costs of joint provision of medical services by multiple providers; this initiative is common in cases the beneficiary requires special attention due to a certain medical procedure or condition (ACA, et al. 2010)
In my opinion, it is hard to determine an acceptable health care insurance coverage for everyone. An acceptable insurance should be done based on the performance of the services rendered by the providers. For everyone to be satisfied with the insurance, it requires prior planning while integrating the systems of care delivery; this is a tedious process that makes it hard to convince all stakeholders and beneficiaries that the health insurance is viable. Besides, investments are required in the development of legitimate, secure, and verifiable data sources; this might make the insurance costs to the middle and low-class income earners. Furthermore, development and testing will require other costs, this will help support the new data sources; this makes health insurance a near impossibility (Valentine, et al. 2015).
The proposal in the expansion plans of Medicaid to have the ‘haves” cater for the cost of health care benefits of the ‘have-nots’ is a misplaced idea. It is difficult to track the performance of such a system; many people will evade healthcare-associated costs if this proposal is implemented. We cannot assume that all the middle- and low-class-income earners are not in a position to pay for their Medicare services; this will encourage people to be careless with their basic health and hygiene since they will not be expected to pay for the services. The high-income earners can alternatively be encouraged to partner with healthcare providers in order to realize better services than contributing more.
Patient education on government and private insurance is vital, this will enable beneficiaries to make wise decisions on the best policies, therefore, limit conflicts in the implementation of the programs. The education program should be structured per the different health policies; this will limit cases of default upon application. Delivery should be made by the health providers upon inquiry for the insurance, alternatively, the use of social media platforms and public awareness forums will provide everyone with information on the insurance.
ACA, A. C. A., Addendum, I., Income, M. A. G., Tracker, R., Policy, A. C. A., & Plan, S. (2010). Patient Protection and Affordable Care Act.
Makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. Bmj, 353, i2139.
Valentine, M. A., Nembhard, I. M., & Edmondson, A. C. (2015). Measuring teamwork in health care settings: a review of survey instruments. Medical care, 53(4), e16-e30.
Student 2- Alexander Amoah
Please discuss the difference between the prospective and retrospective payment system.
The cost of medical services plays a major role and affects the way the patients are attended to by the physicians. Two types of payment plans are prospective and retrospective payment plans and each plan has its own advantages and disadvantages and operates differently.
In perspective, a fixed rate of payment is assigned to certain treatments and the amount does not change even when other factors affecting cost changes. The rate is fixed and the amount will be paid at all times. The fixed rate of payment has been of great benefits to both the patients and the provider.
While in retrospective, the healthcare providers bill all the services provided to the patients and the bill is submitted to the insurance firm. The insurance firm will approve the payment or fail to, but the providers will be paid as per the bill they submit.
Please identify and describe three payment reform initiatives in the Patient Protection and Affordable Care Act.
Global payment: this involves payment made each month by every member for the services that were delivered to a given patient. Adjustments of the payment can be made based on the patient’s risk and performance (Rajkumar et al 2014).
Medical Home: in this model, the provider has a right to receive extra payments if the medical home criterion is met. The calculations of the payments are based on cost and quality performance (Fairman, 2003). Bundled Payment: a single bundle includes many providers in many care settings. It is specifically made for delivered services within a certain period of care related to a medical condition.
Will there ever be (in your opinion) an acceptable solution for providing Health-Care Insurance to all?
Yes, by applying the pragmatic method. This will go a long way in holding in place the realities in the health care system and to ensure that there is no radical restructure is imposed. Affordable health insurance cover can be attained by going beyond the expectation and breaking the status quo which has taken lead in the recent past (Drummond et al, 2015).
Do you feel it is acceptable to expect “the haves” to provide Healthcare Benefits for the “have-nots” through the expansion plans for Medicaid?
Yes, though other parties are opposing it is wise to provide the health care aid to all people especially those with low income. Accessing health care services is a right and everyone should access them with minimal distractions (Drummond et al 2015).
Is there a necessity for patient education with respect to insurance, both for private and government coverage? How should a patient education program be structured and delivered?
Yes. There is a great need to educate patients about insurance. Knowledge is power and when passed down to the grassroots its impact will be felt in the entire health sector. The education should be structured in such a way that all the patients can access and benefit from it. The method of delivering the education should be efficient and within reach by all.
Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes. Oxford university press.
Fairman, K. A., Motheral, B. R., & Henderson, R. R. (2003). Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. Clinical therapeutics, 25(12), 3147-3161.
Rajkumar, R., Conway, P. H., & Tavenner, M. (2014). CMS—engaging multiple payers in payment reform. Jama, 311(19), 1967-1968.
Student 3-Talisha Adams
Healthcare systems and nursing systems have come a long way seeing a series of amendments and reforms. Adoption of technology and other policies are evident over the revolution. Payment mechanisms have also been changing based on inconvenience avoidance and accountability. This has attracted reform and expansion of insurance coverage in the health care sector as well. PPACA has various policies aimed at resolving evident challenges on how health care is provided and paid for in the United States. According to Blumenthal, Abrams, & Nuzum (2015), the Patient Protection and Affordable Care Act (PPACA) of 2010 focuses on developing resources for system-wide improvement, inspiring the change toward fee centered on the value of care given, trying innovative provision models and disseminating the best ones.
Healthcare bundled payment models implementation has two strategies they are retrospective and prospective bundles (Blumenthal, Abrams, & Nuzum, 2015). Retrospective bundled payment model the fee is calculated before time and then compared against service medical claims fee to get the savings pooled after the end of the care event. Prospective bundled payment model encompass making a budget on reaching the event of care measures. Provider organization or intermediary is paid the fee to issue to the concerned clinicians.
Payment reforms evident in the PPACA comprises of the Medical Home, Bundled payment, Accountable Care Organization (ACO) and Global payment (Buck, 2011). An accountable care organization willingly accept obligation for the care of a group of patients share payer savings in case they satisfy quality and charge enactment standards which include assessing negative consequences, measured performance, evaluating the effect of the payment model on quality, cost and identification for quality advancement and high efficiency of care provision provider assistance. Bundled Payment includes several providers in various care settings and services are provided on an event of care connected to a medical situation or process. Medical Homes Payment involve calculations focused on cost and quality result using a P4P-like criteria.
The Health-Care insurance provision to all seems to achieve its goal irrespective of challenges in terms of the policies offered and how they affect the care providers and the patients at large. Unless leaders reverse course, odds are people below the poverty line who do not qualify for subsidies to buy coverage in the private markets will remain at a grave disadvantage. So it is of my personal opinion that is humanly acceptable to expect “the haves” to provide Health care Benefits for the “have nots” through the expansion plans for Medicaid. Educating the general public about the available policies and benefits of the different models is necessary. This will aid the patients to make better informed decisions based on their health needs and status. On close analysis and follow up by the federal government, the payment model reforms are likely to have a balanced benefit to the patients and the care providers though some policies need to be varnished to aim at reducing expenditure while improving quality of care for patients but not relying solely on the profitability scheme.
Blumenthal, D., Abrams, M., & Nuzum, R. (2015). The affordable care Act at 5 years.
Buck, J. A. (2011). The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs, 30(8), 1402-1410.
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