During its adoption, the Affordable Care Act (ACA) was a watershed moment in as far as undertaking effective healthcare reforms across the US is concerned. Nevertheless, as with many public policies; ACA has not been spared opposition especially from the Republicans especially on how to reduce the ever-rising healthcare costs and healthcare spending (Gusmano, 2017). The primary point of debate has been health coverage and more importantly-the Medicare program which is the biggest source of healthcare finance (Rudowitz, 2019). Various views have been raised on how best to re-design different aspects of the healthcare system including Medicare. For instance, according to KFF (2019) several proposals have been made on how Medicare should be designed. Some bills support the idea of Medicare-for-all which in some way resembles a universal health coverage program. Some proposals, on the other hand, feel that Medicare should be for all but at the same time, allow some options for those willing to pursue private health coverage. In another proposal, the conversation is around giving states the power to elect whether to modify Medicare in the best way that suits them under the ACA market place. It is apparent that each of these proposals is intended to minimize health spending and at the same increase access as well as enhance the quality of care provided. These arguments or mindsets have essentially originated from the political class but other players within the larger healthcare industry have different views. Adopting a Medicare-for-all program or universal coverage can significantly kill the private health insurance sector and at the same time- promote government monopoly which somehow beats the logic behind having a liberal healthcare market. In this regard, some players have considered other non-political options intended to reduce healthcare spending without necessarily forgetting the aspect of quality. As can be extrapolated from the ongoing debate, it is no doubt that the political class has been canvassing around the issue of cost which is not the only pillar of the US healthcare system. For instance, Rand Health Care (2019) provides various small ideas that at the end of the day can help ease the current healthcare cost burden and improve quality. This is essentially through modifying various care processes in a view to eliminating unnecessary spending. Among the ideas provided by Rand Health Care (2019) include the use of low-cost antibiotics, reducing the occurrence of hospital-acquired infections, eliminate co-payments and shift some emergency care services to retail healthcare facilities and clinics. These ideas largely support the re-configuration of care processes so as to do away with unnecessary spending. This is an idea that has been shared by Mitre Corporation (2017), whereby they feel that the problem is not with the health coverage model but the primary infrastructure of how care is provided at the grassroots level. According to the Mitre Corporation (2017), reforms should focus on providing incentives for quality and adopting a value-based model whereby reimbursement in pegged on quality. In turn, this will motivate healthcare providers to pursue the best evidence and best practices to ensure high-quality levels. This being the case, a sizeable amount of healthcare costs that go preventable medication errors can be eliminated. McConnell, Charlesworth, Meath, George & Kim (2018) also share the same idea in as far as reducing healthcare spending in the US is concerned. According to McConnell et al. (2018), the solution to the current healthcare spending in the US can be cured by the adoption of the ACO model whereby healthcare organizations are reimbursed based on their cost-savings, quality and essentially-the value of care provided. Different models have been proposed and some of them are currently in operation. However, according to Faster Cures et al. (2018) each of these models comes with unique drawbacks and the best approach is to allow some room for Alternative Payment Models (APMs). The adoption of APMs by Medicare can go a long way towards ensuring that patients get the right value and quality through cost-friendly approaches. For instance, Managed Care Organizations (MCO) provides a cost-reducing model since patients are grouped on the basis of their healthcare needs and contribute towards a common insurance pool. This enhances the use of patient-centered care approaches and brings on board the economies of scale. As Marshall (2018) underscores, the problem is not that the current Medicare program is ineffective but the biggest proportion of healthcare spending is essentially caused by minor and yet preventable issues in the care process. These include the occurrence of medication errors, pursuing unwarranted medical procedures and lack of a quality-oriented care model within public and private healthcare organizations (Meidani, Farzandipour, Farrokhian & Haghighat, 2016). A lot of money goes to unnecessary lab tests and surgical procedures and arguably as Marshall (2018) Marshall asserts- the solution to the US healthcare system is tethered on the existence of practical models intended to promote quality and efficiency. Having reviewed the opposing views about Medicare and ACA, it is apparent that those opposed to the current Medicare program miss the whole point. Of course, with Medicare and Medicaid (CMS) being the biggest healthcare financier-it is expected that it will be on the receiving end on many criticisms as people and especially politicians; debate around the issue of reducing healthcare spending. However, this is entirely not the issue since the biggest cause of increased healthcare spending is centered on the core minor issues which can be easily written off. The problem is entirely on the actual process of care since in its current state provides various pathways for unnecessary spending. Therefore, the ultimate solution to this debate is to re-design the care process by allowing APMs to thrive and at the same time- investing heavily towards quality and safety (Porter & Lee, 2016). This is through the integration of technology, the use of the evidence-based practice, investing in the healthcare workforce to enhance advanced practice skills as well as promoting a culture of value through incentives for quality. Such approaches will address the problem from its roots by the virtue of motivating healthcare providers to use evidence and strive to enhance quality improvements and cut unnecessary costs. References Faster Cures et al, (2018). A Closer Look at Alternative Payments Retrieved from https://www.fastercures.org/assets/Uploads/PDF/VC-Brief-AlternativePaymentModels.pdf Gusmano, M. K. (2017). Obamacare Wars: Federalism, State Politics, and the Affordable Care Act. Political Science Quarterly, 132(3), 551-554. KFF. (2019). Comparison of Medicare-for-all and Public Plan Proposals Retrieved from https://www.kff.org/interactive/compare-medicare-for-all-public-plan-proposals/ Marshall, A., (2018). Unnecessary Medical Care: More Common Than You Might Imagine Retrieved from https://www.npr.org/sections/health-shots/2018/02/01/582216198/unnecessary-medical-care-more-common-than-you-might-imagine McConnell, J., Charlesworth, C., Meath, T., George, R., and Kim, H., (2018). Overview of Research on ACO Performance Retrieved from https://www.naacos.com/overview-of-research-on-aco-performance Meidani, Z., Farzandipour, M., Farrokhian, A., & Haghighat, M. (2016). A review on laboratory tests’ utilization: A trigger for cutting costs and quality improvement in health care settings. Medical journal of the Islamic Republic of Iran, 30, 365. Mitre Corporation, (2017). Alternative Payment Model Framework Retrieved from http://hcp-lan.org/workproducts/apm-refresh-whitepaper-final.pdf Porter, M. E., & Lee, T. H. (2016). From volume to value in health care: the work begins. Jama, 316(10), 1047-1048. Rand Health Care (2019). Small Ideas for Saving Big Health Care Dollars Retrieved from https://www.rand.org/health-care/projects/small-ideas.html Rudowitz, P. (2019). Medicaid Financing: The Basics Retrieved from http://files.kff.org/attachment/Issue-Brief-Medicaid-Financing-The-Basics

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Please review the discussion board rubric under “Start Here”.

 Use in-text citations appropriately and provide full citations for your initial post and at least one of your response posts.  One of your citations needs to be outside of your text.  

The idea is that you would not only comment on your classmate’s post but also do some additional research furthering the discussion.

To begin discussing in this forum, click the forum title, “Week 2 Discussion”. Then, click Create Thread on the Action Bar to post your initial reply. To reply to a fellow participant, click the title of the initial post, then click Reply.

PEER RESPONSE 1

Chenelle Weaver

Week 2 Discussion (Initial Post) Discussion week

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Total views: 2 (Your views: 2)

How does the location of where a service is performed determine which code set is used. Relate issues such as reimbursement schedules, co-pay amounts, and coverage limitations.

Where the service is or was provided determines the code that is used. Every place has its own set of codes. Payers have different reimbursement schedules, co-pay amounts, or coverage limitations depending on the place and/or location of service, this allows for proper billing to Medicaid, Medicare, or other private insurance companies. 

What is a fee schedule?

According to www.cms.gov, “A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers.  This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.  CMS develops fee schedules for physicians, ambulance services, clinical laboratory services, and durable medical equipment, prosthetics, orthotics, and supplies.”

What is a co-pay?A co-pay or copayment is a flat fee that you pay on the spot every time you go to your doctor or fill a prescription. For example, if you hurt sprain your wrist or refill a prescription for an asthma inhaler, the amount you pay for that visit or medicine is considered your co-pay. Your co-pay amount is usually printed right on your insurance card. If your health insurance plan pays 100% for annual check-ups and preventive care services, you may not have a co-pay for those visits.

What types of services does the term “procedure coding” include?

Procedure coding include all healthcare related services like – Medicare, hospital services, ambulance services, insurance coverage services, non-physician services etc.

Word Count: 265

References:

www.cms.gov retrieved on June 14, 2017

www.healthcare.gov retrieved on June 14, 2017

Aalseth, P. (2015). Medical Coding What Is and How It Works. (2nd Ed) Burlington, MA: Jones & Barlett Learning

PEER RESPONSE 2

Quetsy Garcia

discussion week 2 Discussion week

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Total views: 9 (Your views: 2)

  1. How does the location of where a service is performed determine which code set is used.

Procedure codesare a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The code plays an essential role in patient access to new and existing technologies for the following reasons:  It enables providers and payers to identify with specificity, for billing and claims processing purposes, the product that was provided to a patient. It serves as a means to define a health care product and provide a common identifier for providers and payers for obtaining data that measure outcomes and cost.

2. What is a fee schedule:

A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppl. This comprehensive listing of fee maximums is used to reimburse a physician and other providers on a fee-for-service basis.

3. What is a co pay:

A payment made by a patient in addition to that made by an insurer.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865619/

Discussion Board Rubric

Discussion Board: Participation and Professionalism Rubric

Expectations and Points Awarded

Exemplary

Acceptable

Needs Improvement

Unacceptable

Posting Requirements

50 pts

Student always posts to the discussion board on three separate days within the week. Proper APA format is used for in-text citation and referencing in the initial post. The student writes in a scholarly tone demonstrating critical thinking that goes beyond just sharing opinions. Student demonstrates ability to cite sources in proper APA.

50 pts

Student does not post on three separate days of the week, but posts on two separate days of the week.

35 pts

Student posts only one initial response to the discussion board.

20  pts

Student does not post an initial answer to address the topic or answer the question, and/or does not make any responses at all.

0 pts

Level of Engagement and Participation

15 pts

Student posts promote further discussion by offering ideas and asking questions that are relevant to the discussion and course material. The posts offer an expansion on other student’s posts and course material.

15 pts

Student contributes to the class by posting but offers only a few  ideas and  asks questions that promote discussion on occasion but not all the time.

10  pts

Student rarely contributes to the discussion  by offering ideas and asking questions.

3 pts

Student never contributes to the discussion  by offering ideas and asking questions.

0 pts

Response Skill

15 pts

Student responses demonstrate they have read their classmates post.  Their response indicates they are furthering the discussion by building on the post their classmate made. Proper APA format is used for in-text citation and referencing. The student writes in a scholarly tone demonstrating critical thinking that goes beyond just sharing opinions. Student demonstrates ability to cite sources in proper APA.

 15 pts

Student  responses often, but not always, indicate they have read their classmate and instructor posts.

10 pts

Student responses rarely demonstrate an understanding of other posts and course material.

 5 pts

Student posts do not demonstrate they have read the material or other students’ posts.

0 pts

Posting Behavior

10  pts

Student demonstrates a professional level of respect for learning  while participating on the discussion board. This level of respect is shown through behavior and attitude.

10 pts

Student posting is usually respectful. There is no  display of  disruptive posting.

7 pts

Student posts sometimes display a lack of respect or professional writing behavior, including rules of Netiquette

 3  pts

Student is often disruptive by posting posts that are not respectful, do not demonstrate professionalism, or breach Netiquette rules.

0 pts

Preparation

10 pts

Student is always prepared  with discussion posts that demonstrate a commitment to reading the course material and posts. The student’s post contains scholarly support for ideas by citing credible references

10 pts

Student is usually prepared with posts that demonstrate some understanding of the topic.

7 pts

Student is only occasionally prepared for class with posts that demonstrate they have read the course material and posts from the Instructor and other students.

2  pts

Student is never prepared for class with assignments and required class materials.

0 pts

DBRubric7.16.2014.pdf 

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