The Benefit of Healthcare Complications
Introduction
Health care centers and the professionals play a vital in the issuance of quality service to the patients that visit the centers. Any instances of fraud and abuse that may crop up in the process of carrying out the services have to be stopped; this is useful in safeguarding the patients and payers. Fraud and abuse in the health care system has grave impact in the quality of care that is provided as well as safety, while at the same time issuing costs on the clients, employers and tax payers. The losses that have been noted in the health care sector are seen as amounting to several billions. Fraud and Abuse has brought about great negative implication to individuals that are accorded poor forms of care (AMA, 2013). The health planners are supposed to be to be on the fore front in doing away with health care fraud and abuse and their efficiency is seen by coming up with effective practices that will do away with such things. The issue in focus is that in private insurance and Medicare that is used to cover a good number of patients, the prevalence of surgical complications is connected to extreme hospital contribution. With regard to the payer mix, operations have been used to limit surgical complications in extreme financial performance.
It was noted that the financial effectiveness of surgical complications contrast in a great way by the type of payer. Complications were connected to insured patients. The Medicaid and self-pay actions with complications are connected limited contribution levels than with absence of complications (Frank, et al, 2009). Consequently, the payer mix governs the general economics of surgical complications for hospital.
A good number of health centers that are under the Medicare or payers and programs are used to limit complications that may extent the negative their financial performance. Generally it is stated that in the US hospitals that are covered by Medicaid and complication limitation efforts may advance their financial performance.
Quality of Health Care with Cost
The ones paying for the health care – basically they are the employers and elected state officials – and the receivers – patient – are not dissatisfied with the results by the present intersection of health payment system and delivery (Frank, et al, 2009). Additionally, the ones that delivery the care has similarly been uncontended and discouraged with their duty of offering beneficial care taking to fact that there is a fragmented system. They are of the thought the models that the process used are burdensome, overly controlling for some inconsiderate attributes of care and does not connect to science and art. Physicians are of the thought they are poorly paid for the extensive work they do, while at the same time their administrative desires hinder the ‘time and touch’ they look for with the patients, in part for a single and time taking prior authorizations, cumbersome files needed, extensive fraud and risks in addition to malpractice obligation.
The payment method accords the health professional with the needed resources that they are able to offer clinical expertise in their area of work. According to the health experts, they are connected to a scorecard when handling a patient that calls for them to come up with a legal benchmark so as to be part of. The ones that get the best score are well rewarded while the others are not (AMA, 2013). They are at a threat for cost, quality and client expertise of what they provide, however their risks are more based on the payment they have discussed to meet their costs to offer evidence-based care. They are hence not bound by the risk of the form of risk of insurance risk (PROTHETHEUS Payment Inc., 2006). The health experts are issued with ECRs for the patients with the help of PROSMETHEUS model that reduces the errors that may occur.
Patients have similarly risen up in protest as one of the critics of the application of capitated payment model that was used in the 90s. The use of an incentive model where doctors get more for keeping away from patients care was noted to be a physical attack on professional values that they are supposed to show (Wynia, 2009). The health experts that have been noted to be for the insurance are labeled as ‘schmoctors’ and other name calling. With regard to the values of professionals, the health experts ought to make sure and elevate quality and focus on the patient who comes first as opposed to their interests.
The general is in support of a system that ensures that all of the players are handled decently and efficiently. Polls have been a strong proof of this; however, the present system where poor form of quality of health care is rewarded by higher incentives is a shot in the hand of the patients. Support has consequently dropped and favor has been directed to another system where there is a national health support for every one with no disregard.
An article in 2001 in public health journal Health Affairs, it looked at the varied health care strategies and support was issued to a national health care model, with discontent being directed at the present medical operations. It is seen that the government and the relevant bodies are going against what is right and are not for the payment system.
The government on the other hand pushed for a health insurance model reform. The health insurance system is a part of a wide array of efforts by the government to elevate health care for Americans. This is made effective with the help of an Affordable Care Act. There is a National Quality Strategy that looks to act as a model for improved coordination of quality matters (PROTHETHEUS Payment Inc., 2006). The governments has been able to bring on a single table several agencies and bodies in making this to take place; federal and state bodies and health professionals that are bent on providing quality care to patients in the health model and as well as creation an effective transition in the care measures. The government looks to net about $1 billion so as to enable this take place. Moreover, the government has come up with policies in the Accountable Care Organizations so as to elevate coordination of patient care that is seen as would be able to bring about improved health care and more affordable costs.
The government policies the Medicare connects hospital payments will the quality of care that is accorded to patients. The health care institutions acquire payment limitation with a month readmission for patients with cancer, heart issues and other severe conditions. It is through this method that health centers look to see a drop in payments if they are no technology to offer quality service in a more coordinated way. Moreover, the centers with great levels of conditions are bound to get payment drop from the insurance model.
The policies by the government looks to form a center for Medicare and Medicaid Innovation so as to look into better ways to pay and offer patients quality care for better results to be acquire in a more affordable manner (Wynia, 2009). This center will be charged with intensely evaluating the development of its operations and engage in activities with the insurers and employers as well as health experts so as to create effective innovations in the country.
The government sees this as a way for them to be a reliable and active player with other companies that are keen in elevating the quality of service and payment service. It will go on to manage the quality of service programs in a way that is keen in elevating the quality of hospital care.
Conclusion
The health care system does not offer the form of quality that patients need. This has made varied efforts to be put in place so as to elevate quality with the help of measurement, public and private reporting of outcome and sufficient financial support for better service. With the increased spending in the health centers, the form of quality does not match this. The cost for the services offered has been a benchmark for measuring the quality of service offered by the health experts. Capitation has been considered as a way of managing cost and care and comes up with issues of services required and friction of health experts in their duty as advocate for the clients. Proof of disregard for the health services and errors have been noted in the payment and services. There has been no single payment model that has shown or has connected with the goal of issuing the bets form of care for patients.
So as to bring about an effective and qualitative form of care, the providers that are engaged mostly with the patients, and offer vital details to the players in the health care model; employers and elected officials as well as patients, will require a more advanced and effective method.
References
Ahip (2013). Fighting Health Care Fraud and Abuse. Acquired from http://www.ahip.org/Issues/Fighting-Health-Care-Fraud-and-Abuse.aspx
AMA (2013). Health Care Fraud and Abuse. Acquired from: http://www.ama- assn.org/ama/pub/physician-resources/legal-topics/regulatory-compliance-topics/health- care-fraud-abuse.page
Frank, J. et al (2009). High Quality Care and Ethical Pay-for-Performance: A Society of General Internal Medicine Policy Analysis. J Gen Intern Med. 24(7): 854–859. doi: 10.1007/s11606-009-0947-3.
PROTHETHEUS Payment Inc. (2006). PROMETHEUS: Provider Payment for High Quality Care. A White Paper. Acquired from: http://www.allhealth.org/briefingmaterials/PROMETHEUS- ProviderPaymentforHighQualityCare-AWhitePaper-ExecutiveSummary-511.pdf
Wynia, M, (2009). The Risks of Rewards in Health Care: How Pay-for-performance Could Threaten, or Bolster, Medical Professionalism. J Gen Intern Med.; 24(7): 884–887. doi: 10.1007/s11606-009-0984-y
