To complete this assignment, you will need to access to the following databases: CINAHL, MEDLINE, Cochrane Library, and the Joanna Briggs InstituteTo complete this assignment, you will need to access to the following databases: CINAHL, MEDLINE, Cochrane Library, and the Joanna Briggs Institute. I know you can do this work, so don’t go short cut and mess it up. Research each heading and complete. See the article I attached. Find more articles to complete to complete this work. As a writer, you should first write a good introduction for each topic briefly say the story you about to tell, the subjects you going to talk about. You then tall this story by each subject. You summarize all the story for conclusion Don’t do lazy work no beginning , no end. Don’t be repetitive to fill the page Don’t copy old work Don’t give me somebody’s work. I will know. Grammer has got to improve. I end up deleting all work in the process of editing. Most time work below college level. I mean it. And sometimes it can be accepted at masters level. 1: Distinguish selected factors affecting U.S. healthcare delivery systems and organizations Introduction: Find good article 1. 2. 3. 2: Examine factors affecting healthcare finance and payment systems Introduction 1. 2. 3. 3: Evaluate selected healthcare policy models and frameworks Intrduction: Find good article Suptopics 1. 2. 3. 4 5 6 7 4: Formulate strategies for coalition building and health advocacy Intrduction: Find good article 1. 2. 3. 5: Synthesize selected policy analyses affecting advanced practice nursing Intrduction: Find good article 1. 2. 3. Inclusion of all story work Examples Increased health insurance coverage Payer pressures to reduce costs • Medicare physician services payments are based on fee schedule (Resource Based Relative Value Scale, or RBRVS). Change from “reasonable cost” to prospective payment system based on diagnosis related groups for hospital inpatient services begins under Medicare Interview conducted and issues highlighted. Find issues in the policy or issues you can associate to the yellow highlighted in box High staffing turnover Diabetics patients are noncompliant with medication is more predominant The facility denies any safety concerns There is high staff turnover No diabetics education protocol or policy in place for the old and newly diagnosed diabetics Facility denies and sentinel event Yes The relationship is good. Staff are not expected to take short cuts Management is open for suggestions or improvements Examples: Staff members are not mistreated Electronic health Record is not in use, No plans for one. Still using paper medical records No further issues Diabetic education for noncompliant diabetics patients Very good role model The nurse leader will be good preceptor Transformational leadership yes Category Points % Description Introduction Introduces the interview, purpose of the interview, and provides rationale for engaged interview process. To determine existing practice problem within the organization Description of Policy Issue Please discuss the organizational assessment and how you decided upon this particular policy. Also include any subtopics regarding selected healthcare policy issue. Use examples from the interview that support your assertions and relevant examples from your practice situation. Presentation of Policy Analysis Include eight subtopics regarding selected healthcare policy analysis pathway. Summarize your subtopics using examples from the interview that support your assertions as well as relevant examples from your practice situation. Conclusion An effective conclusion identifies the main ideas and major conclusions from the body of your report. Minor details are left out. Summarize the benefits of the selected policy analysis to nursing practice. Clarity of writing Use of standard English grammar and sentence structure. No spelling errors or typographical errors. Organized around the required components using appropriate headers. APA format All information taken from another source, even if summarized, must be appropriately cited in the report (including citation of interview) and listed in the references using APA (6th ed.) format: 1. Document setup 2. Title and reference pages 3. Citations in the text and references. Total: 250 100% A quality report will meet or exceed all of the above requirements. There are more than 9000 billing codes for individual procedures and units of care. But there is not a single billing code for patient adherence or improvement, or for helping patients stay well.” Clayton M. Christensen Health care financing in the United States is fragmented, complex, and the most costly in the world. The Affordable Care Act (ACA) of 2010 takes some steps to reshape how health care is paid for, but its primary purpose is to extend insurance coverage to approximately 30 million uninsured Americans through private insurance regulation, expansion of pubic insurance programs, and creation of health insurance marketplaces to foster competition in the private health insurance market. As the ACA is implemented, making health insurance more affordable and containing the rise in health care costs are significant ongoing policy challenges in system transformation. This chapter will provide an overview of the current system of health care financing in the United States, including the impact of the ACA. Historical Perspectives on Health Care Financing Understanding today's complex and often confusing approaches to financing health care requires an examination of the nation's values and historical context. Some dominant values underpin the U.S. political and economic systems. The United States has a long history of individualism, an emphasis on freedom to choose alternatives and an aversion to large-scale government intervention into the private realm. Compared with other developed nations with capitalist economies, social programs have been the exception rather than the rule and have been adopted primarily during times of great need or social and political upheaval. Examples of these exceptions include the passage of the Social Security Act of 1935 and the passage of Medicare and Medicaid in 1965. Because health care in the United States had its origins in the private sector market, not government, and because of the growing political power of physicians, hospitals, and insurance companies, the degree to which government should be involved in health care remains controversial. Other developed capitalist countries, such as Canada, the United Kingdom, France, Germany, and Switzerland, view health care as a social good that should be available to all. In contrast, the United States has viewed health care as a market-based commodity, readily available to those who can pay for it but not available universally to all people. With its capitalist orientation and politically powerful financial stakeholders, the United States has been resistant to significant health care reform, especially as it relates to expanding access to affordable health insurance. The debate over the role of government in social programs intensified in the decades after the Great Depression. Although the Social Security Act of 1935 brought sweeping social welfare legislation, providing for Social Security payments, workman's compensation, welfare assistance for the poor, and certain public health, maternal, and child health services, it did not provide for health care insurance coverage for all Americans. Also, during the decade following the Great Depression, nonprofit Blue Cross and Blue Shield (BC/BS) emerged as a private 173insurance plan to cover hospital and physician care. The idea that people should pay for their medical care before they actually got sick, through insurance, ensured some level of security for both providers and consumers of medical services. The creation of insurance plans effectively defused a strong political movement toward legislating a broader, compulsory government-run health insurance plan at the time (Starr, 1982). After a failed attempt by President Truman in the late 1940s to provide Americans with a national health plan, no progress occurred on this issue until the 1960s, when Medicare and Medicaid were enacted. BC/BS dominated the health insurance industry until the 1950s, when for-profit commercial insurance companies entered the market and were able to compete with BC/BS by holding down costs through their practice of excluding sick (with preexisting conditions) people from insurance coverage. Over time, the distinction between BC/BS and commercial insurance companies became increasingly blurred as BC/BS began to offer competitive for-profit plans (Kovner, Knickman, & Weisfeld, 2011. In the 1960s, the United States enjoyed relative prosperity, along with a burgeoning social conscience, and an appetite for change that led to a heightened concern for the poor and older adults and the impact of catastrophic illness. In response, Medicaid and Medicare, two separate but related programs, were created in 1965 by amendments to the Social Security Act. Medicare is a federal government-administered health insurance program for the disabled and those over 65 years (Kaiser Family Foundation [KFF], 2014c), and Medicaid, until recently, has been a state and federal government-administered health insurance program for low-income people, who are in certain categories, such as pregnant women with children. Government Programs Current Public/Federal Funding for Health Care in the United States In the United States, no single public entity oversees or controls the entire health care system, making the payment for and delivery of health care complex, inefficient, and expensive. Instead, the system is composed of many public and private programs that form interrelated parts at the federal, state, and local levels. The public funding systems, which include Medicare, Medicaid, the Children's Health Insurance Program (CHIP), the U.S. Department of Veterans Affairs (VA), and the Defense Health Program (TRICARE) for military personnel, their families, military retirees, and some others, continue to represent a larger and larger proportion of health care spending. Other examples of federal programs are the Indian Health Service, which covers American Indians and Alaskan Natives, and the Federal Employees Health Benefits (FEHB) Program, which covers all federal employees unless excluded by law or regulation. Federal health expenditures for these programs totaled $731.6 billion or 26% of all health care expenditures in 2012 (Martin et al., 2014). Medicare outlays were $572.5 billion in 2012 and accounted for 20% of all national health care expenditures with Medicare Advantage (a Medicare-managed care program provided by insurance plans that can be chosen by beneficiaries instead of the traditional Medicare program) growing most rapidly (Martin et al., 2014). Medicaid outlays in 2012 were $412.2 billion and accounted for 15% of total national health care expenditures, and its spending growth also decelerated that year (Martin et al., 2014). Medicare Before the enactment of Medicare in 1965, older adults were more likely to be uninsured and more likely to be impoverished by excessive health care costs. Half of older Americans had no health insurance; but by 2000, 96% of seniors had health care coverage through Medicare (Federal Interagency Forum on Age-Related Statistics, 2000). Medicare had a beneficial effect on the health of older adults by facilitating access to care and medical technology, and, in 2006, prescription drug coverage helped improve the economic status of older adults. The percentage of persons over age 65 years living below the poverty line decreased from 35% in 1959 (when older adults had the highest poverty rate of the population) to 9% in 2012 (U.S. Census Bureau, 2014). 174 Americans are eligible for Medicare Part A at age 65 years, the age for Social Security eligibility, or sooner, if they are determined to be disabled. Medicare Part A accounted for 31% of benefit spending in 2012 and covers 52 million Americans. Medicare Part A covers hospital and related costs and is financed through payroll deduction to the Hospital Insurance Trust Fund at the payroll tax rate of 2.9% of earnings paid by employers and employees (1.45% each) (KFF, 2014a). Medicare Part B, which accounted for approximately one third of benefit spending in 2012, covers 80% of the fees for physician services, outpatient medical services and supplies, home care, durable medical equipment, laboratory services, physical and occupational therapy, and outpatient mental health services. Part B is financed through subscriber premiums and general revenue funding as well as cost-sharing with beneficiaries. Medicare Part C, or the Medicare Advantage Program, through which beneficiaries can enroll in a private health plan and also receive some extra services such as vision or hearing services, accounted for 23% of benefit spending in 2012 and had more than 14.1 million enrollees, or 28% of all Medicare beneficiaries in 2013 (Medpac, 2013). Medicare Advantage enrollment has been increasing and is up 30% since 2010 (KFF, 2014a). Extra payments that the federal government has made to private Medicare Advantage Plans are due to be phased out by the ACA, raising concerns that insurers will drop their Medicare Advantage Plans as a result. Medicare Part D is a voluntary, subsidized outpatient prescription drug plan with additional subsidies for low- and modest-income individuals. It accounted for 10% of benefit spending in 2012 and enrolled 39 million beneficiaries in 2013 (KFF, 2014a, 2014b). Figure 18-1 presents Medicare benefit payments by type of service in 2012 (KFF, 2014a). Medicare Part D is financed through general revenues and beneficiary premiums as well as state payments for recipients who get both Medicare and Medicaid, also known as “dual eligibles” (KFF, 2014b). The ACA phases out the Medicare Part D “donut hole,” a period of noncoverage for prescription drugs that left many seniors unable to pay out-of-pocket for their medications. FIGURE 18-1 Medicare benefit payments by type of service, 2012. (From Kaiser Family Foundation. . Retrieved from kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/.) The ACA authorized that certified nurse midwives (CNMs) be reimbursed at 100% of the physician payment rate. Other advanced practice registered nurses (APRNs), including nurse practitioners (NPs), are paid 85% of the physician rate 175for the same services. In addition, Medicare will not pay for home care or hospice services unless they are ordered by a physician. And, unfortunately, the ACA required physician orders for durable medical equipment for Medicare beneficiaries. Medicaid Medicaid is the public insurance program jointly funded by state and federal governments but administered by individual states under guidelines of the federal government. Medicaid is a means-tested program because eligibility is determined by financial status. Before changes by the ACA, only low-income people within certain categories, such as recipients of Supplemental Social Security Income (SSI), families receiving Temporary Assistance to Needy Families (TANF), and children and pregnant women whose family income is at or below 133% of the poverty level were eligible. To qualify for federal Medicaid matching grants, a state must provide a minimum set of benefits, including hospitalization, physician care, laboratory services, radiology studies, prenatal care, and preventive services; nursing home and home health care; and medically necessary transportation. Medicaid programs are also required to pay the Medicare premiums, deductibles, and copayments for certain low-income persons who are eligible for both programs. Medicaid is increasingly becoming a long-term care financing program of last resort for older adults in nursing homes. Many older adults have to spend down their life savings to become low income and be eligible for Medicaid. Family and pediatric NPs and CNMs are also required to be reimbursed under federal Medicaid rules if, in accordance with state regulations, they are legally authorized to provide Medicaid-covered services. In keeping with its goal to expand health insurance coverage to more Americans, the ACA expands eligibility for the Medicaid program to any legal resident under the age of 65 years with an income up to 138% of the federal poverty level. The intent of the health reform law was to have one eligibility standard across all states and eliminate eligibility by specific categories (Commonwealth Fund, 2011; Rosenbaum, 2011). The federal government has agreed to pay for nearly all the expansion costs to insure more low-income people. The U.S. Supreme Court, however, struck down the mandate to expand Medicaid and ruled that states could decide whether or not to expand the program. Figure 18-2 indicates that as of April 2014, 27 states had decided to expand Medicaid, 5 are still debating this, and 19 are not moving forward (KFF, 2014d). States that decide to opt out of the expansion can follow old federal guidelines for eligibility, leaving wide disparities in health insurance coverage between states and leaving uninsured large proportions of the population below 138% of the poverty level. Of the states that have opted out of expansion, all have Republican political leaders explicit in their opposition to the ACA, although Republican Governor Jan Brewer of Arizona pushed her state to expand Medicaid in 2013 so that 300,000 more poor and disabled residents of the state would have coverage (Schwartz, 2013). In many of the nonparticipating states, physicians, nurses, hospitals, and other health care organizations and stakeholders are pressuring their state governments to expand Medicaid as a way to improve access to health care for more low-income people. FIGURE 18-2 State Medicaid expansion, November 2014. (From FamiliesUSA. . Retrieved fromfamiliesusa.org/product/50-state-look-medicaid-expansion; and Kaiser Family Foundation. . Retrieved fromkff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/.) CHIP was created in 1997 to help cover uninsured children whose families were not eligible for Medicaid. It has been funded through state and federal funds, but states set their own eligibility standards. The ACA commits the federal government to paying most of its costs, beginning in 2015, up to 100%. It also requires states to maintain their eligibility standards for CHIP (Emanuel, 2014). CHIP will be reauthorized in 2015, and, because it is expected that many more children will have gained coverage through family health insurance plans, debate is expected over the role of the program. CHIP is enrolling a record number of children now estimated to be one third of all children in the United States. Advocates want to maintain these high child health insurance rates until the ACA is fully implemented and full coverage for children under the provisions of the ACA is assured. State Health Care Financing State governments not only administer and partially fund some public insurance programs such as Medicaid and CHIP but they are also responsible for individual state public health programs. 176The definition of public health as compared with other types of health programs is not always well understood. The mission of public health as defined by the Institute of Medicine (IOM) is to ensure conditions in which people can be healthy (IOM, 1988). Whereas medicine focuses on the individual patient, public health focuses on whole populations. Medical care for the individual patient is associated with payment by health insurance, but population-based public health programs are funded by local, county, state revenues, often combined with grants from the federal government in areas such as maternal and child health, obesity prevention, HIV/AIDS, substance abuse, and environmental health. Even with a greater federal role in health care through the ACA, states will continue to have a major responsibility for the regulation of health insurance, health care providers and professionals, and public health activities. Reduction of budgets for public health programs during times of fiscal constraint has resulted in the resurgence of infectious diseases such as tuberculosis and sexually transmitted diseases in some communities. A series of natural disasters such as tornados also brought to light gaps in the public health system, especially the ability to respond, for example, to mass casualty events. Although the ACA authorized $15 billion for the creation of a Prevention and Public Health Fund to invest in public health and disease prevention, Congress reduced by one third the amount of funding mandated by the law in 2012 and President Obama signed the legislation to pay for other initiatives (Health Policy Brief, 2012). 177 Local/County Level Similar to state governments, local and county governments in many states also have the responsibility of protecting public health. Some provide indigent care by funding and running public hospitals and clinics, such as New York City's Health and Hospitals Corporation and Chicago's Cook County Hospital. Although receiving a subsidy from their local government, these hospitals, which have served primarily poor patients and those without health insurance, have gotten significant special payments, especially from Medicare to serve these populations. These disproportionate share hospital (DSH) payments are being gradually reduced under the ACA because it is presumed that eventually, under the ACA, many more people will gain health insurance coverage. Because public hospitals and clinics are so dependent on public funds, their budgets are historically squeezed during times of fiscal restraint by local, state, and federal governments, making them vulnerable to long-term sustainability. In fact, many public health hospitals have closed, and in many parts of the country, the populations they have served have been absorbed by other types of hospital providers (KFF, 2013). The Private Health Insurance and Delivery Systems The U.S. health care system has been predominantly a private one that operates more like a business and, more or less, according to free market principles. Private health insurance has been the dominant payer and, for most Americans, it is obtained as a benefit of employment in the form of group health insurance. However, until the passage of the ACA employers have had no obligation to provide employee health insurance, leaving many Americans uninsured or underinsured, especially those working in lower-wage jobs. As private health insurance premiums have risen, employers asked employees to pay for a greater percentage of their insurance premium, and to enroll in plans that required more cost-sharing in the form of copayment, deductibles, and coinsurance. Approximately 15% of insured Americans have purchased their health insurance from the nongroup individual insurance market. Typically, these plans were more expensive and insurers in all but a few states had been able to deny insurance to applicants with preexisting medical conditions, until the practice of discrimination based on medical history was outlawed by the ACA in 2010. Because private insurers are regulated by individual states, there are wide disparities in coverage from state to state, as private insurers are powerful political stakeholders who resist attempts at state or federal regulations to make insurance more accessible and affordable. Whereas private health insurance will continue to be a cornerstone of the U.S. health care financing system, public insurers such as Medicare and Medicaid are paying for an increasing percentage of health care costs. It should be noted that health insurance is regulated by the states. Some states now mandate that NPs be considered primary care providers and eligible for credentialing and payment by private insurers. But there is wide variation in the extent to which APRNs are included in insurers' provider panels. This variation can be seen among states, among insurers within a given state, and among the plans offered by an insurer (Brassard, 2014). Most care in the United States is provided by nonprofit or for-profit hospitals and health care systems and private insurance plans (Truffer et al., 2010). Pharmaceutical companies, suppliers of health care technology, and the various service industries that support the health care system in the United States are part of what has been called the medical industrial complex (Meyers, 1970), and there is little government regulation of these industries. Although the private delivery system is dependent on payment from private insurers as well as government insurers, it has usually been resistant to government-directed efforts to expand access to care or cost-containment measures. Well-financed special interest groups representing industry stakeholders have had a great deal of influence over the political process at both the state and federal levels. For example, the medical device industry is lobbying Congress hard to repeal or reduce the medical device tax that the ACA levied to help pay 178for the expansion of insurance coverage under the health care law and has gained significant support in Congress (Kramer & Kasselheim, 2013). The Problem of Continually Rising Health Care Costs From the 1970s to the present, continually rising insurance premiums and health care delivery costs have strained government budgets, become a costly expense to businesses that offer health insurance to their employees, and put health care increasingly out of reach for individuals and families. Figure 18-3 depicts the annual percentage change in national health expenditures by selected sources of funds, 1960 to 2012 (KFF, 2014e). FIGURE 18-3 Annual percentage change in national health expenditures, by selected sources of funds, 1960 to 2012. (From Kaiser Family Foundation. . Retrieved fromkaiserfamilyfoundation.files.wordpress.com/2014/02/annual-percent-change-in-national-health-expenditures-by-selected-sources-of-funds-1960-2012-healthcosts.png.) Stakeholders in small and large businesses, government, organized labor, health care providers, and consumer groups have convened over the years to tackle the problem of rising health care costs, with little lasting success. Although a range of strategies was employed to curb rising health care costs over those 40 years, health care expenditures as a percentage of the gross domestic product (GDP) increased steadily over that time. Although multiple factors are responsible for rising health care costs as a percentage of GDP, the key one is that, unlike other capitalist democracies, the federal and state governments have little, if any, role in regulating what can be charged for health care services and supplies. Prices are largely negotiated between health insurances and providers, resulting in wide variances in prices for similar or exact services, largely based on the market clout of providers to negotiate higher prices. Other contributing factors to high health care costs include the complex administrative systems of insurers and providers, the use of expensive medical technology and medical specialists, and 179the incentive in fee-for-service reimbursement for providers to increase their volume of services and provide unnecessary health care. Consumers have also lacked knowledge of the actual cost of their care, leading to an inability of the market to accurately respond to cost and differential health care prices by region, type of hospital, or health care facility. Future costs will also be impacted by the aging of the population and increasing number of people with complex chronic illness who use a disproportionately high percentage of the health care dollars. For example, from 1977 to 2007, a very stable 5% of the population who had complex chronic illness accounted for nearly 50% of the health care expenditures (KFF, 2010; Stanton, 2006), despite efforts to control costs among this population. In 2009, the costliest 5% of beneficiaries accounted for 39% of all Medicare fee-for-service spending. The least costly 50% of beneficiaries accounted for 5% of all spending (Medpac, 2013). The majority of those in the high-expenditure group are not older adults but rather those with complex chronic illnesses (Stanton, 2006). All other industrialized countries spend significantly less on health care but have better health outcomes and a longer life expectancy. For example, the United States ranks among the worst of industrialized nations on important health indicators such as infant mortality, maternal mortality, and life expectancy at birth (Squires, 2014). Yet, in 2012, it ranked first in health care costs per capita at approximately $8915 per person (Organization for Economic Co-operation and Development [OECD], 2013b). This amounted to close to 18% of its GDP, compared with The Netherlands, which ranked second at 12% of its GDP (OECD, 2013a). Cost-Containment Efforts Over time, several approaches have been used to contain costs, including the following. Regulation Versus Competition. During the 1970s, modest government regulation attempted to contain health care costs through state rate-setting agencies and health planning mechanisms, such as Certificate of Need (CON) programs and regional Health Systems Agencies (HSAs), which evaluated and approved applications for the construction of new facilities, beds, and new technology. During the 1980s and early 1990s, when proponents of competition and free market health care became politically more influential, rate setting and CON programs were weakened and HSAs were eliminated. While free-market principles, as they apply to health care, have few similarities to a fully competitive market in economic terms, the rise of managed care programs and competition among health insurance plans in the 1980s may have temporarily slowed the growth of health costs before they began to rise again. As health insurers expanded the use of copayments, deductibles, and coinsurance as economic incentives to discourage care, the onus of cost-containment fell more heavily on the consumer/patient. However, ample research shows that low-income people may avoid necessary care because of copayments and deductibles. Chapter 17 more fully describes the mechanisms underlying the market system in health care. Managed Care. The origins of today's managed care plans were in early prepaid health plans of the 1920s, which evolved into Health Maintenance Organizations (HMOs) in the 1970s, and into a variety of models in the subsequent 30 years, including Preferred Provider Organizations (PPOs). A managed care system shifts health care delivery and payment from open-ended access to providers, paid for through fee-for-service reimbursement, toward one in which the provider is a gatekeeper or manager of the patient's health care and assumes some degree of financial responsibility for the care that is given through a capitated budget in which to pay for the patient's care. Managed care implies not only that spending will be controlled but also that other aspects of care will be managed, such as quality and accessibility. In managed care, the primary care provider has traditionally been the gatekeeper, deciding what specialty services are appropriate and where these services can be obtained at the lowest cost. In the 1990s, negative media attention concerning the incentives to restrict care in the managed care model fueled a political backlash. Consumer and provider demands for 180greater choice for services and access to providers caused managed care plans to loosen gatekeeper requirements and provide more direct access to specialists. As a result, managed care became less effective in holding down expenditures and fueled a rise in health insurance premiums. In addition, concerns of consumers and providers challenging the quality of care provided by some Managed Care Organizations (MCOs) resulted in state and federal laws to further regulate managed care plans (Kongstvedt, 2001). These laws included provisions related to grievance procedures, confidentiality of health information, requirements for informing patients of the benefits they will receive, antidiscrimination clauses, and assurances that various quality mechanisms were in place so that patient satisfaction was measured and efforts to control costs did not curtail needed care. In addition, most states adopted policies giving health plan enrollees a right to appeal plan determinations involving a denial of coverage to an independent medical review entity, which is often a private organization approved by the state (American Association of Health Plans, 2001). Efforts to pass into law the federal Patient's Bill of Rights, which contained many consumer protections related to managed care, were not successful. Medicaid and Medicare also promoted managed care plans to control their expenditures for health care by using capitated payment and managing patient care. All 50 states offer some type of Medicaid-managed care plans, and states can decide if participation is voluntary or mandatory. Some states have created state-run Medicaid-only plans, but others enroll Medicaid recipients in private MCOs. By 2010, 70% of the Medicaid population received some or all of their services through Medicaid-managed plans (Kaiser Health News, 2010). Financing Mechanisms Fee-for-Service Reimbursement. Until the 1980s, Medicare and private health insurers paid providers through fee-for-service (FFS) reimbursement. In FFS, providers charge a fee for each service, and then providers or patients submit claims to insurers for payment. There is a strong incentive under the FFS payment for providers to increase the volume of services and raise prices to increase their revenue. In addition, through the reimbursement mechanisms of their patients who are on Medicare, the federal government has paid hospitals according to the percentage of Medicare recipients, which has been inherently inflationary. Both health care organizations (such as hospitals) and individual providers (such as physicians) were historically paid through FFS reimbursement. By contrast, nursing services in hospitals continue to be grouped into an aggregate hospital fee or as part of the room fee, rendering nursing care to be in effect a cost center rather than a revenue generator. This mechanism makes it difficult to measure quality of nursing care in hospital situations. Physician/Clinician Reimbursement Under Fee-for-Service. Payment for physician services is approximately 20% of total national health expenditures (Emanuel, 2014), a significant cost-driver in health care. FFS is still the predominant way of reimbursing for physician and clinician services. Public and private health insurers pay physicians through a complicated formula related to medical coding and medical billing to determine the final payment (Emanuel, 2014). The American Medical Association (AMA) created Current Procedural Terminology (CPT), a coding system for visits to physicians and other providers. There are codes for evaluation and management, office visits, emergency room visits, prevention services, anesthesia, radiology, pathology, laboratory codes, and medicine codes, such as for dialysis (Emanuel, 2014). These codes are then linked to a specific diagnosis as outlined in the International Classification of Diseases IDC-9 (soon to be IDC-10) and then assigned payment levels. Prospective Payment Systems. In the 1980s, the federal government replaced the old FFS system for Medicare Part A with a prospective payment system (PPS) for hospital care, establishing payment based on diagnosis-related groups (DRGs). DRGs set a payment level for each of the approximately 500 diagnostic groups typically used in inpatient care. The prospective payment approach helped to 181slow the rate of growth of payment for hospital care, shortening average length of stay, and increasing patient acuity in hospitals (Heffler et al., 2001). In the past, insurers paid whatever physicians billed. But in 1992, under Medicare Part B physician payment reform, payment was linked to a Resource-Based Relative Value Scale (RBRVS). In this physician reimbursement system under Medicare, the relative value unit (RVU) for each service is based on the degree of physician work (time, skill, training, intensity), practice expertise (nonphysician labor and practice expenses), and the cost of malpractice for the specialty, as well as the geographic cost of living (Emmanuel, 2014). Its goal was not only cost savings but also to redistribute physician services to increase primary care services and decrease the use of highly specialized physicians. However, the RVU system has been criticized for still favoring specialist care and hospital-based care. The Centers for Medicare and Medicaid Services (CMS) adopts over 80% of the recommendations of the AMA's recommendations for RVUs for each service. This mechanism has been criticized as a conflict of interest, especially as specialists and surgeons comprise a significant proportion of the AMA committee making the recommendations (Emanuel, 2014). In addition, the same procedure done in a hospital is reimbursed at a higher rate than if done in a physician's office. Hence, the incentive is to do more procedures in hospital-owned facilities. The Medicare RVUs per service ratings have been adopted by private insurers, but they use different conversion factors, enabling them to pay more for each service. Since 1997, the Medicare program has also attempted to contain costs by limiting how much physician payments can increase through the Sustainable Growth Rate (SGR), a target based on physician costs, Medicare enrollment, and the GDP (Emanuel, 2014). There is no incentive in the SGR for individual physicians to contain costs because the SGR is calculated for physician services for the entire country. The intent of the original law was to reduce Medicare payments to physicians if the SGR was exceeded. However, Congress regularly passes a so-called “doc-fix” bill to prevent SGR cuts from going into effect, enabling higher Medicare payment rates for physicians, APRNs, and other providers (Lowrey, 2014). The SGR continues to be a controversial issue, and Congress has been unable to address the problem, except on an episodic basis. Bundled Payments/Global Payments. An estimated 85% of payment to providers is still through an FFS payment system, creating an inherent incentive to increase volume and costs (Emanuel, 2014). More recently, policymakers are promoting bundled and global payments as a way to not only contain costs but to also provide an incentive for providers to better coordinate and manage patient care. Under payment bundling, hospitals, doctors, and providers are paid a flat rate for an episode of care, rather than by individual service. Bundled payment is a form of prospective payment that is being tested by Medicare, private insurers, and provider systems, such as Accountable Care Organizations (ACOs). Global payment is a form of capitation in which the insurer is usually paid per member per month. Proponents of both argue that these payment models differ from traditional capitation in that payment is risk-adjusted and providers can share in savings if care is coordinated and managed and patients are kept healthy. Massachusetts is an example of a state that has provided incentives to insurers and providers to move to bundled and global payment reform. The ACA and Health Care Costs Although improving access to care by enabling more Americans to gain health insurance coverage is the main objective of the ACA, the law is also expected to have a significant impact on containing health care costs. According to the Congressional Budget Office (2014), the ACA will reduce projected federal spending on health care by $109 billion between 2014 and 2024 (Jost, 2014). The ACA does this through reducing prices and controlling the use of services while maintaining quality (Emanuel, 2014). As of December 2014, there was evidence that spending was indeed decreasing. CMS reported that health care spending for 2013 increased by only 3.5%, the lowest rate of growth 182since 1960. This has been attributed at least in part to the ACA (Carey, 2014). The ACA seeks to contain Medicare costs and pay for coverage expansion through: • Medicare will phase out the extra payments it was making to insurers who offered Medicare Advantage Plans, the managed care private plans that older adults can choose instead of traditional FFS Medicare. • Medicare will pay a lower annual increase in hospital, home, skilled nursing, and hospice care. • Medicare will pay less for durable medical equipment such as wheelchairs, walkers, and oxygen equipment because of a mandated competitive bidding process for these supplies (Emanuel, 2014). Additional provisions to control costs include: • Reduction of special payments the federal government has historically made to hospitals serving disproportionate numbers of uninsured, with the expectation that more people will have health insurance under the ACA • Taxing employers who offer high-cost private insurance plans to employees, encouraging them to redesign their health benefits and provide more affordable choices for their employees, scheduled to go into effect in 2018 • Encouraging the development of ACOs for Medicare recipients, integrated networks of providers responsible for managing and coordinating care of patients, especially those with costly chronic conditions • Penalizing hospitals if they have excessive 30-day readmissions and hospital-acquired infections, by reducing their Medicare reimbursement and providing an incentive for them to improve the quality of care (Centers for Medicare and Medicaid Services, 2013) • Implementing aggressive Medicare/Medicaid fraud and abuse prevention measures, which are projected to save the federal budget $7 billion over 10 years (McDonough, 2011) • Establishing an Independent Payment Advisory Board (IPAB), which will recommend how to reduce the per capita growth of Medicare and reduce health care spending when health care inflation reaches a certain point • Implementing administrative simplification measures that are aimed at the entire health sector and could save more than $11.6 billion in federal budget spending (McDonough, 2011) • Conducting comparative effectiveness research, which will help physicians, other providers, and patients to determine which treatments work Other provisions that have a major impact on nurses in primary care include some of the points that have been mentioned such as increases for reimbursement for primary care services, a strong focus on preventative health care (which is best delivered by nurses), and promotion of Patient-Centered Medical or Health Care Homes (PCMHs). As more and more Americans gain access to primary care services, nurses will be on the front lines of care. In addition, the Graduate Nursing Education (GNE) demonstration at five hospitals was part of the ACA. The demonstration is testing the use of Medicare funds to support clinical training of graduate nursing students, as is done with physicians (Graduate Medical Education, or GME). The outcomes of this demonstration may provide the evidence to move nursing's share of these funds from diploma nursing programs to graduate education. In another example, the Health Resources and Services Administration (HRSA) provided $250 million for nursing workforce demonstrations projects as well as ways to enlarge and refinance APRN workforce education. Discussion Questions 1. What forces have had an effect on increasing health care costs over the past 30 years? 2. What components of the ACA do you think will have a positive effect on improving health care outcomes and decreasing costs? 3. How has nursing fared in health care cost containment and what are the implications of the ACA on nursing? References American Association of Health Plans. Independent medical review of health plan coverage decisions: Empowering consumers with solutions. Author: Washington, DC; 2001. 183 Brassard A. Making the case for NPs as primary care providers. The American Nurse. 2014 [Retrieved from] www.theamericannurse.org/index.php/2013/07/01/making-the-case-for-nps-as-primary-care-providers/. Carey MA. Growth in U.S. health spending is lowest since 1960. Kaiser Health News. [Retrieved from] kaiserhealthnews.org/news/growth-in-u-s-health-spending-in-2013-is-lowest-since-1960/; 2014, December 4. Centers for Medicare and Medicaid Services. Fact sheets: CMS final rule to improve quality of care during hospital inpatient stays. [Retrieved from] www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2013-fact-sheets-items/2013-08-02-3.html; 2013. Commonwealth Fund. Realizing health reform's potential. [Retrieved from] www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2011/Jan/1466_Abrams_how_ACA_will_strengthen_primary_care_reform_brief_v3.pdf; 2011. Congressional Budget Office. Updated estimates of the effects of the insurance coverage provisions of the Affordable Care Act, April 2014. [Retrieved from] www.cbo.gov/publication/45231; 2014. Emanuel E. Reinventing American health care. Public Affairs: New York; 2014. Federal Interagency Forum on Age-Related Statistics. Older Americans 2000: Key indicators of well-being. Hyattsville, MD: Federal Interagency Forum on Age-Related Statistics; 2000. Health Policy Brief. Health policy brief: The prevention and public health fund. Health Affairs. 2012 [Retrieved from] healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_63.pdf. Heffler S, Levit K, Smith S, Smith C, Cowan C, Lazenby H, et al. Health care spending growth up in 1999: Faster growth expected in the future. Health Affairs. 2001;20(2):193–203. Institute of Medicine. The future of public health. National Academy Press: Washington, DC; 1988. Jost T. Implementing health reform: CBO projects lower ACA costs, greater coverage. Health Affairs Blog. 2014 [Retrieved from] healthaffairs.org/blog/2014/04/15/implementing-health-reform-cbo-projects-lower-aca-costs-greater-coverage/. Kaiser Family Foundation. National health expenditures per capita and their share of gross domestic product, 1960–2008. [Retrieved from] facts.kff.org/chart.aspx?ch=1344; 2010. Kaiser Family Foundation. Issue brief: How do disproportionate share hospital (DSH) payments change under the ACA?. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2013/11/8513-how-do-medicaid-dsh-payments-change-under-the-aca.pdf; 2013. Kaiser Family Foundation. Medicare spending and financing fact sheet. [Retrieved from] kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/; 2014. Kaiser Family Foundation. The Medicare prescription drug benefit fact sheet. [Retrieved from] kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/; 2014. Kaiser Family Foundation. Medicare. [Retrieved from] kff.org/medicare/; 2014. Kaiser Family Foundation. A closer look at the impact of state decisions not to expand Medicaid on coverage for uninsured adults. [Retrieved from] kff.org/medicaid/fact-sheet/a-closer-look-at-the-impact-of-state-decisions-not-to-expand-medicaid-on-coverage-for-uninsured-adults/; 2014. Kaiser Family Foundation. Annual percent change in National Health Expenditures, by selected sources of funds, 1960–2012. [Retrieved from] kaiserfamilyfoundation.files.wordpress.com/2014/02/annual-percent-change-in-national-health-expenditures-by-selected-sources-of-funds-1960-2012-healthcosts.png; 2014. Kaiser Health News. Research roundup: Medicare spending, community health centers, children's dental services. [Retrieved from] www.kaiserhealthnews.org/Daily-Reports/2010/February/05/Research-Roundup.aspx; 2010. Kongstvedt P. The managed health care handbook. 4th ed. Aspen: Gaithersburg, MD; 2001. Kovner A, Knickman J, Weisfeld V. Jonas and Kovner's health care delivery in the United States. 10th ed. Springer: New York; 2011. Kramer DB, Kesselheim AS. The medical device excise tax–Over before it begins? New England Journal of Medicine. 2013;368:1767–1769; 10.1056/NEJMp1304175. Lowrey W. For 17th time in 11 years, Congress delays Medicare reimbursement cuts as Senate passes ‘doc fix’. Washington Post. 2014 [Retrieved from] www.washingtonpost.com/blogs/post-politics/wp/2014/03/31/for-17th-time-in-11-years-congress-delays-medicare-reimbursement-cuts-as-senate-passes-doc-fix/. Martin AB, Hartman M, Whittle L, Catlin A, The National Health Expenditure Accounts Team. National health spending in 2012: Rate of health spending growth remained low for the fourth consecutive year. Health Affairs. 2014;33(1):67–77; 10.1377/hlthaff.2013.1254. McDonough G. Inside national health reform. University of California Press: Berkley, CA; 2011. MedPAC. A data book: Health care spending and the Medicare program. [Retrieved from] www.medpac.gov/documents/Jun13DataBookEntireReport.pdf; 2013. Meyers H. The medical-industrial complex. Fortune. 1970;90-91:126. Organization for Economic Co-operation and Development. Health data, 2013. [Retrieved from] www.oecd.org/health/health-systems/oecdhealthdata.htm; 2013. Organization for Economic Co-operation and Development. OECD factbook 2013: Economic and social statistics. [Retrieved from] dx.doi.org/10.1787/factbook-2013-103-en; 2013. Rosenbaum S. The basic health program: Health reform GPS. [Retrieved from] healthreformgps.org/wp-content/uploads/basic-health-plan.pdf; 2011. Schwartz D. Arizona governor Jan Brewer signs Medicaid expansion. Reuters. [Retrieved from] www.reuters.com/article/2013/06/17/us-usa-arizona-medicaid-idUSBRE95G12N20130617; 2013. Squires D. Multinational comparisons of health systems data, 2013. [Retrieved from] www.commonwealthfund.org/Publications/Chartbooks/2014/Multinational-Comparisons.aspx; 2014. Stanton M. The high concentration of U.S. health care expenditures. Research in Action, Issue 19. Agency for Health Care Research and Quality: Washington, DC; 2006. Starr P. The social transformation of American medicine. Basic Books: New York; 1982. Truffer C, Keehan S, Smith S, Cylus J, Sisko A, Poisal J, et al. Health spending projections through 2019: The recession's impact continues. Health Affairs. 2010;29(3):522–529. U.S. Census Bureau. Income, poverty and health insurance in the United States: 2012—Highlights. [Retrieved from] www.census.gov/hhes/www/poverty/data/incpovhlth/2012/highlights.html; 2014. Online Resources Kaiser Family Foundation. www.kff.org. Agency for Health Care Research and Quality. www.ahrq.gov. Commonwealth Fund. www.commonwealthfund.org. . Introduction Excellent introduction of interview process. Rationale is well-presented and purpose fully developed. Basic understanding and/or limited use of interview application and/or inappropriate emphasis on an area. Little or very general introduction of interview process. Little to no explanation; inappropriate emphasis on an area. Description of Policy Issue Excellent discussion of organizational assessment and why the selected healthcare policy issue was selected. Interview subtopics are supported with examples. Basic discussion of organizational assessment and/or why the selected healthcare policy issue was selected. Interview process and/or issue not supported with examples. Little or very general discussion of organizational assessment and why the selected healthcare policy issue was selected. Little or no interview process application or issue not supported with examples. Presentation of Policy Analysis Excellent discussion of all eight required subtopics. Presentation of policy analysis is supported with examples. Basic discussion of all eight required subtopics and/or presentation of policy analysis not supported with examples. Little or very general discussion of all eight required subtopics, or missing one or more of required subtopics. Little or no application to interview and/or practice examples. Conclusion Excellent understanding of policy analysis. Conclusions are well-evidenced and fully developed. Basic understanding and/or limited use of policy analysis and/or inappropriate emphasis on an area. Little understanding of policy analysis. Little to no explanation; inappropriate emphasis on an area. Clarity of writing Excellent use of standard English showing original thought. No spelling or grammar errors. Well-organized with proper flow of meaning. Some evidence of own expression and competent use of language. No more than three spelling or grammar errors. Well-organized thoughts and concepts. Language needs development. Four or more spelling and/or grammar errors. Poorly organized thoughts and concepts. APA format APA format correct with no more than one or two minor errors. Three to five errors in APA format and/or one to two citations are missing. APA formatting contains multiple errors and/or several citations are missing. Evaluating the Work of the Nurses Serving in Congress The performance of members of Congress has been in the limelight during the 113th Congress. Major partisan differences centering on the ACA and economic policies are blamed for increasing dissatisfaction with members of Congress. Overall approval ratings are reported to be very low by many organizations conducting polls. PollingReport.com provides a compilation of polls related to politics and current political events and is useful in getting an overall picture of how Congress is doing. The public is increasingly involved in evaluative political dialogue through the steady adoption of new technology. Social media, including Facebook and Twitter, have provided constituents with immediate, up-to-the-moment, unfiltered communication from politicians and are arguably changing the face of political media strategy. Congressmen post to their Twitter accounts, engaging directly with their followers providing direct access to personal thoughts and opinions (Peterson, 2012). Within minutes of a statement being made by a political leader, the public can, and does, begin discussing and analyzing. Regardless of the results of polls, opinions of analysts, or social media judgments, the ultimate evaluation of a Congressman's success is measured by their reelection. Political Perspective There are several tools available for evaluating political perspective. PolitiFact.com is a Pulitzer Prize winning Tampa Bay Times fact-checking project designed to find the truth in American politics. Reporters and editors of The Times evaluate and rate the factuality of comments made by politicians (PolitiFact.com, 2014). A search of PolitiFact can rapidly confirm or debunk statements and helps constituents evaluate their Representatives. Every year, the nonpartisan National Journal uses voting records to compare lawmakers on an ideologic, liberal/conservative scale based on controversial economic, foreign, or social issues (National Journal, 2013). The most recent National Journal ratings of the six nurses in Congress are listed in Table 42-1.
To complete this assignment, you will need to access to the following databases: CINAHL, MEDLINE, Cochrane Library, and the Joanna Briggs Institute is rated 4.8/5 based on 537 customer reviews.
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