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Module 2 Case

Uploaded by

familysara2004
Copyright
© © All Rights Reserved
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Download as DOCX, PDF, TXT or read online on Scribd
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5.

27 Healthcare policies
Competency V.4 AB
44
Gretchen Murphy, an HIM professional, has been asked to participate in a
community panel discussion
on national healthcare policies as they relate to access, cost, and quality.
Her focus will
be on cost of care. Gretchen wants to provide information on at least three
federal regulations that
have had an impact on the cost of healthcare. Select three federal
regulations with such an impact
and provide a brief synopsis of the key points as they each relate to
healthcare cost.
Gretchen Murphy, tasked with discussing national healthcare policies' impact
on cost, should highlight three pivotal federal regulations. Firstly, the
Affordable Care Act (ACA) stands out. Enacted in 2010, ACA aimed to expand
healthcare coverage, but it also introduced measures to control costs. It
promoted preventive care, reduced Medicare overpayments to insurers, and
encouraged payment reforms emphasizing value over volume. Secondly, the
Health Information Technology for Economic and Clinical Health (HITECH) Act
of 2009 deserves mention. HITECH incentivized the adoption of electronic
health records (EHRs), aiming to improve efficiency and reduce costs
associated with paper-based systems. Finally, the Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015 made significant changes to Medicare
reimbursement. It introduced the Merit-Based Incentive Payment System
(MIPS) and Alternative Payment Models (APMs), encouraging providers to
deliver cost-effective care while maintaining quality. These regulations
collectively impact healthcare costs by fostering efficiency, promoting
preventive care, and reforming payment structures to incentivize value-
based care delivery.

1.36 Managed care versus accountable care


Competency I.1 A
3A
5B
3
G
3
You are the office manager for an orthopedic surgeon who consistently
meets annual quality
benchmarks. He has a strong relationship with the hospital where he has
privileges and uses the
hospital’s information system efficiently, as evidenced by the lack of
duplicative services, such
as MRIs or CT scans.
The surgeon is trying to decide whether to join an accountable care
organization (ACO) or stay
under the managed care organization he has been with for the past several
years. He approaches
you for clarity.
Competency I.1 A
G3
a. Provide a comparison of the two organizations for the surgeon, noting their
characteristics.

Managed care organizations (MCOs) and Accountable Care Organizations (ACOs)


have distinct characteristics. MCOs focus on cost containment through utilization
management, often employing tools like prior authorization and network restrictions
to control costs. They typically operate under fee-for-service or capitation payment
models, where providers are incentivized to deliver care efficiently. In contrast,
ACOs emphasize care coordination and quality improvement. They aim to achieve
better patient outcomes and lower costs by aligning incentives among providers.
ACOs often utilize value-based payment models, such as shared savings
arrangements or bundled payments, where providers share in savings generated
from delivering high-quality, cost-effective care. A key feature of ACOs is their
emphasis on population health management and accountability for the overall
health outcomes of their attributed patient population.
Competency I.1 A
5
b. Then provide a recommendation for his participation.
Considering the orthopedic surgeon's consistent meeting of quality benchmarks and
efficient use of the hospital's information system, joining an Accountable Care
Organization (ACO) would likely be advantageous. ACOs align with the surgeon's
focus on quality and efficiency, offering opportunities for collaborative care
coordination and shared savings incentives. By participating in an ACO, the surgeon
can contribute to improving patient outcomes and controlling costs while
maintaining a high standard of care. Additionally, the emphasis on population
health management within ACOs aligns with the broader trend in healthcare
towards value-based care delivery, positioning the surgeon for long-term success in
a value-driven healthcare landscape. Therefore, I recommend the orthopedic
surgeon consider joining an Accountable Care Organization (ACO) to further
enhance the quality and efficiency of care delivery while also potentially realizing
financial benefits through shared savings arrangements.
References

Kieft, R. A., Brouwer, B. B. de, Francke, A. L., & Delnoij, D. M. (2014, June 13). How nurses
and their work environment affect patient experiences of the quality of care: A qualitative
study - BMC Health Services Research. BioMed Central.
https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-249

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