DHA 8007 Discussion Week 4 Medicare and Medicaid Programs
DHA 8007 Discussion Week 4 Medicare and Medicaid Programs Week 4 Discussion: Medicare and Medicaid Programs Accountable Care Organizations (ACOs) An accountable care organization (ACO) is a healthcare provider organization, made up of physicians and hospitals, that come together to offer coordinated care to Medicaid patients. Baker argues that ACOs seek to achieve the right care at the right time, eliminate redundant services, and eradicate medical errors (Ross, 2023). ACOs encourage provider collaboration, and the end goal is better health outcomes and reduced healthcare expenses. If ACOs provide such quality care and save on the cost of the Medicare program, they can also share the savings they create with the Medicare program. The Centers for Medicare and Medicaid Services (CMS) is an organization that assists the ACOs with such programs as the Medicare Shared Savings Program (MSSP) (Ying et al., 2024). CMS encourages participation in the ACOs using financial incentives that foster better care organization, patient outcomes, and expenses. As CMS shifts the burden onto the ACOs, the quality of care that Medicare beneficiaries receive will also be improved, but the amount spent on health care will also be kept in check. Value-based purchasing (VBP) The value-based purchasing (VBP) model is a healthcare payment plan that pays healthcare providers in accordance with the quality and patient outcomes that they have achieved rather than the quantity of services provided (Ross, 2023). The incentives provided in the VBP programs make the providers offer quality services at reduced costs. It puts the emphasis away from the established fee-for-service and on value-based care that would ideally be patient satisfaction, care coordination, and outcomes to enhance overall healthcare quality. The CMS makes use of VBP programs to necessitate better quality and efficiency of care in hospitals and other health facilities. As an example, under the program of hospital value-based purchasing, CMS provides incentives to hospitals, depending on their performance regarding such measures as patient outcomes, safety, and experience (Chiu et al., 2022). CMS ties a percentage of Medicare payments to the quality of care to facilitate more quality and patient-focused care by healthcare professionals. Never Events Never events are serious, avoidable, as well as expensive medical errors that cannot be experienced in any healthcare setting. They could be wrong body part surgeries, significant pressure ulcers, and others that result in falls and cause minor injuries to patients (Fortier et al., 2023). They are considered to be unacceptable as they lead to severe damage and even death of patients (Ross, 2023). In a bid to reduce recurrences of such incidents, there has been a need to ensure that strict protocols are put in place by healthcare organizations, and there is an increasing need to make hospitals pay financially for preventable mistakes. To deal with never events, CMS has formulated policies that deny reimbursement for some avoidable medical mistakes. This is known as non-payment for preventable complications (Wood et al., 2024). Under this policy, hospitals have been made responsible in terms of patient safety through the denial of payment in care involving never events like hospital-acquired infections or wrong-site surgery. The concept is to encourage caregivers to improve their safety measures and prevent such preventable cases to improve patient safety. References Chiu, N., Aggarwal, R., Song, Y., & Wadhera, R. K. (2022). Association of the Medicare value-based purchasing program with changes in patient care experience at safety-net vs. non–safe–net hospitals. Journal of American Medical Association (JAMA) Health Forum, 3(7). https://doi.org/10.1001/jamahealthforum.2022.1956 Fortier, J. H., Garber, G., Gorter, R. D., Bowman, C. L., & Zaslow, J. (2023). Identifying a list of healthcare “never events” to effect system change: A systematic review and narrative synthesis. British Medical Journal (BMJ) Open Quality, 12(2). https://doi.org/10.1136/bmjoq-2023-002264 Ross, T. K. (2023). Baker healthcare finance: Basic tools for nonfinancial managers (6th ed.). Jones and Barlett Learning. https://www.jblearning.com/catalog/productdetails/9781284233186 Wood, D., Beauvais, B., Sturdivant, R., & Kim, F. (2024). Evaluating the effect of financial penalty on hospital-acquired infections. Risk Management and Healthcare Policy, 17, 2181–2190. https://doi.org/10.2147/rmhp.s469424 Ying, M., Forman, J. H., Murali, S., Gauntlett, L. E., Krein, S. L., Hollenbeck, B. K., & Hollingsworth, J. M. (2024). Factors affecting ACOs’ decisions to remain in or exit the Medicare shared savings program following pathways to success. Health Affairs Scholar, 2(1). https://doi.org/10.1093/haschl/qxad093
