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Context of Health Care Financial Management
Chapter 1
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Learning Objectives
• Identify key elements that are driving changes in health care delivery
• Identify key approaches to controlling health care costs and resulting ethical issues
• Identify key changes in reimbursement mechanisms to providers
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Lowering Costs
• Patient Protection and Affordable Care Act (ACA)
The Affordable Care Act puts consumers back in charge of their health care. Under the law, a new “Patient’s Bill of Rights” gives the American people the stability and flexibility they need to make informed choices about their health.
• CMS trying to control rising costs
• Center for Medicare and Medicaid Services (CMS) demonstrate definitively that private insurance is increasingly less efficient than Medicare.
• Value Based Purchasing (VBP)
• Payment methodology that rewards quality of care through payment incentives and transparency in health care.
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Goals of the Health Care System
• Access
• Cost
• Quality
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1. Access
• Help establish Health Insurance Marketplaces in every state to expand access to coverage for individuals and small businesses, reduce administrative expenses, and increase competition;
• Work with states to expand Medicaid coverage to more low-income Americans;
• Enhance HealthCare gov, which empowers consumers to make informed choices about health care options
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2. Cost
• Improve accessibility and integration of health care databases so researchers can identify cost-saving, health-protective, and quality-enhancing practices
• Improve management of health care cost information to identify key drivers of high costs and reduce delivery of ineffective and inappropriate care;
• Adopt and implement Affordable Care Act provisions to standardize administrative claims transactions and to achieve greater interoperability between administrative and clinical data
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3. Quality
• Identify innovative solutions to minimize harm in all settings by engaging local front-line providers, patients, and families in multi-stakeholder meetings
• Implement Learning and Action Networks to share best practices for promoting quality, patient safety, prevention, health literacy, and improved care transitions
• Improve the quality of, safety of, and access to care in long-term services and supports settings, behavioral health services, and acute care hospitals, and through state health departments;
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Changing Methods Of Health Care Financing and Delivery• Requirement that almost all individuals have insurance coverage
• Requirement that states create insurance exchanges
• Provisions for expansion of Medicaid (is a social health care program for families and individuals with low income and resources)
• Provisions for medical loss ratio and premium rate reviews
• Bundled payments and VBP
• Accountable Care Organizations
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Trends• Rise of uninsured from 36 million to 50 million 2001-2010
• ACA authorizes competitive insurance marketplace
• Rise of uncompensated care for the uninsured 2001-2011
• Accountable Care Organizations
• Patient Centered Medical Home
• New technology
• VBP
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Factors Affecting the Cost of Care
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Impacts to Reimbursement• Cost Accounting Systems
• Group Purchasing Organizations
• Reengineering/Redesigning
• Mergers and Acquisitions
• Retail Health Care
• Medical Tourism
• Compliance
• Recovery Audit Contractors (RACs)
• VBP
• New DRG System
• ICD 10
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Summary
• Health care administrator faces numerous complex issues when making strategic and financial decisions.
• High ethical standards must be demonstrated