Abstract
The transformation of the Primary Care Practices (PCP) into The Patient- Centered Medical Home (PCMH) model is expected to improve patient’s care, comprising even the ones with complex needs. According to Rich et.al (2012), PCMH is expected to reduce the risks associated with fragmented care and poor outcomes. The paper will also address factors as whether or not patient health care needs and even preferences are being met, whether the care is appropriate for the illness, timeliness, and procedures involved. Moreover, it will comprehensively address the state of provider contracting and its direction in the future. Nonetheless, the paper will also discuss how cost containment deals with managing health care costs within a specific budget while restricting expenditures to deliver a particular financial target. Moreover, the report will provide insight into the effects of Medicare and Medicaid in managed health care and its direction in the health care system. Furthermore, the paper will list the future role of government regulations, to include ERISA and HIPAA health care policies. In the end, the paper will list three recommendations connected to quality and change in Medicare and Medicaid managed health care plans.
The Patient- Centered Medical Home (PCMH) model
The transformation of the Primary Care Practices (PCP) into the PCMH model is expected to improve patient’s care, comprising even the ones with complex needs. In the past, patients with complex needs have always suffered because of the discrimination from the health care system. According to Rich et.al (2012), PCMH is expected to reduce the risks associated with fragmented care and poor outcomes. It should guarantee better care and management of chronic diseases and mental illness in the population. Moreover, it also increases the probability to assure preventive services for the grown-ups or any other population that is vulnerable to physical disabilities.
Factors as whether or not patient health care needs and even preferences are being met
The Patient- Centered Medical Home (PCMH) model inspires most Americans with its promise of improving health care delivery across the US. The PCMH aims at transmuting the organization and delivery of primary care services.
The PCMH model entails five functions and characteristics
Comprehensive care
The PCMH model is held responsible for offering health care needs to the patients in many ways. It plays an essential role towards promoting physical and mental health care needs, acute care, prevention and wellness, and chronic care. In the model, numerous health care practitioners join hands in ensuring that the patients’ needs are met (Rich et.al, 2012). The PCMH model encourages the largest health care organizations to bring together a multi-skilled team of qualified professionals. Moreover, it emboldens the smaller health care institutions to build virtual teams that will connect patients to healthcare services.
Patient-centered
The PCMH model offers relationship-based health care and focuses on an individual needs and preferences. It provides and support those seeking health care needs with information and knowledge to manage and organize their individual care (Jackson et.al, 2013).
Coordinated care
The PCMH model is centered on coordinating health care services across the entire health care system, comprising of specialty care, home health care, hospitals, and community services and support (Nielsen et.al, 2012). The coordinated care is essential during the transition in health care services and operates on an effective communication system.
Accessible services
The PCMH ensures quality health care services to the patients and has reduced the waiting times in health care delivery sites. It improves accessibility and guarantees that the preferences of patients will be met.
Quality and safety
The evidence-based medicine and clinical decision-support systems have helped the PCMH to remain committed to offering quality health care to the people in need. The patients and their families are consulted and given a chance to make decisions in health care delivery. It responds to the experiences of patients and also measures their satisfaction (Rich et.al, 2012). The PCMH promotes the distribution of vigorous quality and safety data which is used in health care system to make an evidence-based decision, thus improving quality.
Stakeholders support the PCMH model because of its capacity to involve patients claiming that the model is intrinsically valuable. Although the model is yet to indicate whether it improves health care outcomes or lower costs associated with care services. There is a need to conduct extensive research so as to understand the best approaches that can be integrated into primary care settings. A study conducted by Jackson et.al (2013) illustrated that the PCMH model had the likelihood to improve the experiences of both the staff and patients, but also depicts the lack of evidence of the model contributing to overall cost savings.
Provider contracting
Provider Contracting is when doctors and health care practitioners have a contract agreement through a third party payer to accept a specified payment for services provided to patients.Provider contracting has become very popular in the last two decades. As a matter of fact, the health care delivery system has numerous perceived inefficiencies that can be reduced through provider contracting services. In the process, it is assumed that the accessibility, efficiency, equity, and quality of health care will be improved. Provider contracting entails the contracting out of particular health care services through government agencies or private and autotomized public providers. The proponents of contracting of health care services argue that it will enhance health care service delivery by encouraging healthy competition amongst providers and by introducing economic incentives for enhanced performance. The different approaches to contacting health care delivery services include government services, inter-government agreements, management contracts, service delivery contracts, grants to the private sector, vouchers, franchising, and private sector services (Loevinsohn & Harding ,2005).
According to Loevinsohn & Harding (2005), contracting out health care services has been associated with numerous attractive features. First, it ensures a greater focus on the accomplishment of measurable results, particularly if the contacts describes the verifiable outcomes and outputs. It also overwhelms the limitations that block the government from effectively utilizing the available resources made to them. Nonetheless, it offers an opportunity to the private sector which is flexible and able to improve health care services. Furthermore, provider contracting increases managerial autonomy and decentralizes decision-making to executives at the lower level of the health care system. Provider contracting is the future of health care system because it takes advantage of competition to improve the efficiency and effectiveness of care delivery. In the process, the government will pay attention to unique roles like financing, standard setting, planning, and regulation, amongst others.
Cost containment
Cost Containment deals with managing the costs of doing business within a specified budget while restraining expenditures to meet a specified financial target. Cost containment in the healthcare system is becoming a thing of the present and the future. Ginsburg (2013) article discusses achieving health care cost containment through provider reform that engages patients and providers. The health care system focuses on pursuing cost containment by inducing reforms in provider payment to steadily lessen the role of fee-for service reimbursement. In the recent past, public and private payers have introduced numerous promising payment reform that focuses on integrating fee-for-service with approaches in payment centered on the wide-ranging units of care, for example, the patient’s total need within a specific duration (Ginsburg, 2013). Medicare and Medicaid are therefore expected to introduce stronger incentives for providers to play a crucial role in cost containment. The Medicare and Medicaid model must be designed in a manner at which it will engage the beneficiaries, through introducing incentives for patients to register in already proven care organizations. As a result, the enrollment will ensue that patients receive care offered with a team of highly qualified personnel (Ginsburg, 2013).
The best chance for cost containment is via provider payment reform that detaches from fee-for-service payment. The plans to abandon the fee-for-service payment were put in place because it ended up rewarding greater volume and lacks the capability to support the coordination of care, or the management of chronic diseases (Ginsburg, 2013). The cost containment model will involve and reward providers’ physicians and patients for plummeting costs and increasing quality. Cost containment will create new payment methods that will induce motivation to practitioners, and they will be focused to offer improved delivery approaches. The physicians will also be motivated to eliminate redundancy in health care services. Better health care means the efficiency and effectiveness as the coordination are guaranteed and patient education is enhanced.
Cost-containment is also supported by establishing a performance-based payment system that is better placed to control costs as well as improve the quality of health care is challenging. To date, it has proved difficult determine how large a performance incentive is indispensable to influence the behavior of physicians. Furthermore, it is challenging to determine the manner at which the savings will be measured. For instance, will it be determined by the costs contained under the programs in comparison to a control group, baseline measure of cost, or the trend? Moreover, will be possible to measure the effect on overall costs like annual expenditures for the old-aged in Medicaid. There are also other prevailing challenges like the ability to consolidate a high number of payers that apply the similar pay-for-performance incentives to establish the impact of the program.
The performance-based payment system should implement complementary strategies that will induce a positive impact in cost containment. For example, it should be integrated with other payment methods and programs in health care system. It is essential to incorporate global payments like risk-adjusted capitation programs, medical homes and care coordination, and disease management programs. When the performance-based payment system is integrated with the complimentary strategies, it will automatically lead a superior level of cost containment.
Effects on Medicare and Medicaid in managed health care appear to be moving in a direction where both types of recipients will be enrolled in some type of managed health care plan soon. Pittman (2013) asserts that “roughly 85% of Medicaid enrollees will be in managed care organizations by 2020.” In the current times, “almost half of Medicaid beneficiaries are in managed care, and roughly over 78% of reimbursements come from fee-for-service” (Pittman, 2013). Moreover, at the AGM of the Medicaid Health Plans, it was speculated that “there is tremendous upside potential for serving this population going forward” (Pittman, 2013). Medicaid under the Affordable Care Act will expand, and the government will be required to allocate a bigger percentage of the budget as the enrollment propagates. The states and the federal government aim at turning to managed care to better handle costs for particular populations. In this conferences, various speakers agreed that “the traditional fee-for-service had become a thing of the past” (Pittman, 2013).
A Kaiser Family Foundation Survey conducted in 2012 indicated that a total of 36 states and the District of Colombia has already contracted the managed care organizations on a risk basis (Pittman, 2013). Moreover, over half of the states in the US had already contracted managed care plans for particular services; nonemergency transportation, behavioral health, prescription drugs, or dental care. The enrollment in Medicare promises the improvement of health care services because it assures an improvement in care coordination initiatives. In the future, more states will be enrolled for managed long-term care unlike in the past. The introduction of Medicaid health homes is also becoming prevalent because of the assured coordination between medical practitioners. The advancement of managed care means the health care providers will become more responsible in patient’s care. Medicaid will be treated as a single unit charged with the responsibility to ensure positive outcomes in hospitals and other care institutions. According to Pittman (2013), the state Medicaid programs aims to improve manage care by asking clients to share their confidential information to with primary care providers. The persons who are still covered by the ACA’s Medicaid will focus to be under managed care. Therefore, to induce a positive change, the Medicaid programs, and other health plans must ensure that they create an environment and system that convince people to appreciate the gains from managed care. The managed health care plans may appear highly complicated, but its cost and quality standpoint are enormous. It is the future.
The future of government regulations
The government regulations might influence managed care as well as services provided to the patients in future. HIPPA and ERISA are the two examples of the government regulations. Health Insurance Probability and Accountability Act limits the previous existent medical circumstances excluding health insurance coverage. It launches a period of half a year before the enrolment where the progress of new circumstances could be viewed pre-existing. Moreover, HIPPA composes of two parts known as the title I and II (Fox & Kongstvedt, 2013).
Fox & Kongstvedt (2013) proclaims that Title II drafts numerous rules that focus on upgrading the efficiency of health care systems by creating standards to be employed. Moreover, Title II spreads information in the health care sector. The rules include transactions rule, security rule, and privacy rules. The privacy rule sets standards for the shielding of individually identifiable health information (Fox & Kongstvedt, 2013). Another rule is the security rule which refers setting national standards for protecting the confidentiality, integrity, and availability of electronic protected health information. The enforcement rule offers principles for the implementation of the administrative simplification rules. It comprises of the standards that must satisfy the employee benefits plans to meet the requirements for appropriate tax treatment. Act to reinforce the privacy and security shields for health information recognized under HIPAA, concluding the breach notification rule. Therefore, ERISA influences the quality of services offered to patients (ibid).
Fox & Kongstvedt (2013) addresses that the employee retirement income security act of 1974 refers to the minimal standards for the established pension and health plans in private industry to offer protection for individuals in these plans. These principles focus on safeguarding individuals who are presently listed in the scheme. ERISA require health plans to provide its members with data that illustrate the characteristics of the plan and funding. Schymik & Shoemaker (2013 postulates that it is a mandate for the managed care institutions to adhere to the stipulated government organizations. Non-adherence to these conditions will influence the future of the managed care facilities as the government will prohibit the organizations.
Recommendations
Improvement of the managed care
The managed care should be improved as an initiative to augment the quality of life provided to the patients. Managed care has made it effortless to upgrade the quality of life via cost reduction and financial incentives programs. It has become an obligation among the health practitioners to ensure that they comply with the rules set. In the recent times, these health personnel lacks ample time to spend with the patients.
Managed care should strive to create an equilibrium between the quality of care and reduced expenses.
Maintaining a balance between these two variables is valid to escape ethical and moral concerns related to the managed care systems. The patients will be able to enjoy managed care delivery systems due to the advantages accrued by managed care.
The managed health care programs associated with physicians should be allocated more time
The patients who have not participated in managed care programs accrue less care in comparisons to other patients. Managed healthcare affects the quality of care provided to patients because it compels the physicians to overwork themselves and use fewer drugs. Therefore, the managed care affects the quality of care in various modes. As described, it is evident that managed care affects the quality of care and life. The majority of people enjoy healthy life if they have access to proper medical care.
Accelerated amendment of ERISA
Employee Retirement Income Security Act of 1974 (ERISA) should be reformed to maximize the protections for employees whose proprietors have access to personal medical information via health-insurance plans. The employers or their representatives have reasonable interests in this information.
Accreditation and Monitoring
The states should be anticipated to screen out the Medicare and Medicare health plans. The states should compose the data from claims management and marketing to offer more confidence on comparisons. States should be obligated to test particular elements such as network adequacy and the availability of services. It will be effective for the states to verify managed care plans that are accredited via organizations renowned by CMS. In addition, the States are required to support and review plans before they partner with them.
Lowering the costs of medicines offered to the patients
It is important to subsidize the costs for medicinal products because it will be the quality of life. The monetary values provided to the health practitioners have affected the quality of care rather than improving the quality of life. Their behaviors and norms prevent them from providing favorable care.
References
Fox, P. D., & Kongstvedt, P. R. (2013). A history of managed health care and health insurance in the United States. Essentials of managed health care. Burlington, Sixth Edition: Jones & Bartlett Learning.
Ginsburg, P. B. (2013). Achieving health care cost containment through provider payment reform that engages patients and providers. Health Affairs, 32(5), 929-934
Jackson, G. L., Powers, B. J., Chatterjee, R., Bettger, J. P., Kemper, A. R., Hasselblad, V., & Gray, R. (2013). The patient-centered medical home: a systematic review. Annals of internal medicine, 158(3), 169-178.
Loevinsohn, B., & Harding, A. (2005). Buying results? Contracting for health service delivery in developing countries. The Lancet, 366(9486), 676-681.
Nielsen, M., Langner, B., Zema, C., Hacker, T., & Grundy, P. (2012). Benefits of Implementing the Primary Care Patient-Centered Medical Home. Washington: Patient-Centered Primary Care Collaborative.
Pittman, D. (2013, October 21). Managed Care Seen as Future of Medicaid | Medpage Today. Retrieved from http://www.medpagetoday.com/PublicHealthPolicy/Medicaid/42397
Rich, E., Lipson, D., Libersky, J., & Parchman, M. (2012). Coordinating Care for Adults with Complex Care Needs in the PatientCentered Medical Home Challenges and Solutions (No. add34c152be143b785a961b22b414e1a). Mathematica Policy Research.
Schymik, G., & Shoemaker, D. (2013). Managing Government Regulatory Requirements for Security and Privacy Using Existing Standard Models. ICHITA-2013 TRANSACTIONS, 109(41), 112.
