Discussion: Unintended Consequences of Health Care Reform NURS 8100

A Sample Answer For the Assignment: Discussion: Unintended Consequences of Health Care Reform NURS 8100

With the introduction of Accountable care organizations (ACO) health care quality has improved along the reduction in cost (Moore & Coddington,2010). Ensuring that companies are monitored and the quality of care they provide for their patient is measured holds them accountable and ensures that the patient is getting the best quality care. Since 2013 Medicare has used the Value-based purchasing (VBP) program as financial bonuses and penalties for hospital depending on their quality improvements (Carroll & Clements, 2021). 

With the introduction of the VBP program overall 24% of hospital improved, 14% were consistent and 18% performed well another 11% of hospitals were penalized and for some variables they could not control (Carroll & Clement, 2021). Overall, the VBP program is a tool to help to improve quality on monitoring the care patients are receiving.  

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Working as a nurse for the federal government we not only have to follow hospital regulations, but we must follow federal regulations. I work at a great hospital, but since I am part of the federal system then, if something bad happens at one hospital in the federal system it gives the entire system a bad reputation. We like all other hospitals to get surprised visits from Joint Commission on Accreditation of Health care Organizations (JCAHO) to see first-hand how we perform daily, inspect our hospital, and see the quality of care we are giving our patients (Dlugacz, 2005). Along with exceeding JCAHO standards we must meet federal regulations, which we do, and it is not about just passing test, it is about providing the best care possible to your patients, which is why our patients continue to come back to us for their health care.  

Reference  

Carroll, N. W., & Clement, J. P. (2021). Hospital Performance in the First 6 Years of Medicare’s Value-Based Purchasing Program. Medical Care Research and Review : MCRR, 78(5), 598–606. https://doi.org/10.1177/1077558720927586  

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Dlugacz, Y. (2005). Handling a surprise JCAHO inspection. Surprise! It’s JCAHO. Regular communication with staff is the best way to stay prepared. Modern Healthcare, 35(46), S10–S11.  

Moore, K. D., & Coddington, D. C. (2010). Accountable care the journey begins. Healthcare Financial Management, 64(8), 57-63. Retrieved from https://www.proquest.com/trade-journals/accountable-care-journey-begins/docview/746684537/se-2?accountid=14872  

The PPACA of 2010 fostered new provisions for health care and the structure of health
care delivery. The individual mandate to obtain insurance is one provocative provision.
While this provision attempts to increase access to health care, it raises questions on
how the existing system could sustain the potentially large influx of newly insured
individuals.
Another provision calls for new models of health care provider organizations to ensure
delivery efficiency and continuity of care. In this week’s media presentation, Dr.
Kathleen White discusses the accountable care organization, which comprises a group
of providers coordinating care across a variety of institutional settings. Yet becoming an
accountable care organization may present a number of challenges.

In California, one of the common ACOs is the Shared Savings Programs (SSP) which is a voluntary program that is formed to encourage hospitals, doctors and other health providers in the country to come together as accountable care organizations. The organization gives coordinated and high-quality care to members who are beneficiaries of Medicare.

The SSP was formed wit the intention of moving the payment system of Medicare from a volume perspective to outcome and value-based (Lipa, 2020).  SSP has significantly impacted population health in California. By coming together, SSP has improved the quality of care to patients who could not have afforded such care.

The SSP ensures that patients from different areas in the state get the correct care at the right time. Quality care also means that patients do not go for unnecessary tests. Another way that SSP has impacted population health in California is by focusing on preventative care through coordination of services across the different levels of care (Milwee, 2020).

The concept of bundled care.

Bundled care is a concept that entails Medicare implementing voluntary episode of payment models.  Medicare used to make individual payments to individual services offered to patients. In Bundled care, all payments are combined in a single payment for physicians and hospital facilities.

Bundled care increases the incentives for providers to work together to deliver patient care. Bundled care exposes healthcare facilities to certain risks and challenges. Some of the risks of bundled care include the fact that patients may have comorbidities (Agrwal, 2020). This is where some patients might require expensive treatment procedures that are uncontrollable by the provider. Another risk of bundled care in handling cases of uncompliant patients.

The Accountable Care Organization (ACO)s are defined as are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients and reductions in the rate of spending growth for a defined patient population (Wilson et al., 2020).

The goal of this harmonized kind of care is to ensure that patients get the right care at the right time, in addition to minimizing or totally avoiding unnecessary duplication of services as well as the prevention of medical errors. The ACOs are dedicated to quality and efficient care, e.g, Medicare has a shared services program, where healthcare organizations meet quality benchmarks while reducing spending by a certain percentage to qualify for cost savings.

They also have the authority to impose practice, reporting, and compensation standards including penalties and rewards across a group of physicians on behalf of the patient population (Wilson et al., 2020). The providers are responsible for ensuring the objectives of the coordination are met completely and embody alternative payment models capitation (Blackstone, & Fuhr, 2016). 

They are also primarily accountable to patients and third-party payers for high quality, efficient, and competency-based care, equating provider reimbursements to quality metrics and reducing the cost of care while at it (Burke, 2011).

The ACOS organizations have various advantages, they improve the population health of the community that they serve by increasing emphasis on preventive care, providing basic but essential primary care services, and lowering the cost to the patients (Blackstone, & Fuhr, 2016). This is through preventive care, and increasing operational efficiencies which reduce the chances of readmissions, thereby saving on the operational cost which translates to low patient charges. 

The other advantages include fostering quality through the greater clinical integration of care, across healthcare settings, greater financial efficiency, and increased transparency and information about the process, costs, and outcomes of health care (Colla & Fisher, 2017). Other positive results achieved include having the providers meet patient-centeredness criteria, as developed by the Secretary of HHS, with a focus on strategies to engage patients better and actively in their health, measure patient satisfaction, and increase patient accountability (Burke, 2011). 

It also mandates that both the providers and patients are expected to be mutually accountable for following a predetermined treatment plan. It equips the patients with the knowledge to discuss and request the care they feel they need, instead of completely depending on the physician’s advice and orders (Burke, 2011).

One of the unintended consequences of OCAs is that physician integration with hospitals was associated with higher outpatient spending that did not appear to be warranted by the observed differences in disease burden. This has implications for potential harms from increased hospital market power spurred by consolidation with physicians under ACO formation (Lin et al., 2021). My current organization does not participate in ACOs because it has yet to meet the required quality benchmarks for participation and to focus on prevention and managing patients with chronic diseases (Colla & Fisher, 2017).

References

Blackstone, E. A., & Fuhr, J. P., Jr (2016). The Economics of Medicare Accountable Care Organizations. American health & drug benefits, 9(1), 11–19.

Burke T. (2011). Accountable care organizations. Public health reports (Washington, D.C.: 1974), 126(6), 875–878. https://doi.org/10.1177/003335491112600614

Colla, C. H., & Fisher, E. S. (2017). Moving Forward with Accountable Care Organizations: Some Answers, More Questions. JAMA Intern Med. 177(4):527–528. doi:10.1001/jamainternmed.2016.9122

Lin, M.-Y., Hanchate, A. D., Frakt, A. B., Burgess, J. F., Jr, & Carey, K. (2021). Do accountable care organizations differ according to physician-hospital integration? A retrospective observational study. Medicine, 100(12), e25231. https://doi.org/10.1097/MD.0000000000025231

Wilson, M., Guta, A., Waddell, K., Lavis, J., Reid, R., & Evans, C. (2020). The impacts of accountable care organizations on patient experience, health outcomes, and costs: a rapid review. Journal of Health Services Research & Policy, 25(2), 130–138. https://doi.org/10.1177/1355819620913141

This week’s Discussion builds on Week 1, continuing the examination of those societal
and organizational contexts that influence health care reform. The unintended
consequences of reform policy on the health care system are also considered.

To prepare:

 Review this week’s media presentation and the other Learning Resources focusing on
how reform may lead to improved quality, greater access, and reduced cost of care.
Also think about the unintended consequences that may arise as a result.
 Consider the information presented about the individual mandate and accountable care
organizations. What are some questions or concerns you might have regarding the
individual mandate? What are the pros and cons associated with becoming an
accountable care organization?
 With posting instructions in mind, select either the individual mandate or accountable
care organizations as the focus of your Discussion this week.

By Day 3

Post a cohesive response that addresses the following:
 In the first line of your posting, identify the topic you have selected—either the individual
mandate or accountable care organizations. With regard to this topic, describe one or
more positive results that could be achieved, and one or more unintended
consequence(s) that organizations or individuals may experience.
 Briefly evaluate issues on the topic that may be a consideration for the organization you
work in and the nursing profession.
Read a selection of your colleagues’ postings.

By Day 6

Respond to at least two of your colleagues in one or more of the following ways:
 Ask a probing question, substantiated with additional background information, evidence
or research.
 Share an insight from having read your colleagues’ postings, synthesizing the
information to provide new perspectives.
 Offer and support an alternative perspective using readings from the classroom or from
your own research in the Walden Library.
 Validate an idea with your own experience and additional research.
 Make a suggestion based on additional evidence drawn from readings or after
synthesizing multiple postings.
 Expand on your colleagues’ postings by providing additional insights or contrasting
perspectives based on readings and evidence.
Note: Please see the Syllabus and Discussion Rubric for formal Discussion question
posting and response evaluation criteria.
Return to this Discussion in a few days to read the responses to your initial posting.
Note what you learned and/or any insights you gained as a result of the comments
made by your colleagues.
Be sure to support your work with specific citations from this week’s Learning
Resources and any additional sources.
Submission and Grading Information
Grading Criteria
To access your rubric:

Week 2 Discussion Rubric
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
Week 2 Discussion

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Learning Resources

Note: To access this week’s required library resources, please click on the link to the
Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Bodenheimer, T., & Grumbach, K. (2016). Understanding health policy: A clinical
approach (7th ed.). New York, NY: McGraw-Hill Medical.
 Chapter 5, “How Health Care is Organized – I: Primary, Secondary, and Tertiary
Care”
 Chapter 6, “How Health Care is Organized – II: Health Delivery Systems”
McClellan, M. (2010). Accountable care organizations in the era of health care
reform. American Health & Drug Benefits, 3(4), 242–244.
Note: You will access this article from the Walden Library databases.

The PPACA of 2010 encourages the formation of accountable care organizations
(ACOs) to improve the quality and efficiency of health care delivery. An ACO is a group
of health care providers who coordinate care for their Medicare patients and share the
financial incentives of health care improvement gains.
Moore, K. D., & Coddington, D. C. (2010). Accountable care: The journey
begins. Health Care Financial Management, 64(8), 57–63.

Note: You will access this article from the Walden Library databases.

This article provides information on the importance of health care provider organizations
taking steps to become accountable care organizations (ACOs) and provides examples
of systems that have historically functioned in this capacity. The authors also provide
steps for developing and transitioning to an ACO structure.
Institute of Medicine. (2010). The future of nursing: Leading change, advancing
health. Retrieved from http://www.nationalacademies.org/hmd/Reports/2010/The-
Future-of-Nursing-Leading-Change-Advancing-Health.aspx

This report discusses how nurses can and should play a fundamental role in meeting
the challenges of increased demand for health care brought about by the
implementation of the 2010 Affordable Care Act. In addition, it stresses the need for
nurses to be partners with other health professionals and assume leadership roles in
redesigning health care in the United States.
Institute of Medicine. (2010). Report brief: The future of nursing: Leading change,
advancing health. Retrieved
from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-
Future-of-Nursing/Future%20of%20Nursing%202010%20Recommendations.pdf

This report brief highlights the four key recommendations from the Robert Wood
Johnson and Institute of Medicine The Future of Nursing: Leading Change, Advancing
Health report. The recommendations focus on nursing practice, education and training,
partnerships with other healthcare professionals, and workforce planning and
policymaking.
HealthCare.gov. (n.d.). Understanding the Affordable Care Act. Retrieved from
http://www.hhs.gov/healthcare/rights/index.html

This website introduces the Affordable Care Act and presents the timeline for
implementation of the various provisions of the Act.
HealthCare.gov. (n.d.). Understanding the Affordable Care Act: About the law.
Retrieved from http://www.hhs.gov/healthcare/rights/law/index.html

Read the full Affordable Care Act law at this website. An overview of the law is also
provided along with an outline of how the Affordable Care Act helps reduce health
insurance costs.

Required Media

Laureate Education, Inc. (Executive Producer). (2011). Healthcare policy and advocacy:
Reforming health care delivery: Accountable care organizations. Baltimore: Author.
Note: The approximate length of this media piece is 7 minutes.

In this media presentation, Dr. Kathleen White explains the structure of accountable
care organizations (ACO) and discusses the benefits and challenges of becoming an
ACO.

Accessible player
Optional Resources

APRN Joint Dialogue Group Report. (2008). Consensus model for APRN regulation:
Licensure, accreditation, certification & education. Retrieved
from https://www.aacnnursing.org/Education-Resources/APRN-Education/APRN-
Consensus-Model
Fisher, E. S., & Shortell, S. M. (2010). Accountable care organizations: Accountable for
what, to whom, and how. JAMA: Journal of the American Medical Association, 304(15),
1715–1716.
Fisher, E. S., Staiger, D. O., Bynum, J. W., & Gottlieb, D. J. (2007). Creating
accountable care organizations: The extended hospital medical staff. JHealth Affairs,
26, w44-w57. doi:10.1377/hlthaff.26.1.w44–57
McClellan, M., McKethan, A. N., Lewis, J. L., Roski, J., & Fisher, E. S. (2010). A
national strategy to put accountable care into practice. Health Affairs, 29(5), 982–990.
Kaiser Health News. (2011). Accountable care organization proposed regulations:
Resources. Kaiser Family Foundation. Retrieved
from http://www.kaiserhealthnews.org/Stories/2011/March/31/ACO-Documents-In-The-
News.aspx

Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  The healthcare payment process is undergoing a dramatic transformation as payers and providers shift from volume to value.

While stakeholders are currently piloting many different value-based care models, accountable care organizations are among the most popular and successful strategies to date. Accountable care organizations, or ACOs, are groups of hospitals, physicians, and other providers who agree to coordinate care for patients and deliver the right care at the right time, while avoiding unnecessary utilization of services and medical errors.

ACO participants also agree to take on responsibility for the total costs of care for their patients. ACOs that reduce the total costs of care for their patient populations can share in the savings with the payer.  In certain models, they may also be liable to pay back losses if their costs exceed their spending benchmarks (Moore et al., 2017).

Policymakers and healthcare leaders believe tying financial incentives to care quality, patient outcomes, and care coordination through ACOs is a key solution for fixing the inefficient fee-for-service system. The programs encourage providers to partner with others across the care continuum. Some providers are formally acquiring to gain control over a wide range of services, achieve economies of scale, and access the technology, data, and clinical capabilities of their peers.

In fact, ACOs are and are likely to continue to be a major player in the value-based care and payment transformation. When all the parts work together, providers in an ACO can bring down costs and improve care quality while earning incentive payments. HMOs, on the other hand, seek to cut costs by setting fixed prices for services, which may encourage providers to reduce utilization or skimp on care in an effort to stay under the cap(Colla et al., 2018).

References

Colla, H., & Fisher, E. S. (2018). Moving forward with accountable care organizations: some answers, more questions. JAMA internal medicine, 177(4), 527-528. https://doi.org/10.1001/jamainternmed.2016.9122

Moore, K. D., & Coddington, D. C. (2017). Accountable care the journey begins. Healthcare Financial Management, 64(8), 57-63. Retrieved from https://www.proquest.com/trade-journals/accountable-care-journey-begins/docview/746684537/se-2?accountid=14872