National Health Coverage Plans, Reimbursements, and Quality Essay

National Health Coverage Plans, Reimbursements, and Quality Essay

Healthcare coverage, also known as health insurance, is an important form of financial protection that helps individuals access necessary medical services. Its primary goal is to reduce financial barriers that may prevent people from receiving needed medical care (Institute of Medicine, 2019). Healthcare coverage is critical because it ensures access to essential medical services and improves overall health and well-being. This paper examines how healthcare coverage plans, reimbursements, and quality affect vulnerable populations, as well as the role of nursing interventions in providing safe, high-quality care.

One of the primary benefits of healthcare coverage is that it provides individuals with access to preventive care services that can aid in the early detection and prevention of health issues (WHO, 2021). Routine check-ups, screenings, and immunizations are critical for detecting health problems early, making treatment more accessible, and preventing more serious complications. This is especially important for vulnerable and uninsured populations, who may lack the resources to address health issues once they become more serious.

Healthcare coverage can provide financial protection from unexpected medical expenses and improved access to preventive care. A medical emergency can cause significant financial hardship and even bankruptcy for uninsured people. On the other hand, individuals with healthcare coverage can receive necessary medical care without worrying about the financial burden it may place on them or their families. This can provide individuals with peace of mind and ensure they receive the care they require to maintain their health and well-being.

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Diagnosis Related Groups (DRGs)

Diagnosis Related Groups (DRGs) were introduced in the 1970s as a method of categorizing and reimbursing healthcare providers based on the patient’s diagnosis (Zou et al., 2020). DRGs were created to simplify and standardize the reimbursement process for hospitals, insurance companies, and the government while ensuring patients receive appropriate care for their diagnoses.

DRGs have significantly impacted the length of hospital stays and the payment of medical services. Under the DRG system, hospitals are paid a fixed rate for each patient based on their diagnosis, regardless of the length of stay (Zou et al., 2020). This means that hospitals have a financial incentive to discharge patients as soon as they are stable enough to be treated on an outpatient basis, which has led to a decrease in the length of hospital stays.

In addition to affecting the length of hospital stays, DRGs have significantly impacted the payment of medical services. The DRG system has shifted the focus of healthcare providers from the number of services provided to the quality of care delivered (Zou et al., 2020). Providers are now incentivized to provide efficient and effective care that leads to positive patient outcomes rather than unnecessary tests and procedures.

The quality of patient care has increasingly influenced payments for Diagnosis Related Groups (DRGs) in recent years. Instead of providing unnecessary tests and procedures to increase revenue, healthcare providers are now incentivized to provide high-quality care that results in positive patient outcomes.

The Centers for Medicare and Medicaid Services (CMS) has implemented programs such as the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program (HRRP) that tie payment to the quality of care provided. These programs incentivize hospitals to improve their performance on various metrics, including patient satisfaction, clinical outcomes, and efficiency (Kim et al., 2022). For example, hospitals may be paid more if they provide high-quality care that reduces readmissions or complications. Alternatively, if hospitals have a high rate of readmissions or fail to meet quality standards, they may face penalties. These payment reforms have significantly impacted the healthcare industry, shifting the emphasis from volume-based to value-based reimbursement. Providers are now incentivized to prioritize high-quality care that results in positive patient outcomes over providing unnecessary or low-value services to increase revenue.

BlueCross BlueShield (BCBS) Preferred Provider Organization (PPO) Plan

Nursing Quality Indicator (NQI): Pain control in advance cancer.

Patient: John Smith, diagnosed with stage 4 colorectal cancer.

Access-Facilitating Care Options

John Smith has stage 4 colorectal cancer, and the BlueCross BlueShield (BCBS) Preferred Provider Organization (PPO) Plan provides care access options. One advantage of the BCBS PPO Plan is its extensive network of in-network healthcare providers (Nall, 2021). This means that John can receive medical care from physicians and hospitals with whom the plan has a contract, resulting in lower costs and fewer out-of-pocket expenses. The in-network providers ensure that John receives the medical care to manage his cancer effectively.

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Telehealth services are another access-facilitating care option offered by the BCBS PPO Plan. John has mobility issues, making it difficult for him to get to the doctor’s office. Telehealth services enable John to receive medical care from the comfort of his own home or office, which is especially advantageous for him. John can consult with his healthcare provider and receive the care he requires using telehealth. This convenience ensures that John receives the medical care he requires to effectively manage his cancer, even when he cannot travel to a healthcare facility.

Access-Limiting Care Options

Access-limiting care options can be challenging for patients seeking medical care, such as John Smith, who has been diagnosed with stage 4 colorectal cancer. Out-of-network providers can be an option for John, but he may have to pay more out of pocket. This may pose a significant barrier to care for patients who cannot afford higher costs. In addition, the BCBS PPO Plan may require preauthorization before providing coverage for certain medical procedures or treatments. Preauthorization can be a time-consuming process, delaying John’s access to necessary medical care, and may limit his options if the plan does not approve the treatment or procedure recommended by his healthcare provider.

Medicaid

Nursing Quality Indicator (NQI): Pain control in advance cancer

Patient: John Smith, diagnosed with stage 4 colorectal cancer

Access-Facilitating Care Options

John Smith has stage 4 colorectal cancer, a serious and life-threatening condition requiring immediate and extensive medical attention. As John navigates the challenges of his diagnosis, he may benefit from Medicaid’s access-facilitating care options (Medicaid.gov, 2022). One of Medicaid’s most significant benefits is its ability to provide low- or no-cost medical care to eligible individuals such as John. Medicaid removes the financial burden of healthcare services and medications, allowing John to focus on receiving the medical care he requires without worrying about the costs. Furthermore, Medicaid may provide transportation assistance to patients like John who cannot attend medical appointments. John can ensure that he receives the necessary medical attention by receiving rides to and from medical appointments, regardless of mobility issues or limited transportation options in his area.

Access-Limiting Care Options

In John Smith’s case, the limited provider networks of Medicaid plans may restrict his access to his preferred healthcare provider or specialist, affecting the quality of care he receives (Medicaid.gov, 2022). This could also lead to delays in receiving treatment, which could worsen his condition.

Similarly, prior authorization requirements may create barriers to accessing necessary medical care for John (Medicaid.gov, 2022). Suppose his healthcare provider recommends a treatment or procedure not covered by his Medicaid plan or requires prior authorization. In that case, he may experience delays in receiving the care he needs or be unable to access it.

Priority Nursing Interventions/Considerations

Assess the patient’s knowledge and understanding of their condition and treatment plan: It is critical to assess the patient’s knowledge and understanding of their condition and treatment plan to ensure they can follow the prescribed regimen and make informed health decisions. This can be accomplished by asking open-ended questions, educating the patient, and reviewing the patient’s medical records.

Encourage and support the patient’s involvement in their care: Involving them in their care can help empower them to take an active role in their recovery and self-care. This includes providing resources and guidance to help them make informed decisions about their health and treatment plans.

Provide resources to support the patient’s learning needs: Providing resources such as educational materials, online resources, and referrals to support groups is essential to ensure the patient has the information to make informed decisions about their health and self-care.

Monitor the patient’s physical, emotional, and social well-being: Monitoring the patient’s physical, emotional, and social well-being is important in promoting self-care and ensuring the patient’s overall health and well-being. This includes assessing for potential signs and symptoms of distress, providing emotional support and referrals to mental health services when necessary, and providing resources to help the patient manage their condition.

Conclusion

Healthcare coverage is an essential component of healthcare systems that helps ensure everyone has access to quality healthcare. Diagnosis Related Groups (DRGs) have significantly impacted the length of hospital stays and the payment of medical services and DRG payments are now increasingly influenced by the quality of care provided to patients. BlueCross BlueShield (BCBS) and Medicaid offer access-facilitating care options such as in-network healthcare providers, telehealth services, transportation assistance, and access-limiting care options such as limited provider networks and prior authorization requirements. To promote self-care, the nurse must assess the patient’s knowledge and understanding of their condition and treatment plan, encourage and support their involvement in their care, provide resources to support the patient’s learning needs, and monitor their physical and emotional health and social well-being.

References

Institute of Medicine. (2019). Effects of health insurance on health. Nih.gov; National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK220636/

Kim, H., Mahmood, A., Hammarlund, N. E., & Chang, C. F. (2022). Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Frontiers in Public Health, p. 10, 882715. https://doi.org/10.3389/fpubh.2022.882715

Medicaid.gov. (2022). Medicaid. Medicaid.gov. https://www.medicaid.gov/medicaid/index.html

Nall, R. (2021, December 2). Blue cross blue shield Medicare advantage plans 2021 – healthline.com. Healthline. https://www.healthline.com/health/medicare/blue-cross-medicare-advantage-plans

WHO. (2021, April 1). Universal health coverage (UHC). Who. Int; World Health Organization: WHO. https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)

Zou, K., Li, H.-Y., Zhou, D., & Liao, Z.-J. (2020). The effects of diagnosis-related groups payment on hospital healthcare in China: a systematic review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4957-5

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Activity 1
National Health Coverage Plans, Reimbursements, and Quality
Baccalaureate education includes learning opportunities of healthcare policy, finance, and regulatory environments (AACN, 2008).
Introduction & Healthcare Coverage and Vulnerable Populations
Describe the importance of healthcare coverage (insurance). End with a clearly worded purpose statement for this project. Discuss two ways healthcare coverage is beneficial (helpful) for the vulnerable/ uninsured populations.
Diagnosis Related Groups
Describe the purpose of Diagnosis Related Groups (DRGs). Explain the impact of DRGs on length of stay and payment of services. Discuss how payments for DRGs are now impacted by quality indicators and measures.
Select a Major Healthcare Plan
(Label heading with the name of the plan Ex: Preferred Provider Option Plan)
Select one of the patients from the cases you reviewed in NQI. Summarize two care options provided by the plan that facilitates access for your selected patient. Summarize two care options that limit access to care for your selected patient.
Select a Second Major Healthcare Plan
(Label heading with the name of the plan Ex: Medicaid)
Repeat this activity with the same patient. Summarize two care options provided by the second plan that facilitates access for your selected patient. Summarize two care options that limit access to care for your selected patient.
Impact of Nursing Interventions
Summarize at least four priority nursing interventions or considerations to promote self-care for your selected patient to provide high quality, safe healthcare considering nursing-sensitive indicators. Provide a rationale for each of your selected nursing decisions.
Conclusion
Summarize the key points of your project.
**You will not discuss the deductibles or costs of the insurance plans as this is not the focus of this this assignment.
Following the simulated activity, you will examine the relationship between healthcare coverage (insurance), quality care, and reimbursements (payments) to health care organizations. Select two different major national (U.S.) insurance health plans. You may choose Medicaid, Medicare, HMO, PPO, or private insurance plans. You can choose your own personal insurance plan if you prefer. Review healthcare coverage options offered by both plans that benefit (facilitate) and hinder (limit) access to care. Examples of healthcare coverage (insurance) options that facilitate, or limit access include medication coverage, primary care physician office visits, specialists physician office visits, emergency care, lab or blood work and diagnostics, wellness care, prevention services or surgery (these are just a few examples). You will also explore the role of Diagnosis Related Groups (DRGs) and charity care within healthcare facilities (hospitals) and how charity care impacts the vulnerable or uninsured population. Finally, summarize nursing interventions or considerations for your selected patient to provide high quality, safe healthcare considering nursing-sensitive indicators in his/her unique scenario.
• Textbook and other resources
• Centers for Medicare and Medicaid
Additional Instructions:
1. All submissions should have a title page and reference page.
2. Utilize a minimum of two scholarly resources.
3. Adhere to grammar, spelling and punctuation criteria.
4. Adhere to APA compliance guidelines.
5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One: Instructions:
Paper • 5 page paper. Include title and reference pages.

Healthcare Policy and Regulations- National Health Coverage Plans, Reimbursements, and Quality
Description: The baccalaureate-graduate nurse will compare the benefits and limitations of major forms of reimbursements on the delivery of health care services, advocate for vulnerable populations, and describe how health care is organized and financed, including system cost factors.
Course Competency(ies): 1) Critique key health priorities and goals from a national and global perspective. 3) Examine the effect of health and social policies on persons with diverse ethnic and cultural backgrounds. 5) Construct nursing interventions that provide high quality, safe healthcare using nursing-sensitive indicators.
QSEN Competency(ies): 1) Patient-Centered Care 2) Teamwork and Collaboration
BSN Essential V
Area Gold Mastery Silver Proficient Bronze Acceptable Acceptable Mastery not Demonstrate d
Describes the purpose and importance of the healthcare coverage (insurance). End paragraph with a clearly worded purpose

statement.

Describes the purpose and importance of healthcare coverage (insurance). End paragraph with a clearly worded purpose statement. Describes the purpose and importance of healthcare coverage (insurance). Some details are missing. Purpose statement is unclear or not. Does not explain the purpose and importance of healthcare coverage (insurance). Some content is

missing. No purpose statement.

Does not address section
Describes the purpose of Diagnosis Related Groups (DRGs). Explains the impact of DRG’s on length of stay and payment of services.

Discusses how payments for DRGs are now impacted by quality of care.

Describes the purpose of Diagnosis Related Groups (DRGs). Explains the impact of DRG’s on length of stay and payment of services. Discusses how payments for DRGs are now impacted by quality of care.

Provides details

Minimally describes the purpose of Diagnosis Related Groups (DRGs).

Minimally explains the impact of DRG’s on length of stay and payment of

services. Minimally discusses how payments for DRGs are now impacted by quality of care.

Some details are missing.

Simply describes the purpose of Diagnosis Related Groups (DRGs). Simply explains the impact of DRG’s on length of stay and payment of services. Simply discusses how payments for DRGs are now impacted by quality of care. Some content is missing. Does not address section
Select a Major Healthcare Plan Fully summarizes two care options provided by the plan that facilitates Minimally discusses two care options provided by the plan that Simply discusses one care option provided by the plan that facilitates Does not address section

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(Label heading with Name of Plan

– EX: Preferred Provider Option Plan)

 

Summarize two care options provided by the plan that facilitates access for the patient.

Summarize two care options that limit access to care for the patient.

access for the patient. Fully summarize two care options that limit access to care for the patient.

Provides details.

facilitates access for the patient. Minimally discusses two care options that limit access to care for the patient. Some details are missing. access for the patient. Simply discusses one care option that limits access to care for the patient. Some content is missing.  
Select a Second Major Healthcare Plan and Label Heading with the Name of the Plan

 

Summarize two care options provided by the plan that facilitates access for the patient.

Summarize two care options that limit access to care for the patient.

Summarizes two care options provided by the plan that facilitates access for the patient. Summariz es two care options that limit access to care for the patient. Provides details. Minimally discusses two care options provided by the plan that facilitates access for the patient.

Minimally discusses two care options that limit access to care for the patient.

 

Some details are missing.

Simply discusses one care option provided by the plan that facilitates access for the patient. Simply discusses one care option that limits access to care for the patient. Some content is missing. Does not address section
Summarize at least four priority nursing interventions or considerations to promote self- care for your selected patient to provide high quality, safe

healthcare

Summarizes at least four priority nursing interventions or considerations to promote self-care for your selected patient to provide high quality, safe healthcare

considering

Summarizes at least three priority nursing interventions or considerations to promote self-care for your selected patient to provide high quality, safe healthcare

considering

Summarizes at one to two priority nursing interventions or considerations to promote self-care for your selected patient to provide high quality, safe healthcare

considering

Does not address section

 

considering nursing- sensitive indicators. Provide a rationale for each of your selected nursing decisions.

 

Ends paper with a separate paragraph (with Conclusion as heading) and summarizes key

points in paper.

nursing-sensitive indicators. Provides a rationale for each of your selected nursing decisions.

 

Ends paper with a separate paragraph (with Conclusion as heading) and fully summarizes key points in paper.

nursing-sensitive indicators.

Provides a rationale for three of your selected nursing decisions.

 

Ends paper with a separate paragraph (with Conclusion as heading). Conclusio n paragraph is unclear. Some key points are missing.

nursing-sensitive indicators. Provid es a rationale for each of your selected nursing decisions.

 

Conclusion paragraph is missing.

 
APA, Grammar, Spelling, and Punctuation No errors in APA, Spelling, and Punctuation. One to three errors in APA, Spelling, and Punctuation. Four to six errors in APA, Spelling, and Punctuation. Seven or more errors in APA,

Spelling, and Punctuation.

References Provides three or more references. Provides two references. Provides one references. Provides no references.

 

 

 

 

 

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