Payment Mechanisms and Reform Initiatives under PPACA
A Prospective Payment System (PPS) is a form of payment where the reimbursement is made on the predetermined charge. The fixed payment is made to particular treatments. The reimbursement rate for a certain service is obtained from the classification structure of that service, for instance, prognosis- related groups for inpatient hospital services. The reimbursement might be amended occasionally due to inflation, the high cost of living in some areas or other economic factors. Every health care provider is given the same reimbursement for every treatment of the same type. Many Medicaid programs have adopted the PPS because its constant rate has made budget and expenditure predictable. Retrospective Payment System, on the other hand, offers reimbursement to Medicare depending on the actual charges. RPS are known as fee for service payments. It capitalizes on the liberty of the patients and the medical practitioners to choose what procedures are best suited for every person. This type of payment system gives patients freedom to choose what they want depending on what they can afford.
According to the information given, the payment reform initiatives in the Patient Protection and Affordable Care Act are centered on 3 parts: examining latest delivery models and distributing thriving models, promoting the move toward reimbursement with respect to the significance of care given, as well as increasing resources for systemwide enhancement. Under the new delivery models, an accountable care organization (ACO) is a body established by care givers that are in agreement to jointly take accountability for the superiority and overall costs of care for a populace of patients
Resources for systemwide improvement. The Affordable Care Act formed new resources to set up a foundation for fast public and private segment modernization in health care providence. Center for Medicare and Medicaid Innovation, CMMI, was formed to discover, examine, also broaden new latest payment as well as delivery service replicas to lessen expenses while upholding or boosting superiority of care for beneficiaries of Medicare, Medicaid, as well as the Children’s Health Insurance Program (CHIP) (Pearson & Bach, 2010).
The initial ACA’s provisions identified with provider repayment have hindered development in charge for-administration payment levels. The goal was to give some financial plan alleviation, especially for the Medicare Trust Reserve, and to send a sign to providers to adjust rapidly to motivating forces that compensate fitting, superior care, and great patient results. Other ACA procurements target quality issues that prompt inefficiencies and imperil patient wellbeing. For instance, the law forces money related punishments on medical centers with high rates of clinic obtained conditions and readmissions, an attempt that has added to the current decrease in related unfriendly medicinal events.
The new value based acquiring program for medical facilities, in the mean time, encourages more noteworthy responsibility for the performance by apportioning rewards and punishments tied to openly reported quality measures; comparative projects for doctors are being actualized in stages, with a full rollout to all expense for-service providers in 2017. The ACO is examining a reimbursement approach known as packaged installment, a solitary repayment for every one of the administrations required for a given medicinal condition. This implies that a doctor, medical facility, or post acute administrations could all be secured under a solitary installment, which ought to incentivize the different providers included in a given patient’s consideration to work better together (Pearson & Bach, 2010).
The rising cost of Medicare is so high that the government cannot keep up. More than 40 million citizens including the undocumented immigrants lack insurance. Although the government is doing its best through programs like Medicare, Medicaid, veteran care, Providing universal insurance is another issue which it may not be able to achieve in the near future. The expansion of Medicaid will enable the low-income uninsured citizens to have access to health care. This progress has made the low-income earners. Medicaid expansion is a good thing as it saves the states a lot of money, offers financial protection and supports the economy. The wealthy individuals, however, feel that they do not benefit from the plan. They pay heavy taxes to the government which go into Medicaid but do not qualify. Despite this, Medicaid should be expanded since the poor persons and those with special needs benefit (Goodson, 2010).
It is importance for patients to have an education on the medical insurance. The key role of insurance is to ease financial constraints. Insurances are expensive, and patients need to be well informed of what they are signing into. The patients need to be educated on how to use their insurance effectively. Education on insurance should be designed in a way that is understandable to all even the most illiterate. The health care practitioners should be furnished information on insurance so that they can educate the patients on what is right for them.