TASK 1

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School

Western Governors University *

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Course

C799

Subject

Health Science

Date

Jun 22, 2024

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docx

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Uploaded by PresidentArt13509

TASK 1: Healthcare Ecosystems (C799) A. Discuss how Medicare certification affects healthcare delivery based on the Conditions of Participation. Medicare certification is a vital aspect of the delivery of healthcare services in the United States based on standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAH). The standards set by the JCAH are called the Conditions of Participation (CoP) which are health and safety standards that are the foundation for improving quality and protecting the health and safety of beneficiaries (CMS, 2021). Healthcare providers must meet these standards set forth by the JCAH in order to partake in the Medicare program and being part of this program allows beneficiaries safely assume that they are receiving the safest and highest quality of care. The primary method that Medicare certification affects delivery outcomes is by encouraging strict compliance with all standards set forth by the JCAH. Before becoming Medicare-certified, providers must conform with CoPs to have the ability to participate in the Medicare program; this provides uniformity across all Medicare-certified facilities. One of the CoPs is quality assurance which ensures that Medicare-certified facilities are participating in ongoing quality improvement, conducting regular self-assessments, and reporting findings. Having a Medicare certification ensures that all CoPs are met and that providers are delivering the best quality of healthcare service on a consistent basis to their patients. Accountability and transparency are other aspects of how Medicare-certified facilities affect healthcare delivery. Medicare-certified providers must regularly report their performance data to the Centers for Medicare & Medicaid Services (CMS), and this information is made available to the public (CMS, 2021). The JCAH sponsored the development of PEP, the Performance Evaluation Procedure for Auditing and Improving Patient Care, an elaborate medical audit system that was taught in workshops for accredited hospitals. The PEP methodology was based on several decades of efforts to develop objective methods of appraising clinical performance through retrospective auditing of medical charts using explicit criteria (McGeary, 1990). Having this procedure in place forces providers to make sure they are complying with all rules set by the CoPs, promoting continuous improvement, and allowing beneficiaries to make informed decisions on what facilities they would like to receive care from. When a healthcare provider has Medicare certification, patient-centered care is expected. The medical record services and quality assurance portion of the CoPs require that certified providers must involve patients in their care plans along with providing education and ensuring privileged access to their medical records. This also helps the facility correspond with accountability and transparency which is fundamental for certification.

1. Explain the difference between accreditation and licensing for healthcare organizations. Accreditation and licensing are both processes that healthcare organizations must go through to ensure that they meet certain standards of quality and safety. However, they have different purposes and requirements. Licensing gives legal approval for a facility to operate or for a person to practice within his or her profession (Watters, 2020). It is typically granted by a state or federal agency and involves a review of the organization's compliance with laws and regulations related to healthcare delivery. Licensing ensures that the healthcare organization meets minimum standards for safety, quality, and competency. Licensing is mandatory for the operation of healthcare organizations and failure to obtain or maintain a license can result in fines, penalties, or closure of the organization. Accreditation, on the other hand, is a voluntary process that healthcare organizations undergo to demonstrate their commitment to quality improvement and patient safety; its purpose is to periodically evaluate the quality of an organization’s work against preestablished written criteria (Watters, 2020). Accreditation is typically performed by a non-governmental organization, such as The Joint Commission or the National Committee for Quality Assurance (NCQA), that sets its own standards for healthcare delivery. During the accreditation process, which may include on-site inspections, questionnaires, staff interviews, and patient interviews, an organization's policies, processes, and practices are scrutinized in greater detail. This certifies that hospitals have met the participation standards necessary to receive payment under the federal Medicare program. Although accreditation is not legally required, it may be so in order to get payment from some insurance plans or to participate in government-funded initiatives like Medicare. B. Explain the relationship between a quality reporting system and reimbursement for healthcare services (e.g., Merit-Based Incentive Payment System and value-based care). A quality reporting system is a tool used by healthcare organizations to gather and present information on the standard of patient treatment. The performance of healthcare practitioners is then evaluated using this data, and patient care quality is improved. The Merit-Based Incentive Payment System, among other things, links quality reporting systems to the payment of medical services (MIPS). MIPS is a system that offers financial incentives to healthcare professionals in exchange for providing high-quality care. Quality, cost, improvement efforts, and encouraging interoperability are the four performance criteria that the program grades healthcare providers on. The ultimate MIPS score, which is used to calculate the number of incentive payments the healthcare provider would receive, is created by adding the points attained in each category. The incentive payment increases as the score rises. Also, low-scoring healthcare providers can be charged fines, which might reduce their overall earnings. For example, in 2023, adjustments to disbursement from MIPS scores will

potentially range from –9% to +9%. In order to be eligible for a positive adjustment, a clinician’s score must exceed a certain threshold, which is 75 points in 2022 and in 2023 (ACEP, 2022) Value-based care is a method of providing medical treatment that aims to increase patient outcomes while cutting costs (Agilon Health, 2023). According to this approach, healthcare practitioners are paid according to the value of the service they deliver rather than the quantity. Systems for measuring and reporting quality of care supplied by healthcare professionals are used to calculate the cost-effectiveness of the service provided. 1. Discuss how patient Medicare eligibility requirements influence the types of healthcare services available to patients. Medicare is divided into numerous segments, each of which has its own fees and eligibility restrictions and covers a variety of healthcare services. For instance, everyone who has paid payroll taxes into the program is normally eligible for Medicare Part A, or hospital insurance, which covers hospitalization. An individual must be entitled to receive Medicare based on their own earnings or those of a spouse, parent, or child to be eligible for Medicare Part A. (HHS.gov, 2020). There are different qualifications to be eligible for Medicare which include: being over the age of 65, being disabled, being on dialysis, and having end-stage renal disease. When a person qualifies for Medicare Part A there are certain services covered other than hospital care and they include skilled nursing facility care, home healthcare, hospice care, and inpatient care in a religious nonmedical healthcare institution. Nonetheless, patients could need to make copayments and deductible payments for therapies, which for some people would be a major financial hardship (Watters, 2020). Medicare Part B is a voluntary program that requires individuals to pay a monthly premium as well as a deductible and covers outpatient care and doctor visits. Eligibility rules for Part B depend on whether a person is eligible for Part A (CMS, 2021). Patients who cannot afford these costs may not be able to access the healthcare services covered by Medicare. Medicare Part B covers two types of services which are medically necessary and preventative services. Part B has some services available exclusively to the plan which includes physician care, clinical research, ambulance services, durable medical equipment (DME), mental health care, and emergency department or clinic services (Watters, 2020). Although there are certain conditions needed to qualify for Medicare as a whole, there are certain eligibility requirements that need to be met to be eligible for each division of Medicare. It is important that potential beneficiaries understand what current and potential health issues they may have because this directly affects the type of Medicare they will enroll in. For example, individuals who want any of the benefits of Part D must be enrolled in Part A and B and be in the service area of the plan they wish to enroll in to take advantage of the prescription drug services offered by the plan. Factors such as geographical restrictions and age restrictions along with current health needs are some things that must be considered when deciding which plan to enroll in.

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