C799 Healthcare Ecosystems Task 1

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Western Governors University *

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C799

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Health Science

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Oct 30, 2023

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C799 Healthcare Ecosystems Task 1

MEDICARE CERTIFICATION Medicare certification affects healthcare delivery by requiring hospitals and other healthcare facilities to comply with the Conditions of Participation. Government and non-government organizations evaluate healthcare facilities, individuals, and educational programs to weigh the standards met. CMS oversees the surveyance and certification processes and makes available the information. Consumers can access the information made available by CMS to assess the quality of healthcare facilities before visiting. Providers can use information, such as QI materials, from CMS to improve the quality of care[ CITATION Wat20 \l 1033 ]. ACCREDITATION AND LICENSING State licensure programs require physicians, hospitals, and healthcare organizations to meet specific requirements to provide medical care to individuals. For physicians and other healthcare providers, mandated licensure is granted by passing an examination from their state medical board. Hospitals, nursing homes, pharmacies, and other healthcare organizations are also mandated to operate in the US. They must meet licensure standards for policies and procedures, staffing, and building maintenance. Accreditation, on the other hand, is a voluntary process in which an independent agency evaluates the quality of the volunteer’s work based on pre-established written standards. Accreditation agencies determine the legitimacy and appropriateness of medical practice based on standards of care and quality measurements[ CITATION Wat20 \l 1033 ]. QUALITY REPORTING SYSTEM AND REIMBURSEMENT A strong relationship exists between the quality reporting system and reimbursement for services provided in healthcare. A patient’s experience with a healthcare provider or facility can significantly impact payments received for services. Payment programs reward and penalize healthcare providers for satisfactory and adverse outcomes reported through a quality reporting system. The Value-

Based Purchasing (VBP) Program helps hospitals to improve a Medicare beneficiary’s quality of care, experience, and safety through rewards for high scores in these areas. Hospitals are penalized for low scores in those areas, including healthcare-associated infections, complications, and mortality[ CITATION The22 \l 1033 ]. The Merit-based Incentive Payment System (MIPS) is designed to improve the quality and cost efficiency of care clinicians provide for better care processes and health outcomes. Data is collected and measured in quality, improvement activities, promoting interoperability, and cost. Quality is measured based on the care delivered, and interoperability is the engagement of patients with the exchange of health information. It is the clinician’s responsibility to make improvements in the areas of decline with suitable activities. Payment adjustments are calculated based on final scores and applied to Medicare Part B claims[ CITATION Tra22 \l 1033 ]. PATIENT MEDICARE ELIGIBILITY REQUIREMENTS There are various scenarios to meet Medicare eligibility requirements for healthcare coverage. The first group is individuals aged sixty-five or older receiving Social Security or Railroad retirement benefits. Individuals under sixty-five receiving Social Security Disability Insurance checks for two years with specific disabilities or diagnosed with End-Stage Renal Disease (ESRD) can qualify. Medicare coverage is divided into two main parts covering varying healthcare services. Part A is hospital insurance free to most Medicare beneficiaries meeting specific criteria. This part covers inpatient hospitalization, long-term care, nursing facility care, home health services, and hospice care. Part B covers services in an outpatient setting and can be purchased to supplement Part A. Services include physician services, medical supplies, laboratory services, and outpatient mental health care. It also covers any services not covered under part A in an outpatient setting[ CITATION Cas21 \l 1033 ]. FEDERAL LEGISLATION

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The Hill-Burton Act of 1946, formally known as the Hospital Survey and Construction Act, was created to provide subsidies for the construction of hospitals and nursing homes. After World War II, the country lacked enough hospital beds to accommodate the population. Communities receiving funds had to commit to three specific requirements. Communities could not discriminate on who receives care. Some care would be offered free to community residents who could not afford to pay for 20 years. State and local governments had to match the funds received to prove sustainability. In less than 30 years, nearly one-third of the nation’s hospitals were built with funds designated by the Hill-Burton Act. It significantly impacted the number of hospital beds available in the communities they served[ CITATION Wag20 \l 1033 ].

References Casto, A. (2021). Principles of Healthcare Reimbursement (7thed.). American Health Information Management Association (AHIMA). Retrieved from https//:wgu.vitalsource.com/books/9781584268017 The Hospital Value-Based Purchasing (VBP) Program . (n.d.). Retrieved Oct 2022, from CMS: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value- Based-Programs/HVBP/Hospital-Value-Based-Purchasing Traditional MIPS Overview . (n.d.). Retrieved November 2022, from Quality Payment Program: https://qpp.cms.gov/mips/traditional-mips Wagner, S. L. (2020). The United States Healthcare System: Over, Driving Forces, and Outlook for the Future. Health Administration Press. Retrieved from http://www.ebookcentral.proquest.com/lib/westerngoverns-ebooks/reader.action? docID=6180928 Watters, P. O. (2020). Health Information Management, Concepts, Principles, and Practice (6th ed.). American Health Information Management Association (AHIMA). Retrieved from http://wgu.vitalsource.com/books/9781584267577