BHA FPX 4009 Assessment 2
Reimbursement Options
Till date, the payment for the treatments has become complex and the American Association of Diabetes Educators (2020) reasoned that, both patients and physicians should familiarize themselves with the payment system. In the same way, it is necessary to understand the various ways through which reimbursement can affect the health care to be made available in the future.
In evaluating the methods, different types of compensation systems recommended in the business environment today and classic and postmodern forms of motivation are taken into account. Such models include capitation and pay for performance; these are some of the models that are more liberal while others are more conservative. The evaluation then proceeds to discuss the options for payment for the uninsured persons based in the United States, caucus to the details of medicaid, other funding modalities, self paying method as well as charitable treatment.
Drawbacks of Fee-For Service Reimbursement
Healthcare reimbursement types of models that involve payment for services provided to patients by an organization’s healthcare providers based on a scale of payment whereby each service provided attracts a fixed amount of payment. They proposed that in the fee-for-service system of payment since the cost of each treatment is predetermined, healthcare professionals are paid based on the number of services rendered.
However, other than the fee-for-service payment structures, other reimbursement techniques focus on health, special therapy circumstances, and individual patients’ well-being (Arienti et al. , 2021). Along the same vein, the current system lacks an efficient payment structure: fee-for-service payment. In using this paradigm, it is provides payment on an individual service rendered by the particular service provider.
The single clear result of fee-for-service payment approach, which stimulates utilization of services in accordance with quantity rather than quality or value, is the over utilization. For instance, when the consultation ceases to be a new patient and it is rated $500, would it be easy to get all that amount out of a patient with private health cover? Accordingly, to the words of Bhatnagar et al. (2022) , unpaid payments could disrupt billing and the process of funds collection as well as become a source of financial pressure as well as problems for care delivery.
Drawbacks of Capitation Reimbursement
During capitation reimbursement, hospitals are paid fixed sums for each of the clients, irrespective of the efficiency of their attendance. Therefore, capitation places a considerable emphasis on efficiency, tendency towards prevention, and multiple visits for further treatment of a patient as measures for controlling the institution’s practice. It is not beyond having its disadvantages, but this remedy of employing capitation to encourage preventive services as a complete service has its pros.
Insurance providers or health care organizations’ financial interest may contribute to reduction of therapy due to cost cutting in patient treatment outcomes, which is service underutilization (Cohen, et al. , 2021). This means that the needs required by the patients, as highlighted by their medical status and records will not be given consideration, when the dispensation of adequate treatment under the capitation payment system will be ascertained.
BHA FPX 4009 Assessment 2 Reimbursement Options
Potential problems appear in capitation in relation to costs that need to be recovered in connection with the first consultations of new patients. Because under capitation, an attendant gets a particular amount for a certain capacity of patient volume, important services like new patient consultations which may cost roughly $500 for a single visit will not really be fully catered for.
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Likewise, healthcare in its entirety does not fall under managed care’s predetermined capitation payments. As such, the financial position of the practice is undermined, and retrieving the costs of consultations with patients become even harder (Delavar et al. , 2020).
The problem with most capitation compensation plans and systems, therefore, is the challenge of achieving the two overall objectives that are:
financial sustainability on one hand and delivering patient- specific, individual, personalised, concrete and complete distinctive care on the other hand.
Impact of Pay-for-Performance on Reimbursement
Payment for performance or a performance-based model of payment pays the healthcare professionals a monetary amount that is contingent on their ability to attain certain targets. Optimizing the results for the patients and enhancing the further capacities of healthcare workers, their possibility to provide the necessary quality of the treatment – is the foundation of this approach.
Thus, pay-for-performance incentives relate better to evidence-based, efficient, patient-oriented treatment. The approach relates the volume of financial reward to the standard of the treatment patients receive from healthcare institutions also influences the rates of reimbursement in the business of healthcare in America.
BHA FPX 4009 Assessment 2 Reimbursement Options
Frank et al. (2024) observes that where this form of remuneration system is applied, quality of health care inputs is measured by; clinical outcomes, patient safety, patient satisfaction , and best practices or application of evidence based practice. Compared to traditional FFS payment methods, Hsieh et al. (2020) reported better cost utility, preventive and sickness care, patients’ satisfaction, and efficacy in handling both communicable and chronic diseases in P4P models.
Likewise, Ivynian et al. (2020) conducted a study and discovered that healthcare workers who received pay-for-performance compensation plans enhanced the quality of the services that they offered as well as enjoyed fewer readmissions.
Resource-Based Relative Value Scale or Case-Based
On the relative value system based on resources, the time necessary for care, the quality of the service, money, and the medical personnel required to deliver such service are balanced against the service provided. Thus, resource-based relative value scales, introduced with the aim to standardize payment according to the complexity of care services provided to patients during consultation visits, have these paradoxical effects.
With the intention of increasing their earnings under the resource-based relative value scale model, health care practitioners for example gave patients much care services than were desired. Likewise, HC Professions incurred more cost through resource utilisation through provision of more diagnosis tests in an effort to recuperate expense through the resource-based relative value scale (RRVS) (Jaarsma et al. , 2020).
Since , the case-based payment system was introduced in an attempt to reduce care services utilization, the levels of different type of sessions and those resources used in those sessions were determined by different amounts. The author Kalogirou and his fellows (2020) described a mechanism used usually to motivate providers into obtaining payment, which entails availing extra additional diagnosis, therapies, or consultation time for to a patient case as per instance.
Payment Options for Uninsured Patients
Many never insure themselves for medical, and hence, may not be able to easily navigate the complicated structures involved in health care payments. This demographic has different limitations and themes, thus they may use other forms of solutions when it comes to payment methods.
The others may rely on Medicaid after enrollment as the only social health insurance option for the uninsured and those with low income in the United States. Another factor that is considered while making the assessment of the eligibility for Medicaid is the income as well as the size of the family of the specified individual.
For instance, as cited in King and others (2022), the population without insurance cover in the United State receives health care provision services from the healthcare providers under the program known as Medicaid.
Sometimes, the uninsured people, being in the need of money, get loans or contractual work at various organizations. Such plans therefore allow patients to pay for their medical treatment over a long period. The financing with respect to most patients is usually possible; but, the conditions, including as the terms or rates of interest, could differ from one dealer to another.
Inability to afford medical bills may force patients to pay their bills sensibly through installment if financed (Krause, 2022). If a patient does not have health insurance and cannot qualify for any public programs like Medi-care or Medi-caid they may pay out of pocket. Medical operations are going to cost out of pocket prompting the AMCs need for adequate funding. Paying for this option is probably expensive and since there are no predetermined guidelines on who can opt for this option those on a low end of the economic scale may default on the premium or fail to afford it at all and this may see them delay or drop necessary medical procedures (Li et al. , 2020).
Driven by the desire of availing their services to the low-income or uninsured clients, some healthcare institutions have set up this program known as the charity care program which means that the healthcare providers have to treat the clients at a relatively cheaper or even for free.
Thus, there are many requirements for admission, and often for the patient’s qualification it is necessary to assess all aspects of his financial position. The aim of these programmes is to ensure that those who are genuinely in dire need of money may be able to access the medical care they require without incurring very hefty costs (Goodman et al. , 2020).
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Examples
For instance, while Medicaid may guarantee the health coverage for families with low income. Likewise, funding or loan options are there for the patients who without insurance but still can manage to pay for the treatment through different installments.
For the clients, who can afford it, for instance, to pay $500 for a consultation, the self-pay is available for the care service. While on the part of Charities, the treatment is offered to the poor and needy who are unable to pay and this is irrespective of the type of sickness (Owusu et al. , 2022).
Conclusion
Some of the several payment and reimbursement programmes highlighted include capitation methods, case-based payments, pay-for-performance as well as fee-for-service. Certain factors that were also assessed include how they had faced difficulties, the financial rewards, and how the measures affected the client.
Medicaid, charity care and general other alternative payment methods for the uninsured have also been discussed as viable options of enhancing acces to care for low income people. The given service alternatives for the uninsured populace are illustrative of how the healthcare finance systems are crucial to the quality of treatment rendered by these healthcare facilities.
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BHA FPX 4009 Assessment 1 Reimbursement Models
References
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