History of Reimbursement Issues

Week 7 Discussion: History of Reimbursement Issues

Question 1

Healthcare reimbursement refers to the payment that a healthcare provider receives for giving clients medical services. Often, healthcare costs are fully or partially covered by the government or private health insurers. Although the main goal of healthcare organizations is to offer high-quality healthcare services to patients, these entities are similar to other businesses because they operate on limited margins. They have to get reimbursed in order to offer sustainable healthcare. Therefore, healthcare reimbursement affects the overall operations of a healthcare organization including its employees’ overall satisfaction. In this context, healthcare reimbursement has a huge influence on my nursing practice. According to Sasso et al. (2017), “nurses constitute the largest segment of healthcare professionals; therefore, they are also the most expensive, and in a hospital these costs can reach 25% of the total expenditure.” In my nursing practice, healthcare reimbursement directly affects the compensation that nurses receive for the work they do.

The compensation is crucial in ensuring that nurses have sustainable livelihoods. In turn, this enhances their motivation to work on a daily basis and increases their job satisfaction. It is vital to note that nursing is a very challenging job. There are so many tasks that nurses carry out, which are not officially in their job descriptions. Sasso et al. (2017) term such tasks as ‘invisible work.’ Invisible work includes educating patients and families, providing psychological support to patients who are seriously ill and their family members, and advocating for their patients” (Sasso et al., 2017). Timely and regular reimbursement is crucial for nurses since it keeps them inspired to go beyond their normal duties. However, the complex reimbursement process seen in many institutions may hinder the efficiency in which nurses get paid, which may affect their job satisfaction.

Question 2

The value-based insurance design (VBID) significantly influences clinical outcomes and cost issues. VBID is designed to enhance the effectiveness of healthcare services while simultaneously minimizing the costs of healthcare (Yeung, 2019). Health outcomes and healthcare costs are evaluated by researchers, healthcare payers, and insurers to deduce the relative value of any given service. The value is determined both as a medical cost and a medical outcome. According to Yeung (2019), payers, for instance, employers, can utilize the values of healthcare services to considerably increase benefits for the services that have been deemed to be the most valuable. In this context, high-value health services refer to the ones whose benefits are proportional to their costs. VBID can allow a healthcare organization to assign relatively high out-of-pocket costs to the relatively low-value services, whose expenses have not yet been justified. An example is the emergency department being used for minor illnesses.

Overall, VBID aligns the healthcare costs to the service’s value instead of the acquisition costs. This is crucial in minimizing the barriers that most people face when seeking effective services. Pertinent research reveals that VBID increases medication and treatment adherence, especially for chronic illnesses like diabetes and heart diseases. This translates to more desirable outcomes without any additional expenses. This is because many VBID programs promote preventive health services like wellness programs and education programs (Farley, 2019). These are the programs that are normally underutilized by patients even though they have been proven to be effective in minimizing future healthcare costs. In conclusion, VBID leads to high-quality clinical outcomes and reduced healthcare expenses.

References

Farley, J. F. (2019). Are the benefits of value-based insurance design conclusive? Journal of Managed Care & Specialty Pharmacy25(7), 736-738.

Sasso, L., Bagnasco, A., Aleo, G., Catania, G., Dasso, N., Zanini, M. P., & Watson, R. (2017). Incorporating nursing complexity in reimbursement coding systems: The potential impact on missed care. BMJ Quality & Safety26(11), 929–932.

Yeung, K. (2019). Value-based insurance design: Current evidence and future directions. Journal of Managed Care & Specialty Pharmacy25(7), 738-741.