Category: Sharon V.
During Week 10, I learned about President Trump’s American Health Care Act. Part of President-elect Trump’s platform was to have radical healthcare reform. He believes that Americans have suffered an incredible economic burden ever since the enactment of the Affordable Care Act (ACA) in 2010. He believes the ACA has the following problems: runaway costs, malfunctioning websites, greater rationing of care, higher premiums, less competition, and fewer choices. He believes the ACA will collapse of its own weight and proposed a seven point health care reform plan to repair the problems he observed with the ACA. The Congressional Budget Office in 2015 believed his seven-point plan would save $1.1 trillion but his entire repeal of the Affordable Care Act would cost $1.5 trillion. His plan would have 22 million Americans lose health insurance and there is no indication that health coverage would not decrease. President Trump’s main concept regarding health insurance is that marketplace competition brings costs down. On May 4, House Republicans passed a bill to repeal and replace Obamacare. The bill is now under the Senate’s review where it will face daunting challenges because of the ideological splits between conservative and moderate Republicans. The future of Obamacare remains unclear.
During Week 9, I researched the Patient Protection and Affordable Care Act (2010) which is a piece of legislation enacted by former President Barack Obama that attempts to provide Americans with affordable quality healthcare and tries to lower healthcare spending in the US. I learned that the first aim of the Act is to cover more people and add more benefits. The Act mandates that every insurance company must guarantee coverage no matter what pre-existing health conditions the patient may have had. In addition, insurers must provide coverage for every American who wants to renew their insurance. Guaranteed Availability and Renewability were created to end discrimination of coverage based on gender or health status. The Act also mandates that every American must get health insurance or pay a penalty. This encourages relatively healthy people to pay the small penalty and the people with health issues to invest in health insurance and get early treatment. Regarding coverage, the ACA mandates that all health insurance companies are required to cover ten categories of essential benefits: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services, including oral and vision care. This mandate ensures that patients will have no copayments for these services, therefore, removing barriers to early treatment and preventative care and decreasing costs for insurance companies in the long-run.
Source: Patient Protection and Affordable Care Act, 42 U.S.C. § 18001 (2010).
During Week 8, I learned how Medicaid payment plans work. Medicaid is a Federal-State health insurance program for low income people which covers children, elderly, blind, disabled, and others who are eligible. Federal Law requires states to cover certain groups and individuals such as low income families, qualified pregnant women, and individuals receiving Supplemental Security Income. The Affordable Care Act enacted in 2010 created the opportunity for states to expand Medicaid to cover nearly all low income Americans under the age of 65. With the expansion, eligibility for children extended to at least 133% of the Federal Poverty Level in every state.
I learned that states establish and administer their own Medicaid programs. They determine the type, amount, duration, and scope of the Medicaid services they want to provide. Federal law requires states to have some mandatory benefits such as labs and x-rays, hospital services, physician services, and home health services. States can also provide optional benefits such as prescription drug coverage, physical therapy, and occupational therapy.
During Weeks 9 and 10, I will begin the final stretch of my internship and write my research paper and prepare slides for my presentation at school. It has been a steep learning curve for me but I have understood the basic structure and economics of healthcare in our country.
During Week 7, I researched the Quality Payment Program which is part of the Medicare Access and CHIP Reauthorization Act of 2015 implemented by the Centers for Medicare and Medicaid Services (CMS) in 2014. The Quality Payment Program is focused on moving the payment system to reward high-value patient care and consists of two tracks: Advanced Alternative Payment Models (APM) and Merit-based Incentive System (MIPS). If the clinic does not participate in the Quality Payment Program, they can receive a negative 4% payment adjustment penalty.
APMs allow clinics to earn Medicare incentive payments by changing to their new payment model. APMs were designed to provide quality and cost-efficient care. Clinics can earn a 5% Medicare incentive payment in 2019 if the clinic receives 25% of Medicare Part B payments through an Advanced APM or if the clinic sees 20% of Medicare patients through an Advanced APM.
MIPS allow clinics to participate in traditional Medicare and earn performance-based adjustments. If the clinic or individual provides the full year of 2017 data, then Medicare will award them a moderate positive or negative payment adjustment for quality and value of care. The CMS estimates 500,000 clinicians will be able to participate in MIPS. These penalties and adjustments will be provided in 2015, however, the CMS believes the adjustment payments will grow to a potential of 9% in 2022.
During Week 6, I studied how Medicare payment plans work. Medicare is a health insurance program for people 65 years and older, people under the age of 65 with certain disabilities, and people with End-Stage Renal Disease (permanent kidney failure). Medicare offers three different payment plans: Part A Hospital Insurance, Part B Medical Insurance, and Prescription Drug Coverage. Part A Hospital Insurance allows the patients to pay no premiums because they are usually paid through their payroll taxes. This insurance pays for inpatient care in hospitals, critical access hospitals, and skilled nursing facilities. Part B Medical Insurance patients usually pay a monthly premium. This insurance covers doctors’ services that are medically necessary or preventive. Medicare’s prescription drug coverage also has additional monthly premiums. Prescription drug coverage is also available for everyone with Medicare. However, there are a few drug coverage rules. The drug must have prior authorization meaning clinics must contact the drug plan and may need to show that the drug is medically necessary. There may also be quantity limits on the drug. Medicare can also require step therapy where the patient must try one or more similar, lower cost drugs before the plan will cover the prescribed drug. In 2015, there were 55.3 million total Medicare beneficiaries with 46.3 million people 65 years and older and 9 million disabled patients.
Next week, I will study and research The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which is the law that repealed the Sustainable Growth Rate (SGR) formula and created the Quality Payment Program (QPP) to stabilize Medicare payments and potentially reward providers, hospitals and medical practices for providing quality, high-value care to Medicare patients.
During Week Five, I learned about Meaningful Use (MU) which is maintained and verified through the electronic health record systems (EHRs) many physicians use. The benefits of Meaningful Use are that the data provided can improve the efficiency of their practice. Physicians can maintain the privacy of their patients’ health information. By using Electronic Health Records and participating in Meaningful Use, physicians can qualify to receive reimbursement from the Centers of Medicaid and Medicare. The electronic health records contain information about a patient’s medical history, diagnoses, medications, immunization dates, allergies, and laboratory and other test results. Meaningful Use asks providers to attest that they are following the standard of care for their practice such as checking BMI (Body Mass Index) and following vaccination protocols. It also encourages discussion about tobacco use and other unhealthy habits. EHRs have access controls such as passwords and secure servers to make sure only authorized staff can view patients’ medical information and secure portals for patients to view their own record. Electronic health records can also help providers make decisions about a patient’s care and remind them to provide services through a check list. For the medical clinic, electronic health records may lower costs in the long-term. The government has also subsidized the cost for adopting these systems. Electronic Health Records are meant to standardize medical records to improve the quality and safety of patient care.
During Week 6, I will research the coming changes in Medicare reimbursements.
During Week 4, I shadowed various personnel in the rheumatology medical clinic to understand how each person’s job is an important component in delivering healthcare to patients. When a patient enters the clinic, they first meet with one of the the front desk receptionists who greet and welcomes them to the practice, The patients are registered in the practice management system and entered in the electronic health records. They also answer phone calls and make appointments for the practice. The medical assistant rooms the patients. They begin by weighing and measuring the height of the patients and calculate their BMI (body mass index). They check their vital signs and ask specific medical questions and record the areas on their body where they feel pain. They also record the medications the patient takes. In the back office, triage personnel answer the phones triaging problems of patients and then forwarding them to the appropriate physician. The referral clerk schedules any tests or investigations needed for the patient and looks at the patient’s insurance to determine when and where the tests can take place. The phlebotomist draws the patient’s blood for laboratories. The physician sees the patient and determines their treatment. For the rheumatology clinic, it could be a procedure, medication changes, or injections and infusions. The biller files claims, determines the amount to bill patients based on their insurance, and takes the co-payments. Before the patient leaves, they visit the checkout desk to schedule future appointments. The office manager performs all of the human resource functions for the practice and the day-to-day running of the office.
During Week 3, I spent most of my time with the medical clinic’s billing specialist to learn more about her job and how medical insurance works. I also spent some time observing infusions of medications given for Rheumatoid arthritis and Osteoporosis in the infusion clinic.
The billing specialist first talked about PQRS, Physician Quality Reporting System, and how Medicare incentivizes or penalizes physicians based on the quality of the care provided for patients and documented by physicians. This system was put in place in 2015/2016 and will be replaced by MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payment Systems) in 2017. Because the clinic is a speciality clinic, the government assesses quality based on registry-based reporting based on certain measures. For Rheumatology, these measures include Preventive Care and BMI screening, Pain assessment and follow-up, Tuberculosis screening, Glucocorticoid Management, Assessment and Classification of Disease Prognosis. Once all the reporting is sent to the government, Medicare has a value payment modifier that provides different payments to the physicians. The differential payment is based on quality of care provided to Medicare patients through performance of PQRS measures and the cost of the care that was provided.
The billing specialist and I talked about how patients are billed through Medicare and Commercial insurance plans. I learned that Medicare usually pays 80% of the cost. We went over deductibles, copays, coinsurance, and out of pocket maximums. The deductible is how much the patient must meet out of pocket before the insurance company will begin to pay based on plan benefits. A co-pay is a flat fee assigned to various services which the patient is responsible for paying as well. Coinsurance is a percentage of the allowed amount for which the patient is responsible. Out of Pocket refers to the amount that the patient must pay before insurance will begin to pay at 100% of the cost.
During week two, I met with the different personnel and observed their duties and how they interacted with patients. When a patient enters the clinic, they first go to the front desk. The receptionist registers the patient, collects identification and insurance, and directs the patient to the medical assistant and then the doctors. I shadowed a medical assistant to witness rooming of a patient.
The patient spoke mainly Spanish and told the bilingual medical assistant where she was experiencing pain and the severity of the pain. I could understand a significant amount of the spoken Spanish having studied it for 5 years at school. The medical assistant asked about her medical history, whether or not she takes medications and the dosages, and if she used the voltaren gel prescribed during her last visit to alleviate the pain she felt in her joints. The medical assistant then recorded her temperature, heart rate, and blood pressure and filled out a form recording answers to specific questions. She also calculated the patient’s body mass index (BMI). The doctor then went in to see and examine the roomed patient.
I met with the billing specialist who deals with the patients’ payments and health insurance. I am excited to meet with the billing specialist again next week (week three) to learn more about health insurance, copayments, premiums and billing for services and infusions. I also briefly met with the office manager who performs all the human resource functions for the practice and day-to-day operations. I will be spending more time with her during week four.
I also toured the infusion room where patients are delivered medications through intravenous needles over 1-5 hours. I watched a phlebotomist draw blood from a patient. She drew blood through a syringe and then put it through a centrifuge to separate the serum from the cells. The serum is then then sent for analysis for monitoring and diagnostic tests. I feel I am learning a lot through observation and having my questions answered patiently by the different medical personnel at the clinic. I will continue reading the material and publications provided to me to understand medical economics more fully.
During week one, I did extensive research to understand commercial health insurance including premiums and copayments, Medicare and Medicaid, the Affordable Care Act, and new models for doctor reimbursement namely MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payment Systems). I spoke to my onsite advisor, Dr. Bergstrom, and had a great conversation learning about the microeconomics of a medical business and how health insurance works.
I met a lot of people in the office who were all welcoming and excited to help me with my project. The medical practice I am interning with specializes in Rheumatology; so I met with six doctors, three nurse practitioners, and one physician assistant who work there. One of the physicians takes care of children with arthritis and I would like to learn more about the rheumatologic diseases that affect children from her. The office employs three triage nurses, three front office personnel, seven medical assistants and a few infusion specialists. They told me about some of their own personal experiences with the changes in health care and insurance coverage.
I am excited to work with the billing specialist who records the insurance coverage and the costs of the business. I will spend time next week with her understanding how insurance companies are billed for patient care.
I learned about the interactions medical businesses have with insurance companies in terms of acquiring authorization for expensive medications. I also got a chance to familiarize myself with with some of the medical technology and instruments used in the office. I learned how patient visits are documented using Electronic Health Records (EHRs).
During week one, I learned that health care in our country is extremely complicated and very expensive.