Medicare reimbursement essay – National healthcare issue/ stressor

Walden University NURS-6053 Module 1: Discussion Review of Current Healthcare Issues – Medicare reimbursement essay – National healthcare issue/ stressor 

By Day 3 of Week 1

Post
 a description of the national healthcare issue/stressor you selected for analysis, and explain how the healthcare issue/stressor may impact your work setting. Which social determinant(s) most affects this health issue? Then, describe how your health system work setting has responded to the healthcare issue/stressor, including a description of what changes may have been implemented. Be specific and provide examples.

Medicare reimbursement essay – National healthcare issue/ stressor

Medicare reimbursement

Before 2011, home health agencies could bill Medicare for separate services such as therapy, nursing, or supplies. Medicare changed to bundled payment models in 2011. This created a single payment system where all costs of services and supplies are placed into one payment. The provider is then expected to cooperate with other disciplines and consider how to contain their cost for services and supplies into the new single payment. This payment is based on a case mix depending on the patient’s diagnosis and functional data. The more ill patients are, the higher the reimbursement. This was to prevent overutilization of services like therapy in previous payment systems. This change in payment has caused significant stress in the home health world.

How this has impacted my work setting

 
In the previous PPS system, the home health agency was paid for each service or supply needed.  For example, the agency had a tracheostomy patient with a gastrostomy and a urinary catheter and wounds. The nurse went out thrice weekly for wound care and managed the other medical needs. The home health agency was paid for the nurse’s visits and reimbursed for all wound supplies, catheter supplies, and tracheostomy supplies, from saline bullets to tracheostomy inner cannulas. The nursing payment didn’t matter if the nurse went daily fifty miles away or once a week, they received the same payment based on the patient condition. An additional payment was added for the therapy care if therapy was needed. The agency was paid half upfront and the other half once the care was given at the end of the sixty days. Example: Nursing costs $1200, therapy $2300, and supplies $3000 Medicare reimbursement essay – National healthcare issue/ stressor .

Today, here is an example of one of my current patients with bundled payment based on case mix. $2000 per 30-day period for everything, and this is a high payment. Some are less than $1000. So the nurse goes three times a week for wound care for a stage IV with a wound vac, PICC line care for IV therapy, a Gastrostomy tube, pure wick, and tracheostomy.  That payment must cover nursing, mileage, and supplies. Home health must order each monthly tracheostomy replacement, closed suction systems, inner cannulas, etc, through agencies like Medline. This is due to the higher reimbursement due to patients leaving the hospital. The MD then orders PT, OT, speech, MSW, and aide because of the complexity of care. This is not possible with the reimbursement if just the PT  evaluation is $90 plus mileage. This is why many agencies went under over the last 10 years, and many more closed when PDGM hit. There is no extra for an in-house biller, QA nurse, or marketer. Many agencies are barely surviving.

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The goal of home care when it comes to Medicare is to treat them, get them better then discharge them. What about this patient? These are chronic, long-term, or lifetime illnesses. The longer they stay on services, the less money you get. Outcomes-based reimbursement. Based on functional skills, if this patient is paralyzed, how do I get them better to discharge from services?

Most case mix prospective payment models rely on functional assessment and health-related data to project payment for home health care. This offers only a limited view of the patient’s needs and care in the home. One study used home nurses and health insurers to look at case mix characteristics in the home and found holistic care, such as social networking and mental functioning, to be important indicators of successful home health care (Van den Bulck 2022) Medicare reimbursement essay – National healthcare issue/ stressor .

Many countries are utilizing case-mix models for home health payment. Different models are used, and no one system is the most effective (Van den Bulck et al., 2020).

A study with cardiac patients in the hospital and ninety days post-discharge noted changes in spending costs, care utilization, or improvements by using a bundled payment model. Medicare reimbursement essay – National healthcare issue/ stressor

What social determinants affect this issue?

Fewer agencies are even willing to take complex patients like this because their payment is in the negative. They cannot discharge the patient either due to the patient’s needs.
Healthcare access
and quality is compromised. Different patients have different healthcare payments. They have more difficulty finding providers to care for them if they live in a rural area. Many therapy companies in my area will not travel to surrounding towns due to their decreased payment and use. Agencies must buy generic supplies due to cost Medicare reimbursement essay – National healthcare issue/ stressor .

Many of these patients are low-income or even middle-income, and cannot afford in-home care from providers, and do not qualify for state services. They cannot afford payments on DME like a hospital bed or a shower chair, so they do without. Patient safety is compromised. Patient outcomes are not improved. The bundled payment is a great idea for utilizing services more efficiently, but the payment is not enough to cover patient needs and expenses, much less for an agency to stay afloat. This is with zero profit for the agency.

How has my agency responded

My agency cannot accept medically complex patients like the one described. We cannot afford their supplies much less extra services. We purchase generic wound care supplies and ask for cheaper alternatives to expensive treatments that may have been used in the hospital. We have downsized staff to the bare minimum, and everyone wears multiple hats. Small companies are dying out in this system Medicare reimbursement essay – National healthcare issue/ stressor . These mom-and-pop shops give great personalized care. Hospitals are enduring the same and cutting costs wherever possible. The patient and the agencies giving their care are the ones paying the extra cost.

References

Shashikumar, S. A., Jie Zheng, Orav, E. J., Epstein, A. M., & Maddox, K. E. J. (2023). Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement – Advanced. 
Circulation
, 
148
(14), 1074–1083. https://doi.org/10.1161/CIRCULATIONAHA.123.065109

Van den Bulck, A. O. E., de Korte, M. H., Elissen, A. M. J., Metzelthin, S. F., Mikkers, M. C., & Ruwaard, D. (2020). A systematic review of case-mix models for home health care payment: Making sense of variation. 
Health Policy (Amsterdam, Netherlands)
, 
124
(2), 121–132. 
https://doi.org/10.1016/j.healthpol.2019.12.012
Links to an external site.

Van den Bulck, A. O. E. 
et al.
 Identifying client characteristics to predict homecare use more accurately: a Delphi-study involving nurses and homecare purchasing specialists. 
BMC Health Services Research
, 
[s. l.]
, v. 22, n. 1, p. 1–10, 2022. DOI 10.1186/s12913-022-07733-9. Disponível em: https://search.ebscohost.com/login.aspx?direct=true&AuthType=shib&db=rzh&AN=155953624&site=eds-live&scope=site. Acesso em: 26 fev. 2025. Medicare reimbursement essay – National healthcare issue/ stressor