MACRA and Accountable Care Organizations: Is It Working?

The purpose of this study was to examine how the Medicare Access and CHIP Reauthorization Act (MACRA) has improved health care delivery and to determine its impact on Accountable Care Organization (ACO) goals. ACOs have provided quality care through the reduction in readmission rates, coordinated care, and cost savings. With the passage of the MACRA, it has been estimated that it would further decrease Medicare spending on physician and hospital services. Also, ACOs have had a positive impact on improving health care delivery and have played a significant role in providing exceptional quality of care while also managing to increase the cost savings.

UPCODING MEDICARE: IS HEALTHCARE FRAUD AND ABUSE INCREASING?

Medicare fraud has been the cause of up to $60 billion in overpaid claims in 2015 alone. Upcoding occurs when a healthcare provider has submitted codes for more severe conditions than diagnosed for the patient to receive higher reimbursement. The purpose of this study was to assess the impact of Medicare and Medicaid fraud to determine the magnitude of upcoding inpatient and outpatient claims throughout reimbursements. The methodology for this study utilized a literature review. The literature review analyzed physician upcoding throughout present on admission infections, diagnostic related group upcoding, emergency department, and clinic upcoding. It was found that upcoding has had an impact on Medicare payments and fraud. Medicare fraud has been reported to be the magnitude of upcoding inpatient and outpatient claims throughout Medicare reimbursements. In addition, fraudulent activity has increased with upcoding for ambulatory inpatient and outpatient charges for patients with Medicare and Medicaid.

COVID-19 and Vaccine Hesitancy: A Challenge the United States Must Overcome.

A significant portion of the U.S. population may experience vaccine hesitancy of a new COVID-19 vaccine, which poses dangers to both the individual and their community, since exposure to a contagious disease places the person at risk, and individuals are far more likely to spread the disease to others if they do not get vaccinated. Many individuals are doubtful, and without the healthcare community, speaking with one voice has led to distrust. Experience from the influenza vaccines have shown vaccine acceptance has not been optimal, and this new vaccine, even though it is not approved, is already showing layperson skepticism compounded by political influences.

Reduction of Intensive Care Unit Length of Stay: The Case of Early Mobilization.

Bed rest or immobilization is frequently part of treatment for patients in the intensive care unit (ICU) with critical illness. The average ICU length of stay (LOS) is 3.3 days, and for every day spent in an ICU bed, the average patient spends an additional 1.5 days in a non-ICU bed. The purpose of this research study was to analyze the effects of early mobilization for patients in the ICU to determine if it has an impact on the LOS, cost of care, and medical complications. The methodology for this study was a literature review. Five electronic databases were used, with a total of 26 articles referenced for this research. Early mobilization suggested a decrease in delirium by 2 days, reduced risk of readmission or death, and reduced ventilator-assisted pneumonia, central line, and catheter infections. Length of stay in the ICU was reduced with statistical significance in several studies examining early mobilization. Limited research on cost of ICU LOS indicated potential savings with early mobilization. When implementing early mobilization in the ICU, total costs were decreased and medical complications were reduced. Early mobilization should become a standard of care for critically ill but stable patients in the ICU.

The Growing Problem of Hepatitis C Virus Infection: The Case of West Virginia.

Hepatitis C virus (HCV) is one of the most significant public health problems currently facing the United States, especially in West Virginia. If it is undetected and left untreated, the likelihood of sustaining a treatment response decreases. While early identification has been identified as a critical focus in trying to obtain better health outcomes, new drug treatments appear promising, if somewhat expensive. West Virginia is a predominantly rural state, where the incidence of HCV is 9 times the national average and Medicaid costs for treatment amounted to more than $27 million from 2014 to 2016. The purpose of this study was to conduct a systematic review of the effects of early identification and treatment for patients infected with HCV as it relates to West Virginia. A comprehensive systematic review was limited to 58 articles published from 2008 to 2018 and were in English. Findings from this review identified early detection as the first line of a preventive strategy to help reduce the evolving epidemic and that oral medications could reduce the risk of liver cancer and death. The cost associated with hospitalization of HCV more than tripled from $20 963 in 2005 to $64 867 in 2011 with the average charge per hospitalization at $53 626 due to HVC. The lack of adequate treatment options has led to increasing (and even more expensive) hospital care for untreated HCV. These facts suggest that this state might be facing an expected financial health care crisis due to its increasingly drug-related HCV-infected population.

The 340b Program, Contract Pharmacies, Hospitals, and Patients: An Evolving Relationship Impacting Health Care Delivery.

The 340B Drug Pricing Program, created by Congress in 1992 through the Veterans Health Care Act, has provided discounted drug prices to hospitals and other health care organizations serving a wide population of low-income patients. Some 340B programs use contract pharmacies, an arrangement whereby the hospital or health care organization signs a contract directly with a pharmacy to provide covered pharmacy services at discounted prices. The federal 340B Drug Pricing Program has provided access to reduced price prescription drugs to more than 35 000 individual health care facilities and sites certified by the US Department of Health and Human Services, and clinics have served more than 10 million people in all 50 states, plus commonwealths and US territories. The 340B program has increased profits for hospitals through contract pharmacies because they have still received the same reimbursement but acquired drugs at a lower rate.

Medicare Access and CHIP Reauthorization Act and Rural Hospitals.

The cost of health care within the United States has continued to increase, whereas the quality of patient care has generally decreased in some areas. With the continued use of Medicare's former physician reimbursement algorithm, termed sustainable growth rate, national expenditures within the United States have been expected to increase 5.6% annually. To modernize the delivery and financing of care, Congress has introduced the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which has permanently eliminated and replaced the sustainable growth rate. The purpose of this study was to review MACRA and its implementation to determine how it would financially impact rural hospitals. Two reimbursement pathways have been created for physicians under the MACRA. In addition, the financing and competition among facilities created by the act have been expected to impact physicians and health care organizations. Rural hospitals have been set to receive reduced government reimbursements and have been predicted to compete poorly with larger hospitals and health care corporations. Furthermore, the payment tracks available through the act have been projected to impact solo and small practice physicians negatively.

Prenatal Opioid Maintenance in the United States and Its Effect on Neonatal Abstinence Syndrome: The Case of West Virginia's Opioid Epidemic.

West Virginia's opioid epidemic has been the cause of more than 42 000 deaths each year. Opioid abuse has become an issue among pregnant mothers and has increased the effects of neonatal abstinence syndrome (NAS) in infants. The purpose of this study was to evaluate the participation of prenatal opioid maintenance to determine whether it has decreased the amount of treatment needed for NAS in infants in West Virginia. The methodology utilized a literature review complemented with a semistructured interview. Thirty-six sources were referenced for this literature review. It was found that buprenorphine maintenance therapy had the most positive effect on NAS after birth. This review also reported a lack of availability for addicted pregnant women to enroll in maintenance programs and a high dropout rate. Opioid maintenance therapy has permitted pregnant women to refrain from illicit drug use without experiencing withdrawal symptoms, and it has allowed the opportunity for their infants to have better health after birth.

The Opioid Epidemic in West Virginia.

The rate of overdose related to the use of licit and illicit opioids has drastically increased over the last decade in the United States. The epicenter has been West Virginia with the highest rates of overdoses accounting for 41.5 deaths per 100 000 people among the 33 091 deaths in 2015. The purpose of this research was to examine and analyze the cause of the opioid epidemic and subsequent responses to it in the state of West Virginia. This study conducted a literature review using 37 references that were published between the years 2009 and 2018, complemented with a semistructured interview. The number of people injecting drugs has increased from 36% in 2005 to 54% in 2015. The total US cost of prescription opioid abuse in 2011 has been estimated at $25 billion, and criminal justice system costs to $5.1 billion. The reasons for this opioid epidemic incidence in West Virginia have been a combination of sociocultural factors, a depressed economy, lack of education, and a high rate of prescribing and dispensing of prescription opioids.

Rethinking the Obvious: Time for New Ideas on Medical Malpractice Tort Reform.

States have engaged in medical malpractice litigation reforms over the past 30 years to reduce malpractice insurance premiums, increase the supply of physicians, reduce the cost of health care, and increase efficiency. These reforms have included caps on noneconomic damages and legal procedural changes. Despite these reforms, health care costs in the United States remain among the highest in the world, provider shortages remain, and defensive medicine practices persist. The purpose of this study was to determine how successful traditional medical malpractice reforms have been at controlling medical costs, decreasing defensive medicine practices, lowering malpractice premiums, and reducing the frequency of medical malpractice litigation. Research has shown that direct reforms and aggressive damage caps have had the most significant impact on lowering malpractice premiums and increasing physician supply. Out of the metrics that were improved by malpractice reforms, similar improvements were shown because of quality reform measures. While traditional tort reforms have shown some targeted improvement, large-scale, system-wide change has not been realized, and thus it is time to consider alternative reforms.

Use of Teledermatology to Improve Dermatological Access in Rural Areas.

Introduction: Dermatological access in rural regions has been impacted due to an acute, global dermatologist shortage coupled with a striking disparity in dermatologist density between urban and rural areas. As a result, the dermatological arena has been under notable pressure to amplify access. Teledermatology has entailed the use of technology to provide dermatological services to individuals located at a remote distance. The purpose of this literature review was to examine the effect of utilization of teledermatology to determine enhancement of dermatological access to residents of rural areas. Materials and Methods: This review followed a systematic approach and utilized five electronic databases to obtain peer-reviewed journal articles. A PRISMA approach was used and a total of 86 references were employed. Results: Teledermatology programs have been able to complement conventional dermatological care to enhance dermatological access to rural areas that have suffered from a shortage of dermatologists and could aid in supplementing traditional care as well. Within rural settings, the results of three studies in this review indicated the importance of improved quality for diagnostic precision, whereas one study reported that clinical images might not provide sufficient insight to deliver clear-cut diagnoses. In addition, enhancements in diagnostic precision could be obtained by upgrades in phone cameras to capture images. Finally, to most of the existing literature, in using teledermatology, physician satisfaction has been stronger than patient satisfaction. Conclusions: Teledermatology has had a beneficial impact in improving dermatological access to rural areas. The success of this technology is contingent upon the commitment and willingness of the dermatologist in utilizing it.

Still an Epidemic: The Burnout Syndrome in Hospital Registered Nurses.

The number of registered nurses (RNs) in the United States is roughly 3 times the number of physicians and surgeons, making RNs a critically important component of the US health care system. Registered nurse burnout-the state of emotional exhaustion in which the individual feels overwhelmed by work to the point of feeling fatigued, unable to face the demands of the job, and unable to engage with others-is a real concern, having been reported in many hospitals. The purpose of this research was to examine the causes and consequences of burnout syndrome among RNs in US hospitals and its role in the RN shortage in hospitals. The methodology involved a review of the literature and semistructured interviews. Seven primary databases, 2 websites, and 43 articles were consulted in this project. Findings indicated that burnout syndrome in RNs can be analyzed in terms of 4 clusters of characteristics: individual, management, organizational, and work. The consequences of burnout syndrome have increased RN turnover rates, poor job performance, and threats to patient safety. Burnout syndrome was more prevalent in hospitals with a higher number of patients per nurse and among younger RNs. Registered nurse burnout in hospitals has negatively impacted the quality of care, patient safety, and the functioning of staff workers in the health care industry.

The Nationwide Health Information Network: The Case of the Expansion of Health Information Exchanges in the United States.

The Nationwide Health Information Network (NHIN) implemented secure exchange of health records through utilization of the Internet. The NHIN has greatly assisted in achieving the goals of the Health Information Technology for Economic and Clinical Health Act by promoting the adoption of Meaningful Use. Epic introduced a Health Information Exchange platform, Care Everywhere, which has facilitated Health Information Exchange availability. The purpose of this research was to determine the impact of NHIN and Epic Care's Care Everywhere on health care to determine whether their use in the emergency department (ED) has increased. The methodology for this study utilized a literature review. Twenty-eight sources were referenced for this study. With the NHIN implementation, repeated visits were decreased, visit times became faster, and charges were lower. Emergency department reported significant benefits with sharing clinical information. The NHIN implementation throughout the ED has increased the quality of health care; duplicated tests and drug usage were determined, and a reduction of the ED length of stay was also achieved.

Examining the Benefits of the 340b Drug Discount Program.

The 340B Drug Discount Program required drug manufacturers to provide discounted outpatient drugs to health care organizations serving vulnerable patient populations to allow these institutions to offer more services to more people. As the 340B program expanded, controversy centered on which entities have benefited from the program. Many health care organizations sold 340B drugs to well-insured patients at full price and have thus been financially rewarded. Amendments to the program have permitted 340B providers to use contract pharmacies to dispense 340B medications, furthering the debate over which stakeholders are benefiting from the program. The purpose of this study was to determine which stakeholders benefited because of the 340B Drug Discount Program and what have been the drivers of recent changes to the program. The study used a literature review. One database aggregator and six academic databases were used to collect 70 total sources. These sources were reviewed and reduced to 39 sources, which were used in the written research. Of these, 20 sources were used in the Results section. Research showed that 340B eligible entities and contract pharmacies have financially benefited from the 340B program. Patient benefit has been indirect, as qualified providers have expanded service offerings and increased access to health care services. Regulatory reform, as well as profit potential, has driven the expansion of 340B as more providers have expanded eligible service lines. Although the goal of the 340B program has often been misconstrued, direct financial benefits to eligible providers have allowed for this expansion of access.

Strategies for Fighting Medicare Fraud.

In 2014, the United States spent approximately $3 trillion on health care. Medicare accounted for $554 billion of these costs, and approximately $60 billion were squandered because of incorrect billing methods, abuse, and fraud. Types of fraud included kickbacks, upcoding, and organized fraudulent crimes. To reduce the financial burden associated with these activities, the United States has created various fraud prevention programs. The purpose of this study was to identify methods of Medicare fraud, examine the various programs implemented by the US government to combat fraud and abuse, and determine the effectiveness of these programs. Although fraud prevention strategies have proven to be effective, the furtherance of these strategies is imperative to continually combat rising health care expenditures in the United States. Benefits of increased fraud prevention and detection are discussed in detail.

Provider Reimbursement Following the Affordable Care Act.

Decreasing health care expenditures has been one of the main objectives of the Affordable Care Act. To achieve this goal, the Centers for Medicare and Medicaid Services (CMS) has been tasked with experimenting with provider reimbursement methods in an attempt to increase quality, while decreasing costs. The purpose of this research was to study the effects of the Affordable Care Act on physician reimbursement rates from CMS to determine the most cost-effective method of delivering health care services. The CMS has experimented with payment methods in an attempt to increase cost-effectiveness. Medicare has offered shared cost-savings incentives to reward quality care to both primary care providers and preventative services. The CMS has determined fee-for-service payments obsolete, opting instead for a value-based purchasing method of payment. Although a universal payment method has yet to be adopted, it has been evident that a value-based purchasing model and preventative care can be used to decrease health care expenditure.

Maryland's All-Payer Health Care System: A Light at the End of a Tunnel.

The state of Maryland, in collaboration with the Centers for Medicare & Medicaid Services, developed the first all-payer system model in the Unites States in 1971 and 35 years later in response to financial pressures undertook to modernize this program. The focus of the modernized program was to improve overall per-capita expenditure, quality of care, and the outcome of Marylanders' health. The financial status of Maryland hospitals was declining because of the rate setting of the Health Services Cost Review Commission while hospital admission rates and spending were increasing. This study showed positive change in moving Maryland health care delivery model in hospitals from volume-driven care to value-driven coordinated care. Maryland hospitals have changed their mind-sets to achieve the Triple Aim of cost reduction, health improvement, and quality-of-care improvement. The modernized model does require hospitals and business individuals to change their approach to be accountable in providing health care to all citizens, as well as trying to solve chronic social problems such as poverty and unequal access to health care.

The Impact of Big Data on Chronic Disease Management.

Population health management and specifically chronic disease management depend on the ability of providers to prevent development of high-cost and high-risk conditions such as diabetes, heart failure, and chronic respiratory diseases and to control them. The advent of big data analytics has potential to empower health care providers to make timely and truly evidence-based informed decisions to provide more effective and personalized treatment while reducing the costs of this care to patients. The goal of this study was to identify real-world health care applications of big data analytics to determine its effectiveness in both patient outcomes and the relief of financial burdens. The methodology for this study was a literature review utilizing 49 articles. Evidence of big data analytics being largely beneficial in the areas of risk prediction, diagnostic accuracy and patient outcome improvement, hospital readmission reduction, treatment guidance, and cost reduction was noted. Initial applications of big data analytics have proved useful in various phases of chronic disease management and could help reduce the chronic disease burden.

International Classification of Diseases, Tenth Revision Implementation: Is the Workforce Ready?

After many delays, the United States finally implemented the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedural Coding System on October 1, 2015, bringing the United States into line with other industrialized nations, most of which had been using the International Classification of Diseases, Tenth Revision for many years. We outline the benefits and challenges to the preparatory activities of the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedural Coding System implementation for the US health care industry. To ease the transition, the Centers for Medicare & Medicaid Services allowed health care facilities to submit test claims prior to the implementation date and delivered feedback on the acceptability of those claims. Early results indicated a relatively smooth transition, although some questions regarding the available data remain. Additional data, especially data concerning outcomes, are required.