Sheri Saluga, MSN, RN U.S. Healthcare System Payment Structure • Cost of healthcare in the U.S. is higher than any other country. • Healthcare cost “$3.3 trillion dollars” • “Cost per person was $9900” (Schreck, 2018). (Schreck, 2018). • High cost healthcare has several negative ripple effects 2018). (Schreck, U.S. Healthcare System Payment Structure Health care providers are paid by: • Private insurance • Government insurance programs • Personal, out of pocket • Government directly provides some health care (Schreck, 2018). (Haughom, 2014) Affordable Care Act The Affordable Care Act (ACA) was enacted in 2010 by President Barak Obama. Purpose1. Availability 2. Affordability 3. Expansion of the market 4. Incentives for employers 5. Requires the purchase private health insurance (Schreck, 2018). Affordable Care Act How it applies to mental health benefits: • Mental Health Parity and Addiction Equity Act (MHPAE) 2008 • Mental health and substance abuse treatment equal to medical/surgical treatment • Applies to small group, individual plans, and Medicaid • Large group plans and Medicare excluded • Prescription medications (APA, 2019). Affordable Care Act ACA changes from 2017 • Repeal of the individual mandate • Eliminating cost sharing reductions • Increased used of Medicaid waivers • Increase in the association health plan availability • Short-term limited duration insurance ) (Solnick, 2017 Case Scenarios PATIENT 68– year-old patient Diagnosis- depression • • • • COVERAGE 80% Covered by Medicare part B Provider must accept Medicare Medications per preferred drug list Co-pay and deductible applies • • • • Coverage varies by state Falls under the parity law Provider selection may be limited Medications per the preferred drug list Insurance- Medicare 34- year-old patient (homeless) Diagnosis- Schizophrenia Insurance- Medicaid PATIENT 43–year-old patient Diagnosis- bipolar Insurance- private/work provided insurance 22- year-old patient (undocumented immigrant) Diagnosis- PTSD/anxiety Insurance- uninsured COVERAGE Depending on size of company (50+ employees) • Not required to provide mental health coverage (large insurance plans) • If mental health coverage is provided, falls under the parity law • Co-pay may apply • Unlimited or medically necessary visits • Prescription coverage may vary • Emergency services covered, under federal law • Will have to pay for services • Community health centers provide low-cost care Provision of Care • ACA has expanded the provision of care • Care should be equitable • Private practice doctors • Medicare and Medicaid (Bresnick, 2016) Quality Determinants • Creation of Accountable Care Organizations (ACO) • AHRQ develops healthcare quality measures • Structural • Process • Outcome (Agency for Healthcare Quality and Research [AHQR], 2015) Quality Determinants • IOM six domains of quality healthcare • Safe • Effective • Patient-centered • Timely • Efficient • Equitable (AHQR, 2015). Quality Determinants •AHQR three aims for improving healthcare 1. Achieving better care 2. Achieving healthy people and communities 3. Making care affordable (AHQR, 2017). • Centers for Medicare and Medicaid core measures Barriers to Healthcare • Availability of appointments • Geographic • Provider shortages • Transportation • Language • Financial • Cultural (Rayome, 2017) Issues Related to Advance Practice Nursing • Consensus model of nursing • Regulatory requirements for APRN’s vary • Obstacle to portability • Preventing access to care (NCSBN, 2019) Getting Involved If your state is not in the consensus model • Sample letter to legislator https://www.ncsbn.org/APRN_formletter_Legislator web.pdf • Sample letter to board of nursing https://www.ncsbn.org/APRN_formletter_Supporter s_web.pdf • Other ways to support the consensus model https://www.ncsbn.org/APRN_CommunicatingwLeg islator_web.pdf (NCSBN, 2019). References American Nurses Credentialing Center. (n.d.). APRN consensus model. Retrieved from https://www.nursingworld.org/certification/aprn-consensus-model/ Agency for Healthcare Research and Quality. (2015). Consider culture, customs, and beliefs: Tool #10. Retrieved from https://www.ahrq.gov/professionals/qualitypatient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool10.html Agency for Healthcare Research and Quality. (2015). Types of health care quality measures. Retrieved from https://www.ahrq.gov/talkingquality/measures/types.html Agency for Healthcare Research and Quality. (2017). Overview of quality and access in the U.S. health care system. Retrieved from https://www.ahrq.gov/research/findings/nhqrdr/nhqdr16/overview.html American Psychological Association. (2019). What you need to know about mental health coverage. Retrieved from https://www.apa.org/helpcenter/parity-guide Beaton, T. (2018). Affordable care act changes may bring a rocky 2018 for payers. Retrieved from https://healthpayerintelligence.com/news/affordable-care-actchanges-may-bring-a-rocky-2018-for-payers Centers for Medicare and Medicaid Services. (n.d.). Core measures. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/QualityMeasures/Core-Measures.html Commonwealth Fund. (n.d.). The U.S. healthcare system. Retrieved from https://international.commonwealthfund.org/countries/united_states/ Gold, J. (2011). Accountable care organizations, explained. Retrieved from http://www.npr.org/2011/04/01/132937232/accountable-care-organizationsHealthinsurance.org. (2019). How Obamacare improved mental health coverage. Retrieved from https://www.healthinsurance.org/obamacare/how-obamacareimproved-mental-health-coverage/ Heath, S. (2018). Top challenges impacting patient access to healthcare. Retrieved from https://patientengagementhit.com/news/top-challenges-impacting-patientaccess-to-healthcare Holland, S. (2018). New health plans discriminate against mental illness. Retrieved from https://www.nami.org/Blogs/NAMI-Blog/October-2018/New-Health-PlansDiscriminate-Against-Mental-Illne McCoy, J. (2006). Obligation to provide services: A physician-public defender comparison. Ethics Journal of the American Medical Association , 8(5), 332-334. Medicare.gov. (n.d.). Is my test, item, or service covered? Retrieved from https://www.medicare.gov/coverage/mental-health-care-outpatient References Medicare.gov. (n.d.). Is my test, item, or service covered? Retrieved from https://www.medicare.gov/coverage/mental-health-care-outpatient Meuter, R. F., Gallois, C., Segalowitz, N. S., Ryder, A. G., & Hocking, J. (2015). Overcoming language barriers in healthcare: A protocol for investigating safe and effective communication when patients or clinicians use a second language. BMC health services research, 15, 371. doi:10.1186/s12913-015-1024-8 National Alliance of Mental Health Ilness. (2019). Types of health insurance. Retrieved from https://www.nami.org/Find-Support/Living-with-a-Mental-HealthCondition/Understanding-Health-Insurance/Types-of-Health-Insurance NCSBN. (2019). APRN consensus model. The consensus model for APRN regulation, licensure, accreditation, certification and education. Retrieved from https://www.ncsbn.org/aprn-consensus.htm Office of Disease Promotion and Prevention. (2019). Access to healthcare services. Retrieved from https://www.healthypeople.gov/2020/topicsobjectives/topic/Access-to-Health-Services Schreck, R. (2018). Overview of health care financing. Retrieved from https://www.merckmanuals.com/home/fundamentals/financial-issues-in-healthcare/overview-of-health-care-financing Substance Abuse and Mental Health Services Administration. (2018). Medicaid coverage of medication-assisted treatment for alcohol and opioid use disorders and of medication for the reversal of opioid overdose. Retrieved from https://store.samhsa.gov/system/files/medicaidfinancingmatreport.pdf Substance Abuse and Mental Health Services Administration. (n.d.). What immigrants and refugees need to know about the Affordable Care Act. Retrieved from https://www.samhsa.gov/sites/default/files/immigrants-refugees-affordable-care-act-with-notes.pdf U.S. Department of Health and Human Services. (2013). Affordable care act expands mental health and substance abuse disorder benefits and parity protection for 62 million Americans. Retrieved from https://aspe.hhs.gov/report/affordable-care-act-expands-mental-health-and-substance-use-disorder-benefits-and-federal-parityprotections-62-million-americans Photos Bomb http://datalingua.com/Index5.htm Coaching http://mikejentes.com/wp-content/uploads/2012/11/Coaching.jpg Disability http://ts2.mm.bing.net/th?id=H.4593713461133641&pid=15.1 Diversity http://www.corrections.com/system/article/image/30240/Diversity-g.jpg?1329854766 Emergency http://ts2.mm.bing.net/th?id=H.4882708841302037&pid=15.1 Emergency preparedness http://shopcybercoupons.com/images/Emergency-Preparedness.jpg Hazardous www.junkit.ca Hospital http://www.hopkinsmedicine.org/sebin/p/g/curtainwall2.jpg Joint Commission http://www.jointcommission.org/certification/certification_main.aspx Leadership http://betterboards.net/wp-content/uploads/2011/02/leadership-web.jpg Magnet http://nursecredentialing.org/Magnet Mission statement http://ts3.mm.bing.net/th?id=H.5031035550761186&pid=15.1 Sexual harassment http://ts4.mm.bing.net/th?id=H.4756578584167435&pid=15.1 http://ts2.mm.bing.net/th?id=H.4584608116967593&pid=15.1 Succession planning piercecfo.com Teamwork http://ts4.mm.bing.net/th?id=H.4825521380656243&pid=15.1 Tornado http://hahathatsfuney.wordpress.com/2009/01/06/tornados/ Bresnick, J. (2013). Why mental healthcare is key to population health management. Retrieved from https://healthitanalytics.com/news/why-mental-healthcare-is-key-topopulation-health-management Haughom, J. (2014). Whats good about U.S. healthcare. Retrieved from https://www.healthcatalyst.com/positive_healthcare_transformation/ NCSBN. (2019). APRN consensus model toolkit. Retrieved from https://www.ncsbn.org/739.htm Rayome, A. (2017). The top 10 barriers to digital transformation. Retrieved from https://www.techrepublic.com/article/the-top-10-barriers-to-digital-transformation/ Solnick, C. (2017). Free affordable care act seminar. Retrieved from https://libn.com/2017/11/21/free-affordable-care-act-seminar/
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