Showing Page:
1/5
1
Nursing
Nursing Care and Healthcare Payment System
Student’s Name
Institutional Affiliation
Professor’s Name
Course
Date
Showing Page:
2/5
2
Overview of the Criteria and Parameters for Implementing Medicare Prospective
Payment Systems (PPS)
The aspect of the healthcare payment system is Medicare Prospective Payment Systems
(PPS). The federal government of the United States established this system to enhance motivation
to healthcare providers to facilitate the delivery of effective and efficient care to patients without
utilizing excess resources. The concept of prospective payment service began around the 1960s
with the initiation of Health Maintenance Organizations (HMO). The Health Maintenance
Organization is responsible for receiving a certain amount of finance in terms of monthly
premiums. They take the responsibility of providing all the services needed by the patients. Hence,
there is a built-in incentive, particularly to healthcare providers, to form a management pattern that
works towards effective and efficient diagnosis and treatment of the patient seeking healthcare
services (Wang, V. et al., 2018).
However, there are a few changes that healthcare intended to make in the Health
Maintenance Organization (HMO) model to have a complete description of the Medicare (PPS)
for hospitals, agencies of homecare, and skilled nursing facilities. The healthcare facility would
not have a premium given every month to cover the entire family. However, the healthcare facility
would receive a single payment that describes a single beneficiary to cover a specified period or
specifically the whole stay. The payment amount generally depends on the diagnosis and
standardized functional assessment. Nevertheless, the concept of payment is the same as the Health
Maintenance Organization defined. The healthcare facility receiving the payment is responsible
for providing the patient's healthcare services with expectations of effective and efficient care. The
main objective of the Prospective Payment System was to facilitate a reduction of an increased
rate of inpatient payment by Medicare and the overall cost of the hospital. The following three key
Showing Page:
3/5
3
elements were expected to enhance the achievement of the main objective. The provision of
marginal incentives generally places healthcare facilities at increased financial risk for inefficient
and unnecessary intensity, thus allowing healthcare facilities to retain the gain from a lower cost
and at the same time provide a more efficient operation. Other’s elements include financial
stringency and regulatory control on admission rates (Wang, V. et al., 2018).
Additionally, the amount of payment might cover the following criteria. It could be
distributed per diem, per stay, or an episode of sixty days. The payment is based on an individual
assessment of every client and only part A class of patients. However, a patient who continues to
remain as an inpatient has the opportunity to exhaust the benefits of part A until they become a
case of part B. In that case, the Prospective Payment System will not pay for such a claim, and the
Medicare Physician Fees Schedule will determine the payment for evaluation and treatment of part
B case. It is imperative to note that Medicare Hospital Outpatient is not under the pure
classification of PPS since they do not fall under the criteria above because payment is on the
evaluation and treatment of the individual (Mukhopadhyay, P. et al., 2019).
The payment amount for a particular service is based on the following parameters. Firstly,
the inpatient acute care hospital adjusts the diagnostic related groups based on sex, major
procedures, age, etc. The payment is conducted per stay in the healthcare facility. Another
classification is the inpatient rehabilitation hospitals or district units using case-mix groups.
Another classification is the skilled nursing facility, where each beneficiary receives payment per
diem based on the minimum data set comprehensive assessment. Home health agency receives
payment at a sixty-day episode; however, they adjust if the patient's condition changes. Hospice
care has four levels of care, and they receive per diem for every level of care. These are routine
Showing Page:
4/5
4
home care and continuous home care. Other are general inpatient care and inpatient respite care
(Centers for Medicare & Medicaid Services [CMS] 2018).
Impact on Nursing Practice
The Prospective Payment System did not impact the patients only, but it also impacted the
nursing practice from different perspectives. It provides nurses with the opportunities to better
coordinate patient care and increases the availability of nurses to practice in a nonhospital setting,
thus providing the opportunity to use the four meta-paradigm of nursing care. Hence, it improves
their knowledge of care and provides the satisfaction of care to patients. The role of nursing is to
provide quality healthcare services and ensure that there is an improvement in the patient's
outcome. Therefore, the incentives provided to healthcare providers, including nurses, motivate
them with morals to provide high-quality care, develop medical innovation, and use evidence-
based practice to enhance better health outcomes of the patients (Schippel, N. et al., 2021).
Showing Page:
5/5
5
References
Centers for Medicare & Medicaid Services (CMS), HHS. (2018). Medicare Program: changes to
hospital outpatient prospective payment and ambulatory surgical center payment systems
and quality reporting programs. Final rule with comment period. Federal
Register, 83(225), 58818-59179.
Mukhopadhyay, P., Pearson, J., Cogan, C., Gaber, C., Gillespie, B. W., & Turenne, M. (2019).
Does one size fit all with the effects of payment reform? Dialysis facility payer mix and
anemia management under the expanded Medicare Prospective Payment System. Medical
Care, 57(8), 584-591.
Schippel, N., Hower, K. I., Zank, S., Pfaff, H., & Rietz, C. (2021). Considering the role of context
when implementing government policies in hospitals: introduction of a prospective
payment system for psychiatry. Journal of Health Organization and Management.
Wang, V., Coffman, C. J., Sanders, L. L., Lee, S. Y. D., Hirth, R. A., & Maciejewski, M. L. (2018).
Medicare’s new prospective payment system on facility provision of peritoneal
dialysis. Clinical Journal of the American Society of Nephrology, 13(12), 1833-1841.

Unformatted Attachment Preview

1 Nursing Nursing Care and Healthcare Payment System Student’s Name Institutional Affiliation Professor’s Name Course Date 2 Overview of the Criteria and Parameters for Implementing Medicare Prospective Payment Systems (PPS) The aspect of the healthcare payment system is Medicare Prospective Payment Systems (PPS). The federal government of the United States established this system to enhance motivation to healthcare providers to facilitate the delivery of effective and efficient care to patients without utilizing excess resources. The concept of prospective payment service began around the 1960s with the initiation of Health Maintenance Organizations (HMO). The Health Maintenance Organization is responsible for receiving a certain amount of finance in terms of monthly premiums. They take the responsibility of providing all the services needed by the patients. Hence, there is a built-in incentive, particularly to healthcare providers, to form a management pattern that works towards effective and efficient diagnosis and treatment of the patient seeking healthcare services (Wang, V. et al., 2018). However, there are a few changes that healthcare intended to make in the Health Maintenance Organization (HMO) model to have a complete description of the Medicare (PPS) for hospitals, agencies of homecare, and skilled nursing facilities. The healthcare facility would not have a premium given every month to cover the entire family. However, the healthcare facility would receive a single payment that describes a single beneficiary to cover a specified period or specifically the whole stay. The payment amount generally depends on the diagnosis and standardized functional assessment. Nevertheless, the concept of payment is the same as the Health Maintenance Organization defined. The healthcare facility receiving the payment is responsible for providing the patient's healthcare services with expectations of effective and efficient care. The main objective of the Prospective Payment System was to facilitate a reduction of an increased rate of inpatient payment by Medicare and the overall cost of the hospital. The following three key 3 elements were expected to enhance the achievement of the main objective. The provision of marginal incentives generally places healthcare facilities at increased financial risk for inefficient and unnecessary intensity, thus allowing healthcare facilities to retain the gain from a lower cost and at the same time provide a more efficient operation. Other’s elements include financial stringency and regulatory control on admission rates (Wang, V. et al., 2018). Additionally, the amount of payment might cover the following criteria. It could be distributed per diem, per stay, or an episode of sixty days. The payment is based on an individual assessment of every client and only part A class of patients. However, a patient who continues to remain as an inpatient has the opportunity to exhaust the benefits of part A until they become a case of part B. In that case, the Prospective Payment System will not pay for such a claim, and the Medicare Physician Fees Schedule will determine the payment for evaluation and treatment of part B case. It is imperative to note that Medicare Hospital Outpatient is not under the pure classification of PPS since they do not fall under the criteria above because payment is on the evaluation and treatment of the individual (Mukhopadhyay, P. et al., 2019). The payment amount for a particular service is based on the following parameters. Firstly, the inpatient acute care hospital adjusts the diagnostic related groups based on sex, major procedures, age, etc. The payment is conducted per stay in the healthcare facility. Another classification is the inpatient rehabilitation hospitals or district units using case-mix groups. Another classification is the skilled nursing facility, where each beneficiary receives payment per diem based on the minimum data set comprehensive assessment. Home health agency receives payment at a sixty-day episode; however, they adjust if the patient's condition changes. Hospice care has four levels of care, and they receive per diem for every level of care. These are routine 4 home care and continuous home care. Other are general inpatient care and inpatient respite care (Centers for Medicare & Medicaid Services [CMS] 2018). Impact on Nursing Practice The Prospective Payment System did not impact the patients only, but it also impacted the nursing practice from different perspectives. It provides nurses with the opportunities to better coordinate patient care and increases the availability of nurses to practice in a nonhospital setting, thus providing the opportunity to use the four meta-paradigm of nursing care. Hence, it improves their knowledge of care and provides the satisfaction of care to patients. The role of nursing is to provide quality healthcare services and ensure that there is an improvement in the patient's outcome. Therefore, the incentives provided to healthcare providers, including nurses, motivate them with morals to provide high-quality care, develop medical innovation, and use evidencebased practice to enhance better health outcomes of the patients (Schippel, N. et al., 2021). 5 References Centers for Medicare & Medicaid Services (CMS), HHS. (2018). Medicare Program: changes to hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs. Final rule with comment period. Federal Register, 83(225), 58818-59179. Mukhopadhyay, P., Pearson, J., Cogan, C., Gaber, C., Gillespie, B. W., & Turenne, M. (2019). Does one size fit all with the effects of payment reform? Dialysis facility payer mix and anemia management under the expanded Medicare Prospective Payment System. Medical Care, 57(8), 584-591. Schippel, N., Hower, K. I., Zank, S., Pfaff, H., & Rietz, C. (2021). Considering the role of context when implementing government policies in hospitals: introduction of a prospective payment system for psychiatry. Journal of Health Organization and Management. Wang, V., Coffman, C. J., Sanders, L. L., Lee, S. Y. D., Hirth, R. A., & Maciejewski, M. L. (2018). Medicare’s new prospective payment system on facility provision of peritoneal dialysis. Clinical Journal of the American Society of Nephrology, 13(12), 1833-1841. Name: Description: ...
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.
Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4