Why did CMS become more involved in the reimbursement component of health care?

Read the scenario that you will use for the Individual Projects in each week of the course. The Centers for Medicare and Medicaid Services (CMS) has taken on a more visible role in health care delivery. Many changes have transpired to improve patient safety along with the implementation of additional quality metrics, and these changes impact reimbursement rates.

Likewise, the Patient Protection and Affordable Care Act has changed the reimbursement fee structure of Medicare and Medicaid reimbursement for health care services.  Other legislation including the HITECH Act and the Medicare Authorization and CHIP Reactivation Act of 2015 (MACRA) all impact how healthcare organizations receive reimbursement and demonstrate use of data to improve quality and delivery of patient care.

Mr. Magone, CEO of Healing Hands Hospital, has asked you to join the “Future of Healing Hands” Task Force, and your first assignment is to work with the Hospital Chief Financial Officer, Mr. Johnson, and provide a summary of the current regulations regarding Medicare reimbursement including how MACRA will impact reimbursement if/when Healing Hands coordinates delivery of services by affiliating with physician practices.

For this assignment, write a 2-3 page report that you will deliver to Mr. Magone on how the new CMS initiatives and regulations will impact the organization’s revenue structure. In your presentation, address the following questions:

 

  • Why did CMS become more involved in the reimbursement component of health care? How does CMS’s involvement impact the reimbursement model for Healing Hands Hospital and other health care organizations?  If CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other insurance providers change their policies on reimbursement?
  • What tools can be implemented to ensure organizations such as Healing Hands Hospital and physician practices are meeting the policies and procedures set forth by CMS?

Identify 3 tools from the CMS Web site that are helpful in meeting the requirements for Medicare reimbursement set forth by CMS.   (2-3 page report not including title page or reference page).

 

 

Scenario

Throughout this course, you will provide information and analysis using a fictitious community hospital, Healing Hands, located in a suburban community about 15 miles outside of a major metropolitan area.  Each week, you will complete specific assignments, and in the final weeks of this course, you will provide a final report detailing your findings.

The following scenario will be utilized throughout this course to assist you in completing each week’s assignment:

Healing Hands Hospital is an acute care community hospital in a suburb 15 miles outside of a large metropolitan city. The hospital, which was founded over 50 years ago, is dedicated to serving the local community consisting of working professionals, families and retired individuals.  It has 320 beds and is comprised of a group of 500 physicians.  The hospital has in-patient services for short-stay acute care patients; an in-patient mental health unit; an ambulatory surgical clinic; and specialized units in cancer, maternal and child services, orthopedics, and cardiac care.  Healing Hands Hospital serves a community of approximately 500,000.

Mr. Jeff Magone, the new Chief Executive Officer of Healing Hands Hospital recognizes that an important trend in healthcare delivery that is linked to reimbursement is accountable care and integrated delivery models.   He has set the goal for the hospital to remain financially viable and increase services and quality of care available to the community served by Healing Hands Hospital.   To accomplish this goal, Mr. Magone realizes that there are several options to consider such as:

  1. Addition of outpatient services including urgent care centers and affiliations with more local physician practices,
  2. Merging with another community hospital in a neighboring suburb, or
  3. Affiliating with one of the two large academic medical centers in the city.

Mr. Magone and the hospital Board of Directors have discussed the options and they realize that some changes need to be made to not only maintain and improve the high quality of patient care for which Healing Hands is recognized but also to ensure future financial stability in the changing healthcare industry.

Mr. Magone and the Healing Hands Hospital Board of Directors have created a “Future of Healing Hands” Task Force, and as a Director of Operations, you have been asked to participate on the Task Force and provide support through research, analysis and reports to the Task Force as they evaluate options to meet the goals outlined by Mr. Magone.  You will work with your supervisor, the Chief Operating Officer, Ms. Woods, as well as the Chief Financial Officer, Mr. Johnson, and provide research and analysis.  Community leaders will also be part of the Task Force providing recommendations and input from the community served by Healing Hands Hospital.  Mr. Magone realizes that developing outpatient services, urgent care clinics, affiliations with medical practices  or merging with an academic medical center will also require upgrades to the electronic health record system (EHRs) and other computer systems.  Therefore you will also work with the hospital’s Chief Information Officer to determine if current systems such as the EHRs and Clinical Decision Support Systems are scalable or need to be replaced.

Mr. Magone has made it clear that patient needs and future financial stability are driving the project. He wants to ensure that Healing Hands Hospital stays current with reimbursement and quality care models and remains financially sound through reimbursement by Medicare and other health insurance plans.  Leadership at Healing Hands also recognizes that strong relations with the community and the Healing Hands staff will be imperative to success.

Throughout this course, you will research and analyze different aspects of the developing strategic plan for this initiative.  Each week, you will build the information needed for the plan, and in the final weeks of this course, you will provide a final report detailing your findings.

Your final report to the Future of Healing Hands Task Force will include the following components :

  • Week 1: Legislative and regulatory requirements for Medicare reimbursement including changes for physician practices related to MACRA
  • Week 2: Difference between provider organizations, Healing Hands and an academic medical center, in terms of mission, services, organization structure, etc.
  • Week 3: Reimbursement models including managed care and changes to Medicare reimbursement models
  • Week 4: Impact of advances in health information technology on operations and reimbursement.
  • Week 5: Complete Final Report of findings from each section (week) to the Task Force with the inclusion of research and analysis of healthcare quality metrics and impact on budget and reimbursement.
 

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