Healthcare Policy and Economics Sample Paper
Health Policy and Insurance
Various health organizations have specific policies on admissions types, criteria, and requirements. The process of hospitalization from admission to post-admission follow-up care also vary from one health organization to the other. Hospitalization can be done on an emergency or elective basis. Elective hospitalizations are based on clinicians’ orders to keep the client stay in the hospital overnight for close medical monitoring and nursing care. In both cases of hospitalizations, there are typical steps or processes which patients must undergo when seeking medical or nursing care regardless of the purpose of admission. The current discussion explores the typical hospitalization process under the ACA guidelines.
Health insurance covers medical, surgical, dental, and pharmaceutical expenses that the subscriber incurs during their hospitalizations. The details and specifics of the items covered by the insurance vary between insurance firms or companies’ policies. some companies reimburse the expenses while others pay the health organization directly. The American Affordable Care Act (ACA), enacted into law in March 2010 by President Barrack Obama, is a federal health policy that covers various areas in health, including costs. Before the implementation of ACA, patients with preexisting chronic medical conditions did not have easy access to medical coverage (Huguet et al., 2019). The journey by a patient during a hospitalization follows a defined path. However, the after-care path may vary depending on the indication for hospitalization or the results of the care. The ACA, in summary, is not an insurance scheme but a government policy regulating individual private health insurance firms and businesses related to health (U.S. Centers for Medicare & Medicaid Services, n.d.). The daily businesses of the health organization are also regulated in terms of patent protection and cost of care reduction.
Hospital admission can be classified into two broad types: emergency admission and elective admission. The ACA policy terms allow coverage for a patient admitted through both types of the mentioned admission situations. Some health organizations charge consumers for registration and the financial settlement of these charges depends on the terms of medical cover between the ACA-compliant patient and the insurance company. It is during admission that the health insurance status of the client is declared. The ACA policies seeks to ensure that all citizens regardless of age have access to a medical cover. This meant that the children and young adults under the age of 26 years are allowed to stay under their parents’ insurance covers. Elective admissions usually progress to inpatient ward admission or general outpatient care.
Emergency admission and critical care are two related processes in a typical hospitalization. Not all emergency admission end in the inpatient or critical care but most emergency admission and critical care requires close patient monitoring, thus the need for the best quality. The ACA provisions, though not all were implemented by 2019, have enabled better emergency care. The improvement in the delivery of critical and emergency care after implementation of the ACA has been associated with telemedicine incorporation, change in care systems (Rambur, 2017), and improvement of profitability of critical care centers.
Inpatient and Outpatient Care
A typical inpatient admission means that the clients have to spend at least one night under the care of professionals in the wards. This happens to patients with medical or surgical conditions that require close monitoring and the clients cannot care for themselves at home. Various chargeable medical and surgical services are offered at the inpatient care. In a typical hospital setting, these include but are not limited to laboratory services, nursing care, physician consultation, medical procedures, surgical operations, bed and bedside procedures among other services. Outpatient care majorly involves specialist consultation, lab services, minor surgical procedures, and nursing care among other minor one-day processes. Outpatient hospitalization does not require the client to spend the night in the hospital under the caregivers’ custody
Medical Investigations and Radiology
Lab services typically offered mainly include clinical investigative tests, follow-up monitoring tests, and pathology diagnostic tests. Imaging tests or investigations form a major interest for most insurance companies. The costs of imaging and radiological investigations such as Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Ultrasound Scan (USS), PET scan, Bone scan, among others are very high. Moreover, the costs of these radiological and imaging tests vary from one health institution to the other. Before the implementation of the ACA, the payment for radiological and medical procedures was based on the fee-for-service model. This forced the legislators to rewrite the codes relating to charging patients on radiological procedures in the 2014 Radiological Society of North America (RSNA) meeting.
The new financial model for chargeable radiological services is value-based, hence justifiable. This has promoted a regulated system where the insurance companies cover radiological and procedure fees based on their values (Gerst, 2021). However, this has created controversy in quality assessment to justify the value-based system (Vasko & Basu, n.d.). Radiological tests are commonly used in current healthcare not only for investigation purposes but also for intervention and treatment purposes. Another diagnostic and interventional procedure with implications in healthcare is the endoscopy. Endoscopy procedures are performed by physicians in most cases and their charges are relatively high. For this reason, some healthcare insurance providers have strict regulations on endoscopy procedures.
Consultation during hospitalization can be done in the outpatient clinic or during consultant reviews in the inpatient admission. According to Glied et al. (2017), the probability of consumers under the ACA accessing specialist care has increased under the new Affordable Care Act from 47.1% to 87% for insured consumers. This means that access to specialist caregivers had improved for Americans compliant with the ACA regulations. Private practitioners have been greatly affected by the reduction in fee-for-services that was common before the ACA due to changes in payment methods.
However, the out-of-pocket payments continues to rise, especially among consumers who already had medical covers before ACA but had to default because of an increase in their premiums (Glied et al., 2017). There has been a reduction in reimbursements from the Centers for Medicare and Medicaid Services. The value-based payment criterion has improved the quality of specialist consultation services while levying penalties on physicians who do not meet certain practice quality levels (American Medical Association, 2017). This has promoted patient protection to a greater extent.
Discharge, Aftercare, and Follow-up
The process of discharging hospitals paves way for administrative processes such as billing. This is the point where all care services provided to the patient are billed and forwarded to the insurance provider for reimbursements. When the patient is stable enough to take care of themselves or there are extra-hospital care methods that can be provided by the paramedics or heath affiliated institutions, the patient is discharged to start their journey to recovery. With current advancements in healthcare, remote health monitoring is used to care for stable patients with chronic medical conditions. The ACA directs the insurance firms to cover for patients with preexisting chronic medical conditions.
This means that whether the disease occurred before the patient took cover or thereafter, the insurance company has no right to reject their application to for medical cover. As such, insurance providers are obliged to cover the care provided after discharge from the hospital. A patient suffering from substance addiction or mental condition is also taken care of under the ACA policies. Management of these patients during the rehabilitation process is part of the hospitalization care whenever they are referred to a rehab institution (Steffen, 2019). Even without a referral from a medical hospital institution, the health insurance firm has no right to decline medical cover for mental and substance abuse patients.
Patients may also be referred to an external pharmacy to buy prescription medication. Sometimes, the required prescribe medication may not be available in the health institution or the institution may not be having a pharmacy (Manchikanti et al., 2017). The patient may be required to buy the drug either as an off-label medication or approved medication for the purpose. The ACA in its aim to provide affordable care, regulated the process of prescription medication. The costs of prescription medications before ACA implementation varied greatly and were mostly unregulated. Pharmacists and pharmaceutical companies would charge different amounts for these medications thus raising the overall cost of healthcare.
The processes of typical hospitalization revolve around chargeable services and the requisite medical products in every health institution. The type of care determines the duration of stay and the overall cost the patient would have to incur at the end of care. Most patients in the US would pay for this care using health insurance cards. If unregaled, the health institutions would charge whatever amount they deem appropriate for the services, and the insurance firms would charge the premiums according to the fees charged by the hospital.
Therefore, the ACA was signed into law to regulate these discrepancies and ensure affordable care costs. Services provided to the patient under the ACA are regulated by the policy until after the discharge. Among the important care aspects regulated by ACA include the rehabilitation, mental health treatment, and costs of prescription medications.
- American Medical Association. (2017). Federal funding for the Medicaid program should not be capped: AMA. Ama-Assn.Org; American Medical Association. Retrieved February 26, 2021, from https://www.ama-assn.org/practice-management/medicare-medicaid/federal-funding-medicaid-program-should-not-be-capped-ama
- Gerst, S. (2021). Accountable care organizations could dramatically affect radiology practice. Diagnosticimaging.Com. Retrieved February 26, 2021, from https://www.diagnosticimaging.com/view/accountable-care-organizations-could-dramatically-affect-radiology-practice
- Glied, S. A., Ma, S., & Borja, A. (2017). Effect of the ACA on health care access. The Commonwealth Fund. Retrieved February 26, 2021, from https://www.commonwealthfund.org/publications/issue-briefs/2017/may/effect-affordable-care-act-health-care-access
- Huguet, N., Angier, H., Hoopes, M. J., Marino, M., Heintzman, J., Schmidt, T., & DeVoe, J. E. (2019). Prevalence of Pre-existing Conditions Among Community Health Center Patients Before and After the Affordable Care Act. The Journal of the American Board of Family Medicine, 32(6), 883–889. doi:10.3122/jabfm.2019.06.190087
- Manchikanti, L., Helm, S., Ii, Benyamin, R. M., & Hirsch, J. A. (2017). A critical analysis of Obamacare: Affordable care or insurance for many and coverage for few? Pain Physician, 20(3), 111–138. https://www.ncbi.nlm.nih.gov/pubmed/28339427
- Rambur, B. A. (2017). What’s at stake in U.s. health reform: A guide to the Affordable Care Act and value-based care. Policy, Politics & Nursing Practice, 18(2), 61–71. https://doi.org/10.1177/1527154417720935
- Steffen, L. (2019). Intensive rehabilitation for post-acute rehabilitation services: The impact of value-based regulatory change on service delivery. Journal of Healthcare Finance, 45(3). https://www.healthfinancejournal.com/~junland/index.php/johcf/issue/view/31
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Essential health benefits – HealthCare.Gov glossary. Healthcare.Gov. Retrieved February 26, 2021, from https://www.healthcare.gov/glossary/essential-health-benefits/
- Vasko, C., & Basu, P. (n.d.). PPACA is unlikely to dramatically affect imaging volume, but a deeper cost focus is probable. Radiologybusiness.Com. Retrieved February 26, 2021, from https://www.radiologybusiness.com/sponsored/1065/topics/imaging-informatics/ppaca-unlikely-dramatically-affect-imaging-volume-deeper