Health Reimbursement System: Then and Now

Recent changes in the health reimbursement system have taken place that would challenge the capacity of health care providers to provide insurance to uninsured Americans. Among these changes are the emergence of a competitive system of health care, the improvement of Medicaid managed care, which has somehow reduced the income of health care providers, and the reduction of Federal, state, and local funds which have previously provided subsidy for free or low-cost care (Lipson & Naierman, 1996).

Likewise, the demand for free or subsidized health care increased with the steady growth in the number of uninsured Americans. From 1990 to 1993, uninsurance in the United States was consistently growing annually. This number dropped in 1994. While the changes are evident in various parts of the country, the degree and pace of changes are different across communities (Lipson & Naierman, 1996). Implementing changes in the federal health care system requires initiating modifications in the roles and responsibilities of the staff as well as in their training needs.

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The present system of regulation is quite complicated and cumbersome since it is dominated by professional interests. Likewise, the current health care system is slow in reacting to changes in the industry (Pindus & Greiner, 1997). The State of Health Care in the United States Over the years, the health care system of the United States was at a dismal state. According to reports, annual expenditures for health care is at $7,500 per individual for a total of $2. 2 trillion. Likewise, many patients have experienced being denied of basic services.

The Federal health care system is viewed as a massive structure supported by several pillars. Each health care structure needs to be supported by financing otherwise the entire system would collapse (DeVoe, 2008). Most Americans had the experience of shouldering their own health insurance because the cost of getting an insurance was quite expensive. From 1996 to 2003, annual expenditures for family health insurance increased an average of 11% while household income went up by 3%.

According to studies, the average cost of family income will exceed their income by 2025 (DeVoe, 2008). Recent expansions in cost-sharing mechanisms have shifted the burden of payments to families which have slowed down the increase in the amount of health insurance costs. However, these mechanisms are only meant to slow down the likelihood of reforms in the employer-sponsored health insurance (DeVoe, 2008). It is estimated that close to 82 million Americans will experience coverage gap within a two-year period.

As such, majority of them have to wait for coverage and it usually ends once they become eligible for Medicare (DeVoe, 2008). Obstacles to Reimbursement System Reforms While the aim of health occupation regulation is to safeguard the health and safety of the public, the regulatory system likewise had the impact of establishing and retaining professional identities and allowing various health professions to establish exclusive domains. These conflicts have become obstacles to reforms and have directly obscured connected to safeguarding of the consumer (Pindus & Greiner, 1997).

The regulation of the health care system has been transformed into fifty independent state systems making it a more complicated and irrational organizational patchwork. The absence of uniform language, laws, and regulations among the states restricts the effective practice and mobility of health care and creates confusion in the public. This has likewise created a barrier to the integration and utilization of emerging technologies in health care (Pindus & Greiner, 1997).

Although the impact of information technology is quite evident in almost all aspects of life, these technologies have not been felt in the health information sector. In 2002, the use of electronic health records (EHRs) was only at 13% and only 14 percent of physicians were practicing their profession. Here are some of the reasons why the health care system has been slow in adopting these technologies (Thompson, 2004):

• The extent and differences in the American health care system requires community ownership and resilience. There is a need for joint efforts between the health care and technology industries. Federal, state, and local government is required to address a wide range of technical, administrative, and other considerations needed to underlie a solid health information technology sector (Thompson, 2004).

• Although the Federal government remains as the single biggest provider of health care, there has been a history of absence of cohesion in Federal policies in support of health information technology. Recently, this issue has started to be addressed (Thompson, 2004).

• There is insufficient resources as well as lack of proof for a positive return of investment. It is important to consider non-monetary factors such as training needs and changes in workplace practice (Thompson, 2004). Latest Trends in Federal Health Care System In an article he wrote in Medscape Medical Journal, Robert Centor (2006) recommended three possible reforms in the American health care system. His first proposal is the establishment of an agency that would conduct an unbiased research on proposed new drugs.

Each pharmaceutical company would have to do their share in financing their agency but it should be free from the influence of another drug company. It is the responsibility of the agency to ensure the safety and efficacy of the drugs they produce (Centor, 2006). The second proposal that Centor made is the use of universal electronic medical records (EMRs). In order for physicians to provide the best health care, they need to have all the information they can get regarding their patients. The adoption of EMRs would lessen medical discrepancies, repeat testing, and reduce medical fraud (Centor, 2006).

Third, Centor proposed shifting from encounter-based to time-based health care reimbursement system. Basing health care costs to consultation time would provide greater benefits to physicians as they could squeeze a couple more patients daily (Centor, 2006). The Balanced Budget Act of 1997 Since the implementation of the Balanced Budget Act of 1997, the Health Care Financing Administration (HCFA) has made headway in generating savings for the health insurance coverage of Medicare plan holders. Under the BBA, the Children’s Health Insurance Program was established.

Its aim is to improve the health conditions of children. For Medicaid holders, the Balanced Budget Act provided new eligibility options, extended support for low-income Medicare beneficiaries, as well as putting in place new quality guidelines for Medicaid managed care plans (Center for Medicare & Medicaid Services, 2002). Under the Balanced Budget Act of 1997, Medicare plan holders would have access to more health care options. One such kind of alternative is the provider-sponsored organization.

One of the many challenges faced by the HCFA is information dissemination about the various options available to plan holders. In order to ensure that fair and accurate information is received by the planholder, the HCFA launched the National Medicare Education Campaign (Center for Medicare & Medicaid Services, 2002). Likewise, the HCFA set up a consumer-friendly Internet web site as well as a program to help Medicare-oriented organizations how to discuss the reforms in the new law. This education campaign started in 1998 in five states.

The feedback from the pilot program would then be utilized for the open enrollment which started in 1999 (Center for Medicare & Medicaid Services, 2002). In the case of Medicaid planholders, managed care plans would provide coverage for emergency care expenses and bans the requiring of prior approval or requiring enrollees to go to approved facilities only for emergency care. Aside from that, managed health care plans would provide for the immediate resolution of grievances. During enrollment, Medicaid beneficiaries would be given an option of two plans (Center for Medicare & Medicaid Services, 2002).