Patient Centered Medical Home Models

Patient-Centered Medical Home Models

The medical home is described as a viewpoint or model of primary care that is comprehensive, consistent, patient-centered, accessible, team-based, and focused on safety and quality. Primary care has been a model that is recognized widely and should be planned and delivered all the way through the health care system. The viewpoint on the delivery of healthcare should inspire healthcare professionals and providers to see patients wherever they are, from the simplest to the most difficult situations. It is necessary to improve primary care by focusing on the relationship between doctor-patient and to make the dynamic stronger through a more widespread tactic to patient care and making patients more involved in their care.

“Approximately 65 million Americans live in officially designated primary care shortage areas, and a recent survey found that only 27 percent of U.S. adults can easily reach their primary care physicians by telephone, obtain after-hour care or advice and schedule timely office visits. (American Hospital Association, 2010) It is important and necessary to improve patient-doctor relationships and all-inclusiveness care to improve the care to patients. It is also important that access to healthcare is increased and more accessible. It has been stated the PCHM model puts strain on dealing with patient health and increasing access to healthcare. This can mean going further than the doctor’s office, steering, and interacting with providers and partners within the community. Converting primary care to a PCMH could possibly reduce the cost of healthcare while also improving patient quality. It also could speak on cultural, racial, and socioeconomic inequalities in the outcomes pertaining to healthcare. Throughout this paper, I will discuss the future of healthcare pertaining to patient-centered medical home models.

The PCMH model involves a private doctor and a care team that will provide you with medical care. If and when you need to seek medical attention from a specialist (patient’s request), your appointed care team and provider will manage, coordinate, and facilitate the care with the applicable skilled specialists, such as hospitals, pharmacies, etc, personally. Investing in PCMH will offer short and long-term savings for employers, patients, policymakers, and health plans. Controlling the increase in healthcare costs is vital in this current economic setting. Providing Americans with high healthcare quality will result in a reduced amount of unnecessary trips to the emergency room and hospital admission. It will increase the coordination of better care. In the long term, PCMH will help with the transmission of health information, training for a strong workforce, education, improving patient overall experience, and restructuring payment for primary care.

A patient-centred medical home is developing as a cornerstone of exertions to improve healthcare in the United States and to form a basis of primary care for improving healthcare values. It is commendable that the backing, assessment, and development as important building blocks used for an extraordinary significance healthcare system. Replacing poorly coordinated, discontinuous, critical-focused care with coordinated, acute, preventive, proactive, and long-term care is introductory to the re-establishment of the U.S. healthcare system. A primary care model that improves will deliver wide-ranging care that is timely with proper compensation, highlighting the chief role of teamwork and commitment by the receiving the care.

Managed Health Care Quality

There are millions of Americans who are chronically ill that depend on managed care plans as their care. Millions of individuals every day receive quality care that assists in restoring or maintaining their health and their capability to function. Yet, there are so does not. “Quality problems are reflected in a wide variation in the use of health care services, underuse of some services, overuse of other services, and misuse of services, including an unacceptable level of errors.” (AHRQ, 2014) The main goal of improving the quality of healthcare is to uphold the things that are good in the healthcare system today while concentrating on the area that needs attention and improvement. There are millions of Americans that do not receive essential care and suffer unnecessary complications that contribute to cost and decrease efficiency. “Each year, an estimated 18,000 people die because they do not receive effective interventions.” (AHRQ, 2014) There are millions each year that receive unnecessary healthcare services, which causes costs to increase and can harm their health. Also, there are a lot of people who get injured during their treatment, and some suffer premature death as a result.

The responsibility of managed care organizations is to ensure that the individuals that are enrolled in plans receive quality care. The managed care organizations that are funded publicly through Medicaid and Medicare programs are required by Federal and State governments to meet specific quality standards. (Stanton, 2014) In order for the responsibilities of managed care organizations to be fulfilled, “MCOs need ready access to a comprehensive array of evidence-based clinical information and other clinical performance measures to enable them to evaluate their provider’s performance and identify areas where improvement is needed.” (Stanton, 2014) It is necessary to know about the care patients receive that their feeling about it, and the way they are treated.

Provider Contracting

Provider contracts are what oversees the relationship between provider, healthcare plans, service fee agreements, and rendering services. Provider contracts track motivation actions, the outcome for quality, and devotion to practices. Healthcare plans recognize provider contracts are vital for the accuracy of the processing of claims and payments. The effect that errors have on a plan’s satisfaction on patient and provider, medical loss, and administration cost is important. Provider contracts can be very complex. “In order to have value-based provider contracts, the system and processes have to comprehend the performance and quality that will drive reimbursement methodologies.” (Anantha, 2009) It is necessary that insurance plans have an agenda for understanding the success of contracts that exists now and finding ways to improve them.

It is important to organize and unify provider contracts of health plans to a more chief source. It will assist in reducing administrative complications and increase access to the contracts. “Health plans should move to a more structured, streamlined, and automated process in which contracts adhere to health plan standards.” (Anantha, 2009) This will allow automatic offering, contract authoring, converting, and approval. Adopting this will upturn the devotion to the standards of the contract, decrease the cost of medical, and raise the visibility of the contract process.

Cost Containment

“During the latter half of the 1990s, health care cost inflation slowed after several years of rapidly rising price increased.” (Stanton, 2002) At that time, it was hoped that numerous programs and policies that were set forth by employers, insurers, and the government to control costs would grow continuously to restrain the increases for the future. But the cost of healthcare has become a serious issue. “In 2000, the average annual health insurance premium in the private sector rose to $2,655 for single coverage and $6,772 for family coverage, an increase of 33.3 per cent and 36.7 per cent.” (Stenton, 2002) For many years there have been a lot of strategies to contain the cost. “Competition among HMOs managed care as a way to handle the cost implications of parity mandates, and certain employer contribution methods, have been at least partly successful.” (Stenton, 2002) Merges among hospitals and cost-sharing have mixed results.

Effects on Medicare and Medicaid

Medicare and Medicaid are programs run by the government that provide medical services as well as other health-related services to a particular group of individuals in the U.S. “Both Medicaid and Medicare were created when President Lyndon B. Johnson signed amendments to the Social Security Act on July 30, 1965.” (MNT, 2014) Even though the programs are different and offer different services, both are managed by the same division. Medicare has over 40 million enrollees and is a social insurance program. Medicaid serves about 35 million people and is a social welfare program. (MNT, 2014)

Medicare pays for medical and hospital care for the elderly and certain Americans who are disabled. The program consists of two parts: Part A, which is for hospitals, and Part B, which is for medical care. Medicare also has Part C & D, which are for prescription drugs. Individuals have to be at least 65 years or older to be eligible for Medicare. Or disabled and under 65, or at any age if an individual has a Renal disease that is at its end stage. Medicare is great and has great qualities about them. “Medicare’s fee structure, low co-pay, easy administration, wide acceptance, broad coverage, and low restrictions make it most useful for America’s seniors.” (SunSentinel, 2011)

Medicaid was established in the 1960s. The Medicaid program is geared toward those individuals that have low income. Medicaid has eligibility strengths. Each state sets its own eligibility guidelines. Eligibility also depends on other requirements such as age, citizenship, disability status, and pregnancy status. Medicaid does not provide services for all persons in poverty. There is over 50% of poor Americans that are not covered under Medicaid. (MNT, 2014) Members are offered a complete package where they choose the provider of their choice. With Medicaid coverage, there are a variety of services where the member does not have to pay out-of-pocket expenses. Medicaid costs are less than private insurance. States can negotiate more resourcefully for providers and plans when there are a huge amount of beneficiaries. “Medicaid expansion allows states to receive federal matching funds.” (Bumpres, 2014)

“The Obama Administration is offering to cut tens of billions of dollars from Medicare and Medicaid as part of the negotiation to reduce the federal budget deficit.” (Shikuma Law Office, 2014) The cut will have a serious impact. It will make it harder for Medicare and Medicaid members to find providers who will see them, and that is due to the low reimbursement rates from the government. The cuts to Medicare and Medicaid will limit the access to care severely to the members. Both programs are facing serious restricting and cuts financially.

Recommendations

It is necessary to improve Medicaid eligibility for all pregnant women, children, adults without children, and young adults. There are so many people that are in poverty who are unable to obtain private insurance. Because the funding comes from the government and tax dollars, the eligibility requirements should not be so strict, knowing that there are millions of Americans, young and old, who are without some type of health insurance coverage. Modernizing health care and improving the outcome of patients’ health can stand to be improved in Medicare and Medicaid. Medicare and Medicaid need to come up with the times. Another recommendation for improving Medicaid and Medicare is improving preventive service access. It is necessary to improve the coverage and access to immunizations and preventive services. Offering incentives to members who complete specific healthy living programs that focus on chronic diseases is great for motivating patients to do the right thing. It is important for both plans to promote healthy living because preventive service will help to reduce chronic diseases, especially if caught at an early stage.

In conclusion, it is important to improve the relationship between doctor and patient. Patient-centred medical home models are the fundamental views of primary care, and the values are established very well. The value includes quality of care that is above expectations, discrimination reduction, and lower healthcare costs matched to other healthcare systems that are not grounded on primary care. PCMH is earnest of support, assessment, and development as an essential stepping stone for a health care system that is high in value.

References

American Hospital Association. 2010 Committee on Research. AHA Research Synthesis Report: Patient-Centered Medical Home (PCMH). Chicago: American Hospital Association, 2010.

AHRQ. (2014). Improving Health Care Quality. Retrieved February 16, 2014, from http://www.ahrq.gov/research/findings/factsheets/errors-safety/improving- quality/index.html

Stanton, M. W. (2014). AHRQ Tools for Managed Care. Retrieved February 16, 2014, from http://www.ahrq.gov/research/findings/factsheets/managed/mcotoolria/index.html

Anantha, V. (2009). Provider Contracting Model. Retrieved February 16, 2014, from http://www.insurancetech.com/management-strategies/healthcare-reform-will- revolutionize-the/218900453

Stenton, M. W. (2002). Reducing Cost in the Health Care System: Learning From What Has Been. Retrieved February 16, 2014, from http://www.ahrq.gov/research/findings/factsheets/costs/costria/index.html

MNT. (2014). What is Medicare / Medicaid? Retrieved February 16, 2014, from http://www.medicalnewstoday.com/info/medicare-medicaid/

SunSentinel. (2011). Medicare has its strengths, but it also has weaknesses. Retrieved February 16, 2014, from http://articles.sun-sentinel.com/2011-06-28/news/fl-medicare-letter-0628- 20110628_1_control-medicare-costs-strengths-expensive-procedures

Bumpres, B. (2014). Strengths of the Medicaid Program. Retrieved February 16, 2014, from http://www.ehow.com/list_6876764_strengths-medicaid-program.html

Shikuma Law Offices. (2014). The Future of Medicare and Medicaid. Retrieved February 16, 2014, from http://shikumalaw.com/the-future-of-medicaid-and-medicare/

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Week 7 Discussion: The Patient-Centered Medical Home Model
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Step 1: The patient-centred medical home (PCMH) model, also known as a health home, is a health care delivery model designed to improve access to care, increase quality, and reduce costs. Familiarize yourself with the PCMH model. Use these websites or research them on your own.

Patient Centered Medical Home Models

The Medical Home Model of Care Links to an external site.
How the Affordable Care Act Will Strengthen the Nation’s Primary Care Foundation Links to an external site.
Health Policy Gateway Links to an external site.
Step 2: For this discussion, select one of the healthcare delivery settings discussed in the assigned reading (e.g. home health/hospice, long-term care, the VA system, retail/nursing clinics, community health centres) and consider ways in which the setting could incorporate aspects of the PCMH model. Specifically address access, quality, and cost. Finally, discuss the nurse’s role in advocating for these changes. If possible, share your own experiences and example of this model (or related principles).

Step 3: Read other students’ posts and respond to at least two of them by Friday at 11:59 pm MT.

Cite any sources in 7th. Ed APA format.

Select Reply to join the discussion. See the rubric for grading details. You can find this by clicking the three dots at the top right of this thread.

Response Posts: In your responses to your classmates, contribute to the discussion with your own original opinions or interpretation of the course materials.