Discuss managed care, the initiatives implemented by private insurers to transform healthcare, and the various roles nurses play to improve quality patient outcomes tied to healthcare reimbursement
Overview: Consumers of healthcare are expected to pay for goods and services at the time of service (Nickitas, Middaugh, & Feeg, 2019). Today, mostly due to the Affordable Care Act, private insurers are aimed more at managing populations than underwriting risks (Nickitas, Middaugh, & Feeg, 2019). Nurses are in the forefront and directly tied to patient outcomes that impact healthcare reimbursement. This week’s module examines healthcare costs and financing and how they impact healthcare providers and consumers. The history of how private health insurance and managed care evolved will be discussed. The impact of consumer-driven healthcare and the role nurses play in empowering healthcare consumers will be a primary focus. Professional Standards: Essential V: Healthcare Policy, Finance, and Regulatory Environments – Healthcare policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the healthcare system and thereby are important considerations in professional nursing practice. Learning Materials Nickitas, D. M., Middaugh, D. J., & Feeg, V. D. (2019). Policy and politics for nurses and other health professions: Advocacy and action. (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers. Read Chapters 9 & 10. Additional Resources: Bird, K., Reney, M., & Ross, R. (2015). Funds flow in the era of healthcare transformation. Healthcare Financial Management, 69(12), 42–47. CMS.gov (2019). What’s the quality payment program? (Explore the various links found on the Quality Payment Program website to learn more about the new way healthcare providers are being paid. Also, you will find resources on evidence-based measures that encourage improvement in clinical practice and the utilization of advanced technology that allows providers of care to easily exchange patient information) Mulder, J. (2017). The value of “smart growth” in the era of value-driven care. Health Management Technology, 38(9), 6–7. Wright, B., Potter, A. J., & Nattinger, M. C. (2016). Iowa Wavering on Medicaid: From Expansion to Modernization. Journal of Health Politics, Policy & Law, 41(2), 287–300. Discussion Question: Discuss managed care, the initiatives implemented by private insurers to transform healthcare, and the various roles nurses play to improve quality patient outcomes tied to healthcare reimbursement. What are some strategies nurses can use to advocate for healthcare consumers and reduce the increasing cost of healthcare?
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