The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
Since 1977, Maryland's unique all-payer system has succeeded in keeping healthcare costs relatively low. Now the state is embarking on a new demonstration project that could influence healthcare delivery across the country.
The All-Payer System
In most states, facility fees for episodic care are negotiated between hospitals and their various payers. But in Maryland, these fees are fixed by the state's Health Services Cost Review Commission (HSCRC). Hospitals statewide receive uniform reimbursements for their services, subject to price adjustments for factors like labor costs and acuity mix. Maryland's top-down pricing even applies to Medicare (which provides the state with a special waiver for this purpose).
Saint Francis Memorial Hospital Featured as Readmission Reduction Success Story
As administrators are increasingly concerned with reducing hospital readmissions, FierceHealthcare has highlighted six readmission reduction success stories, including Saint Francis Memorial Hospital in San Francisco. In an interview, CEP America hospitalist medical director, Joseph Mallon, MD, describes how his team used patient education and follow-up after discharge to keep patients from needing to return to the hospital. "'Our goal, again, is to encourage understanding of this process [and] ultimately to improve response to therapy, to improve [patients] being able to respond to their triggers medically, when necessary,' he said." You can read more about Saint Francis' success in our recent post by Courtenay Kohlman, RN, BSN.
The Affordable Care Act's (ACA's) reforms are designed to achieve the triple aim — reduced cost, improved quality and better patient experience. The foundational underpinning for the transition to population care is the ACO — Accountable Care Organization.
These "new," legally recognized healthcare providers were established by the ACA. Their goal: facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee-for-service (FFS) beneficiaries and reduce unnecessary costs. This goal requires an integrated network of providers and services.
Nurse practitioners (NPs) and physician assistants (PAs) are now an integral part of the U.S. healthcare system and have assumed a major role in both primary care and some specialty care areas. Like our physician colleagues, we have encountered increasing expectations to "do more with less" (i.e., see more and sicker patients and provide quality, comprehensive care in less time — all while meeting challenging national metrics).
As the number of NPs and PAs working in emergency medicine and other episodic care settings increases, it is essential that these professionals master the medical-decision making (MDM) process to justify the degree and complexity of each patient encounter.
Recently, an emergency physician group in California successfully appealed a prior Superior Court ruling and won an important case that held Health Net responsible for payment when the plan's delegated payer, La Vida Medical Group, went bankrupt, leaving the out-of-network claims of the emergency physicians unpaid.
The principle at issue was negligent delegation, the failure of the health plan to properly oversee the financial viability of the IPA/medical group to which the plan had made capitation payments and to which the plan had delegated the responsibility for paying these claims.
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