SIM 410 Activity 1 National Health Coverage Plans Reimbursements and Quality

Activity 1

National Health Coverage Plans, Reimbursements, and Quality

Baccalaureate education includes learning opportunities of healthcare policy, finance, and regulatory environments (AACN, 2008).  

Introduction & Healthcare Coverage and Vulnerable Populations 

Describe the importance of healthcare coverage (insurance).  End with a clearly worded purpose statement for this project.Discuss two ways healthcare coverage is beneficial (helpful) for the vulnerable/ uninsured populations.

Diagnosis Related Groups

Describe the purpose of Diagnosis Related Groups (DRGs).  Explain the impact of DRGs on length of stay and payment of services.  Discuss how payments for DRGs are now impacted by quality indicators and measures.

Select a Major Healthcare Plan

(Label heading with the name of the plan Ex:  Preferred Provider Option Plan)   

Select one of the patients from the cases you reviewed in NQI.  Summarize two care options provided by the plan that facilitates access for your selected patient.  Summarize two care options that limit access to care for your selected patient.

Select a Second Major Healthcare Plan

(Label heading with the name of the plan Ex: Medicaid)  

Repeat this activity with the same patient.  Summarize two care options provided by the second plan that facilitates access for your selected patient.  Summarize two care options that limit access to care for your selected patient.

Impact of Nursing Interventions

Summarize at least four priority nursing interventions or considerations to promote self-care for your selected patient to provide high quality, safe healthcare considering nursing-sensitive indicators.  Provide a rationale for each of your selected nursing decisions.

Conclusion

Summarize the key points of your project.

**You will not discuss the deductibles or costs of the insurance plans as this is not the focus of this this assignment.

Following the simulated activity, you will examine the relationship between healthcare coverage (insurance), quality care, and reimbursements (payments) to health care organizations. Select two different major national (U.S.) insurance health plans.  You may choose Medicaid, Medicare, HMO, PPO, or private insurance plans.  You can choose your own personal insurance plan if you prefer.  Review healthcare coverage options offered by both plans that benefit (facilitate) and hinder (limit) access to care.  Examples of healthcare coverage (insurance) options that facilitate, or limit access include medication coverage, primary care physician office visits, specialists physician office visits, emergency care, lab or blood work and diagnostics, wellness care, prevention services or surgery (these are just a few examples). You will also explore the role of Diagnosis Related Groups (DRGs) and charity care within healthcare facilities (hospitals) and how charity care impacts the vulnerable or uninsured population. Finally, summarize nursing interventions or considerations for your selected patient to provide high quality, safe healthcare considering nursing-sensitive indicators in his/her unique scenario.

Additional Instructions:

  1. All submissions should have a title page and reference page.
  2. Utilize a minimum of two scholarly resources.
  3. Adhere to grammar, spelling and punctuation criteria.
  4. Adhere to APA compliance guidelines.
  5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One:Instructions:
Paper5 page paper. Include title and reference pages.

Activity 1 National Health Coverage Plans, Reimbursements, and Quality Example Paper

Healthcare coverage, also known as health insurance, is an important form of financial protection that helps individuals access necessary medical services. Its primary goal is to reduce financial barriers that may prevent people from receiving needed medical care (Institute of Medicine, 2019). Healthcare coverage is critical because it ensures access to essential medical services and improves overall health and well-being. This paper examines how healthcare coverage plans, reimbursements, and quality affect vulnerable populations, as well as the role of nursing interventions in providing safe, high-quality care.

One of the primary benefits of healthcare coverage is that it provides individuals with access to preventive care services that can aid in the early detection and prevention of health issues (WHO, 2021). Routine check-ups, screenings, and immunizations are critical for detecting health problems early, making treatment more accessible, and preventing more serious complications. This is especially important for vulnerable and uninsured populations, who may lack the resources to address health issues once they become more serious.

Healthcare coverage can provide financial protection from unexpected medical expenses and improved access to preventive care. A medical emergency can cause significant financial hardship and even bankruptcy for uninsured people. On the other hand, individuals with healthcare coverage can receive necessary medical care without worrying about the financial burden it may place on them or their families. This can provide individuals with peace of mind and ensure they receive the care they require to maintain their health and well-being.

Diagnosis Related Groups (DRGs)

Diagnosis Related Groups (DRGs) were introduced in the 1970s as a method of categorizing and reimbursing healthcare providers based on the patient’s diagnosis (Zou et al., 2020). DRGs were created to simplify and standardize the reimbursement process for hospitals, insurance companies, and the government while ensuring patients receive appropriate care for their diagnoses.

DRGs have significantly impacted the length of hospital stays and the payment of medical services. Under the DRG system, hospitals are paid a fixed rate for each patient based on their diagnosis, regardless of the length of stay (Zou et al., 2020). This means that hospitals have a financial incentive to discharge patients as soon as they are stable enough to be treated on an outpatient basis, which has led to a decrease in the length of hospital stays.

In addition to affecting the length of hospital stays, DRGs have significantly impacted the payment of medical services. The DRG system has shifted the focus of healthcare providers from the number of services provided to the quality of care delivered (Zou et al., 2020). Providers are now incentivized to provide efficient and effective care that leads to positive patient outcomes rather than unnecessary tests and procedures.

The quality of patient care has increasingly influenced payments for Diagnosis Related Groups (DRGs) in recent years. Instead of providing unnecessary tests and procedures to increase revenue, healthcare providers are now incentivized to provide high-quality care that results in positive patient outcomes.

The Centers for Medicare and Medicaid Services (CMS) has implemented programs such as the Hospital Value-Based Purchasing (VBP) Program and the Hospital Readmissions Reduction Program (HRRP) that tie payment to the quality of care provided. These programs incentivize hospitals to improve their performance on various metrics, including patient satisfaction, clinical outcomes, and efficiency (Kim et al., 2022). For example, hospitals may be paid more if they provide high-quality care that reduces readmissions or complications. Alternatively, if hospitals have a high rate of readmissions or fail to meet quality standards, they may face penalties. These payment reforms have significantly impacted the healthcare industry, shifting the emphasis from volume-based to value-based reimbursement. Providers are now incentivized to prioritize high-quality care that results in positive patient outcomes over providing unnecessary or low-value services to increase revenue.

BlueCross BlueShield (BCBS) Preferred Provider Organization (PPO) Plan

Nursing Quality Indicator (NQI): Pain control in advance cancer.

Patient: John Smith, diagnosed with stage 4 colorectal cancer.

Access-Facilitating Care Options

John Smith has stage 4 colorectal cancer, and the BlueCross BlueShield (BCBS) Preferred Provider Organization (PPO) Plan provides care access options. One advantage of the BCBS PPO Plan is its extensive network of in-network healthcare providers (Nall, 2021). This means that John can receive medical care from physicians and hospitals with whom the plan has a contract, resulting in lower costs and fewer out-of-pocket expenses. The in-network providers ensure that John receives the medical care to manage his cancer effectively.

Telehealth services are another access-facilitating care option offered by the BCBS PPO Plan. John has mobility issues, making it difficult for him to get to the doctor’s office. Telehealth services enable John to receive medical care from the comfort of his own home or office, which is especially advantageous for him. John can consult with his healthcare provider and receive the care he requires using telehealth. This convenience ensures that John receives the medical care he requires to effectively manage his cancer, even when he cannot travel to a healthcare facility.

Access-Limiting Care Options

Access-limiting care options can be challenging for patients seeking medical care, such as John Smith, who has been diagnosed with stage 4 colorectal cancer. Out-of-network providers can be an option for John, but he may have to pay more out of pocket. This may pose a significant barrier to care for patients who cannot afford higher costs. In addition, the BCBS PPO Plan may require preauthorization before providing coverage for certain medical procedures or treatments. Preauthorization can be a time-consuming process, delaying John’s access to necessary medical care, and may limit his options if the plan does not approve the treatment or procedure recommended by his healthcare provider.

Medicaid

Nursing Quality Indicator (NQI): Pain control in advance cancer

Patient: John Smith, diagnosed with stage 4 colorectal cancer

Access-Facilitating Care Options

John Smith has stage 4 colorectal cancer, a serious and life-threatening condition requiring immediate and extensive medical attention. As John navigates the challenges of his diagnosis, he may benefit from Medicaid’s access-facilitating care options (Medicaid.gov, 2022). One of Medicaid’s most significant benefits is its ability to provide low- or no-cost medical care to eligible individuals such as John. Medicaid removes the financial burden of healthcare services and medications, allowing John to focus on receiving the medical care he requires without worrying about the costs. Furthermore, Medicaid may provide transportation assistance to patients like John who cannot attend medical appointments. John can ensure that he receives the necessary medical attention by receiving rides to and from medical appointments, regardless of mobility issues or limited transportation options in his area.

Access-Limiting Care Options

In John Smith’s case, the limited provider networks of Medicaid plans may restrict his access to his preferred healthcare provider or specialist, affecting the quality of care he receives (Medicaid.gov, 2022). This could also lead to delays in receiving treatment, which could worsen his condition.

Similarly, prior authorization requirements may create barriers to accessing necessary medical care for John (Medicaid.gov, 2022). Suppose his healthcare provider recommends a treatment or procedure not covered by his Medicaid plan or requires prior authorization. In that case, he may experience delays in receiving the care he needs or be unable to access it.

Priority Nursing Interventions/Considerations

Assess the patient’s knowledge and understanding of their condition and treatment plan: It is critical to assess the patient’s knowledge and understanding of their condition and treatment plan to ensure they can follow the prescribed regimen and make informed health decisions. This can be accomplished by asking open-ended questions, educating the patient, and reviewing the patient’s medical records.

Encourage and support the patient’s involvement in their care: Involving them in their care can help empower them to take an active role in their recovery and self-care. This includes providing resources and guidance to help them make informed decisions about their health and treatment plans.

Provide resources to support the patient’s learning needs: Providing resources such as educational materials, online resources, and referrals to support groups is essential to ensure the patient has the information to make informed decisions about their health and self-care.

Monitor the patient’s physical, emotional, and social well-being: Monitoring the patient’s physical, emotional, and social well-being is important in promoting self-care and ensuring the patient’s overall health and well-being. This includes assessing for potential signs and symptoms of distress, providing emotional support and referrals to mental health services when necessary, and providing resources to help the patient manage their condition.

Conclusion

Healthcare coverage is an essential component of healthcare systems that helps ensure everyone has access to quality healthcare. Diagnosis Related Groups (DRGs) have significantly impacted the length of hospital stays and the payment of medical services and DRG payments are now increasingly influenced by the quality of care provided to patients. BlueCross BlueShield (BCBS) and Medicaid offer access-facilitating care options such as in-network healthcare providers, telehealth services, transportation assistance, and access-limiting care options such as limited provider networks and prior authorization requirements. To promote self-care, the nurse must assess the patient’s knowledge and understanding of their condition and treatment plan, encourage and support their involvement in their care, provide resources to support the patient’s learning needs, and monitor their physical and emotional health and social well-being.

References

Institute of Medicine. (2019). Effects of health insurance on health. Nih.gov; National Academies Press (US). https://www.ncbi.nlm.nih.gov/books/NBK220636/

Kim, H., Mahmood, A., Hammarlund, N. E., & Chang, C. F. (2022). Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives. Frontiers in Public Health, p. 10, 882715. https://doi.org/10.3389/fpubh.2022.882715

Medicaid.gov. (2022). Medicaid. Medicaid.gov. https://www.medicaid.gov/medicaid/index.html

Nall, R. (2021, December 2). Blue cross blue shield Medicare advantage plans 2021 – healthline.com. Healthline. https://www.healthline.com/health/medicare/blue-cross-medicare-advantage-plans

WHO. (2021, April 1). Universal health coverage (UHC). Who. Int; World Health Organization: WHO. https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)

Zou, K., Li, H.-Y., Zhou, D., & Liao, Z.-J. (2020). The effects of diagnosis-related groups payment on hospital healthcare in China: a systematic review. BMC Health Services Research, 20(1). https://doi.org/10.1186/s12913-020-4957-5

SIM 410 Activity 2 Global Health Goals and Health Disparities

Baccalaureate education provides learning of globalization, diversity, and sensitivity to vulnerable populations’ healthcare (AACN, 2008).  

This activity is designed for you to examine global health goals and health disparities among vulnerable groups.  Start by selecting one of the eight Millennium Developmental Goals (MDGs) from the World Health Organization (WHO).  After choosing one of the MDGs, explore a specific outcome measurement (indicator) for a country of your choosing, from the list below, to determine the progress towards achieving the MDG. In addition, you will explore nursing roles that would be helpful in achieving the MDG. 

Countries
FranceItalySingaporeSpainJapanGreeceIcelandUnited KingdomIrelandSweden
GermanyIsraelSwitzerlandUAEChinaRwandaUSACubaIranIraq
VenezuelaSyriaEthiopiaBrazilSudanKenyaNorth KoreaIndiaSouth AfricaSaudi Arabia
NicaraguaEcuadorAustraliaChadHaitiCanadaSouth KoreaRussiaCentral African RepublicRepublic of the Congo

Also, you will explore health disparities among vulnerable population groups.  The term “health disparities” describes the phenomenon of different health outcomes of varied vulnerable groups of citizens. Access the Virtual Library and search in the CINAHL full text database the term “health disparity.”  Choose at least two articles that describe health disparities of a particular vulnerable population or group of people (gender or sexuality identity-based groups, children, elderly, disabled, ethnic, or cultural minority).

Resources:

Additional Instructions:

  1. All submissions should have a title page and reference page.
  2. Utilize a minimum of two scholarly resources.
  3. Adhere to grammar, spelling and punctuation criteria.
  4. Adhere to APA compliance guidelines.
  5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One:Instructions:
Paper5 page paper. Include title and reference pages.

SIM 410 Activity 3 The Interrelationships of Socio-Cultural Influences in Healthcare

Within this activity, you will explore how determinants of health such as poverty, behavior, education, and income are related. One common element underlies poor health: poverty. Money is required to purchase the essentials of health such as food, clothing, shelter, clean water, education, and access to preventative health services. Each day in nursing, you are faced with persons from varying economic, social, and cultural backgrounds. In addition to varying backgrounds, you will also experience differing patient values and preferences related to their individual health and behavior. Caring for the vulnerable, at-risk, and aging populations is an essential competency for nursing. Therefore, we need to explore the interrelationships of socio-cultural influences, behavioral influences, as well as economic and non-economic barriers to healthcare to improve our knowledge. In doing so, we will be able to plan specific interventions designed to help achieve healthier outcomes. You will have the opportunity to examine poverty, behavior, and other determinants of health in Sentinel City®. As providers of care, BSN nurses need to understand how these are related and impact the health of our patients.

Activity Instructions:

  1. Review course textbook and other resources.
  2. Review World Health Organization (2017). The determinants of health.  Retrieved from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
  3. Review Healthy People 2020 (Jan 25, 2017). Health Determinants. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

Review Sentinel City® demographics and neighborhood demographics. Meet with Mayor Hill who can provide some information about Sentinel City® economics.  Enter Sentinel City® and begin the bus tour. After touring Sentinel City, select a specific vulnerable or minority population group and identify one of the most common diseases, chronic condition, injury, or health concern that impacts your population group. Then list a total of 3 determinants of health from the Healthy People website.  During your tour of the city, describe 1 observation related to the 3 selected determinants of health. (a total of 3 observations must be described). Note indicators of high or low employment. Consider education levels, number of female head of households, and median household incomes for example.  Finally, describe a total of 3 strategies or evidence-based recommendations to help reduce or eliminate the selected observations noted during your Sentinel City® tour. 

Additional Instructions:

  1. All submissions should have a title page and reference page.
  2. Utilize a minimum of two scholarly resources.
  3. Adhere to grammar, spelling and punctuation criteria.
  4. Adhere to APA compliance guidelines.
  5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One:Instructions:
Paper2 page paper. Include title and reference pages.

The Interrelationships of Socio-Cultural Influences in Healthcare Example Solution

Effective healthcare requires understanding the complex interplay between sociocultural influences and various health determinants. Poverty, behavior, education, and income are just a few factors that influence individual and community health outcomes. Poverty, in particular, is a significant determinant of poor health because it restricts access to necessities such as food, shelter, and healthcare services. It is critical to investigate the relationships between socio-cultural influences, behavioral influences, and economic and non-economic barriers to healthcare to address the needs of vulnerable populations.

The Sentinel City demographic data shows that the African-American community is vulnerable and has a higher risk of cancer than the white community (Zavala et al., 2021). High poverty levels limit access to quality care, including cancer screening and treatment plans like chemotherapy. Consequently, African-Americans have a higher cancer mortality rate than the white population in the city.

In Sentinel City, health determinants for the black community include health services, social factors, and genetics. High healthcare costs and insufficient care affect access to quality care for African Americans, resulting in disparities in cancer outcomes (Healthy people.gov. 2020). When caring for this population, social determinants like employment, education, and poverty should also be considered.

After spending time in Sentinel City, it was evident that the African American population resides in impoverished neighborhoods with high poverty rates on the city’s outskirts. Most of this demographic faces unemployment, with only a few finding work. The work available is often inhumane in a polluted environment, increasing cancer risk. Additionally, they are limited to low-wage jobs that restrict their economic growth. Furthermore, the impoverished neighborhood lacks access to adequate healthcare facilities due to a lack of healthcare investment. Lastly, the absence of quality food stores results in limited access to nutritious food options.

The African American community in Sentinel City faces several challenges, including high unemployment and poverty (World Health Organization, 2017). These economic factors have had a negative impact on their health, with many experiencing chronic diseases like cancer. Unfortunately, access to cancer prevention and treatment is often limited due to the cost of maintaining a healthy diet, which is difficult for many African Americans in the city to afford. In addition, poverty also limits educational opportunities, with only about 20% of the population able to receive adequate schooling and formal employment opportunities remaining scarce. As a result, this population is at a higher risk of developing chronic diseases like cancer. It is crucial to address these issues through various strategies to improve the well-being of African Americans in Sentinel City.

Several strategies are suggested to improve cancer screening awareness among the African American community in Sentinel City. One approach is implementing a healthcare intervention by expanding healthcare facilities and offering quality care. Education programs and employment incentives can engage and empower the community toward a healthy lifestyle, which will also aid in preventing chronic diseases like cancer (Rivera et al., 2020). Finally, advocacy measures can be employed to ensure that cancer prevention measures like screening are adopted. This comprehensive approach will help to address health determinants that may jeopardize cancer prevention and treatment for low-income families.

Conclusion

In conclusion, sociocultural influences significantly impact healthcare outcomes for vulnerable populations, particularly the African American community in Sentinel City. Poverty and lack of access to quality care have led to disparities in cancer outcomes for this demographic. To reduce health disparities and improve cancer prevention and treatment, health interventions, education, and advocacy must be implemented to empower the African American community and provide them with the tools for a healthy lifestyle and access to quality healthcare.

References

Healthypeople.gov. (2020). Determinants of Health | Healthy People 2020. Retrieved 10th March 2023, from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

Review World Health Organization (2017). The determinants of health. Retrieved 10th March 2023 from http://www.who.int/hia/evidence/doh/en/

Rivera, M. P., Katki, H. A., Tanner, N. T., Triplette, M., Sakoda, L. C., Wiener, R. S. & Aldrich, M. C. (2020). Addressing disparities in lung cancer screening eligibility and healthcare access. An official American Thoracic Society statement. American Journal of Respiratory and Critical Care Medicine, 202(7), e95-e112. https://www.atsjournals.org/doi/full/10.1164/rccm.202008-3053ST

Zavala, V. A., Bracci, P. M., Carethers, J. M., Carvajal-Carmona, L., Coggins, N. B., Cruz-Correa, M. R., & Fejerman, L. (2021). Cancer health disparities in racial/ethnic minorities in the United States. British Journal of Cancer, 124(2), 315-332. https://doi.org/10.1038/s41416-020-01038-6

SIM 410 Activity 4 Healthcare Delivery and Quality Case Study

Landmark studies To Err is Human (1999) and Crossing the Quality Chasm (2001) from the Institute of Medicine (IOM) identified medical errors are causing harm and death to almost 45,000 Americans and costing over $29 billion every year.  Other studies have indicated preventable healthcare associated conditions (HACs) such as infections, sepsis, CHF, and pneumonia are main contributors for increasing the length of patient stays, the cost of care, and the likelihood of mortality (death). 

Consider the below case study:

Margret Spinner-Ramirez is a 66 y/o female Hispanic-American who speaks both Spanish and English fluently. She is retired, lives alone, and has Medicaid as her primary insurance.  Ms. Spinner-Ramirez was scratched by a stray cat that she feeds on her back porch daily. She has been cleaning the wound daily; however, after 2 days she went to her local ER for increased pain, redness, and swelling in her left lower leg wound where she was scratched by the stray cat.  Ms. Spinner-Ramirez explained she recently had her left knee replaced about 6 months ago and verbalized new difficulty with baring weight on that extremity to the point that she was having to use her cane again. Her vital signs at the ER visit were stable.  Her left leg wound was cleaned and redressed.  After 5 hours in the ER, Ms. Spinner-Ramirez was discharged to home on oral Keflex for her left lower leg infection and was instructed to call her primary care physician for a follow-up appointment. Five days later Ms. Spinner-Ramirez was taken back to the same ER via ambulance.  Her neighbor found her lethargic, short of breath, and was experiencing difficulty being able to move. A CT scan and blood work revealed that Ms. Spinner-Ramirez’s knee replacement in her left leg was infected secondary to the cat scratch. She was admitted as an inpatient for sepsis. She needed to have a second left knee replacement surgery with wound irrigation and debridement, which extended her inpatient stay to 3 weeks.  Once she was discharged to home, she required six weeks of IV antibiotics, extensive rehab, and home health. 

 If you were in charge of a healthcare insurance company:

  • Explain why insurance companies (which are considered payers) should or should not pay (reimburse) for injuries, extended costs, readmissions, or death (mortality) from a hospital-acquired infection or medical error. Support your why or why not? 
  • Describe two ways (initiatives) healthcare quality can be improved to help reduce errors and improve patient safety. 
  • Discuss how creating incentives for providers (healthcare organizations) can improve quality and reimbursements (payments) for services/care.

Resources:

Additional Instructions:

  1. All submissions should have a title page and reference page.
  2. Utilize a minimum of two scholarly resources.
  3. Adhere to grammar, spelling and punctuation criteria.
  4. Adhere to APA compliance guidelines.
  5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One:Instructions:
Paper2 page paper. Include title and reference pages.

SIM 410 Activity 5 Healthcare Priority Issue

Baccalaureate education will provide learning opportunities to use safety principles, quality improvement concepts, basic quality and safety investigations, and monitoring the results and outcomes (AACN, 2008).  

Transforming healthcare and improving quality are priorities for the profession of nursing.  The following activity will help you explore key national priority health care areas for quality improvement as identified by the Institute of Medicine.  Begin by selecting a key healthcare priority area and a population. Next, review and locate 2 article that describes a nursing intervention designed to improve a patient outcome for the chosen population selected healthcare priority issue.  Finally, discuss why it is important for nursing to be involved in Quality Improvement and describe how nursing values can be used to help improve safe patient care.

Access the Priority Areas for National Action: Transforming Health Quality and read Chapter 3: Priority Areas for Quality Improvement, pages 41-45.  Select ONE priority area (priority healthcare issue) and identify a patient population you would like to explore. 

Additional Instructions:

  1. All submissions should have a title page and reference page.
  2. Utilize a minimum of two scholarly resources.
  3. Adhere to grammar, spelling and punctuation criteria.
  4. Adhere to APA compliance guidelines.
  5. Adhere to the chosen Submission Option for Delivery of Activity guidelines.
Submission Options
Choose One:Instructions:
Paper 5 page paper. Include title and reference pages.