Hcs 235 Week Health Care Utilization Paper

Health Care Utilization Paper HCS/235: Health Care Delivery in the U. S. Health Care Reform The Patient Protection and Affordable Care Act of 2010 (PPACA) was designed to decrease health care costs and require health care access to all U. S. citizens. The Act has the potential for reducing the cost of health care in the United States; however, with many risks which could possibly strain the health care system, increase debt, and decrease the quality of care many are concerned. Access to Care The PPACA was enacted in 2010; however, the Act was not completely implemented right away.

The health care reform has been dispersing provisions as the years progressed. Provisions such as simply investing in new resources to fight against fraud, waste, and abuse in government sponsored programs such as Medicare and Medicaid will strengthen the quality of the programs and also protect taxpayer’s money. Under the Affordable Care Act—young adults are allowed to continue in their parents’ health insurance plans until they reach twenty –six years of age, unless the young adult has health care insurance under their own employer.

In the past, medical health insurance companies have denied payments for patients who got sick. Incidents where breast cancer patients were found to have lost medical coverage from their insurance companies after diagnosed with the major disease. The Act makes this action illegal for insurance companies to rescind medical benefits. The purpose of the PPACA is to provide health care services to all Americans, whether through government programs or employer–offered health insurance plans. The Act provides small businesses and some large businesses with tax credits for providing health care benefits to their employees.

Huge investments are placed into prevention. Preventing diseases and illnesses with free preventative care to individuals will impact the costs of emergency room claims from individuals who wait until their diseases or sickness is unbearable. Emergency room claims are far more expensive than preventative care. Keeping previously uninsured individuals healthy before they join Medicare reduces the cost burdens of taxpayer dollars for uninsured patients receiving care at hospitals which go unpaid and drive the cost of health care. Utilization

Utilization management has taken a key role in the health reform act because it evaluates the need, appropriateness, and the efficiency of the health care services which will be used by the covered individual. Health insurance plans are pressured to find ways to reduce plan costs and improve the quality of care provided to their members. Utilization management efforts have reduced inappropriate services and high medical costs just by taking some time to review pre-authorizations instead of providing clinically inappropriate, out-of-network services which prevents the accurate care for patient and increases cost for plans.

Today’s decision-making and support of utilizations for members are performed in real-time. Real-time utilization achieves the decrease of unnecessary expenses and improves member’s health. Use of unnecessary services increases the cost for plans and limits them on the amount of services they can provide to members who are in dire need of them. Universal Health Care Achieving the goal of providing health care benefits for all U. S. citizens is a goal that is not new in our health care system and still lingers to be resolved by government officials.

The health reform act’s provisions are stated to achieve these goals. The Medicaid expansion could possibly insure 21. 3 million Americans; however, States are given the opportunity to opt-out of the health reform Medicaid expansion. States will not be penalized for not expanding coverage to low-income individuals or families. The Medicaid expansion will provide services to low-income adults with or without dependent children, low-income children who turn nineteen years of age and classified as adults, and low-income adults with disabilities who do not qualify for Social Security Benefits.

Previous States who have expended Medicaid benefits to their low-income residents have reported a decrease in uninsured residents, improved access to health care, and an increase in a healthy population. The result of States opting out of Medicaid expansion benefits will increase emergency uncompensated care for hospitals and other health care entities. The health reform act will be less effective and will drive the cost of care for the rest of the country when States opt-out of the Medicaid expansion efforts creating an imbalance within the nation. Personal Experience

The Medicaid expansion efforts have provided strict regulations to managed care organizations such as the one I currently work for. However, the provisions for increasing Medicaid expansion in the state of Florida will allow more residents to acquire health care benefits which eventually will improve the overall health of the residents in Florida and lower the costs of providing health care benefits. Utilization management has become a great asset in decreasing costs for the organization allowing for benefits to be distributed to more members who are in need of medical care.

The consolidations of Managed Care Organizations (MCOs) into Health Maintenance Organizations (HMOs) or the Provider Service Network (PSN) will allow the members to receive services from a vast of in-network providers and achieve a higher quality of care. The transition will start taking affect August of 2013 and will continue through 2014 until the transition is complete. The not knowing how the reform affects our jobs is what is most daunting.

Getting the proper facts and also communicating with your employer to get a better understanding on their action plan for the provisions of the health care reform are most encouraging. Knowing what is currently happening, what is going to happen, and where you will be situated at the end of the day is what matters the most—especially in this economy. Conclusion The Patient Protection and Affordable Care Act will help the nation to provide health care access to all U. S. citizens.

The provisions in health care reform act will allow all uninsured individuals to acquire at least some type of basic health care coverage through government programs or employer–offered health insurance plans starting as early as January 2014. Small and large business employers are able to register now to provide health insurance benefits to their employees at a tax credit or some type of incentive if they have not done so already. Preventing the costly hospital claims by offering preventative care to individuals will not only save lives, but will also lower the costs of hospital bills which, unfortunately, are later paid by taxpayers.