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The Financial Health Care Environment: Reimbursement, Pricing, and Trends

Explore the complex world of reimbursement, pricing, and emerging trends in the financial healthcare environment. Learn about bundled charges, capitation, fee-for-service, managed care, and more. Discover how supply and demand, pricing, and cost factors impact the healthcare industry. Gain insights into pay-for-performance, consumer-directed health plans, and providers joining forces. Explore other trends such as care management, regional health information organizations, and nursing implications in this ever-changing landscape.

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The Financial Health Care Environment: Reimbursement, Pricing, and Trends

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  1. 10 C H A P T E R THE FINANCIALHEALTH CARE ENVIRONMENT

  2. Key Terms • Bundled Charges • Capitation • Diagnosis Related Groups (DRG) • Fee for Service • Fiscal Intermediary

  3. Key Terms • Managed Care • Resource Based Relative Value Scale • Self Insured Plans • Third Party Administrator

  4. Primary Sourcesof Reimbursement • Patient • Private insurance • Government

  5. Supply and Demand • Health care responds to demand. • Also creates demand through marketing • Marketing targets providers and patients (Figure 10-3). • Many regulations also affect care (Table 10-1).

  6. Supply and Demand (cont.) Growth in Promotional Spending Source: Kaiser Foundation, 2004

  7. Pricing and Cost • Pricing is very complex. • Costs are rising rapidly (Figure 10-5). • Managed care is a response to high costs. • Prospective payment systems also contain costs.

  8. Pricing and Cost (cont.) Source: California Health Care Foundation, 2005

  9. Cost, Quality, and Access • U.S. spends more money on health care than other countries. • Health care quality is not the best. • High numbers of uninsured are a problem.

  10. Pay for Performance • Paying for quality and efficiency • Shifts financial risk to provider • Providers may focus on patients that meet the outcome. • Different payers may have different expectations.

  11. Consumer Directed Health Plans • Shifts risk to patients (Figure 10-8) • High Deductible Plans • Tiered Benefit Plans • Health Reimbursement Accounts • Health Savings Accounts

  12. Providers Joining Forces • Specialty Hospitals/Outpatient Surgery Centers • Emphasis on service and outcomes • Joint Ventures • Creating strategic and efficient alliances

  13. Other Health Care Trends • Care or disease management • Regional Health Information Organizations (Figure 10-7) • Price Transparency • Charity Care • Changing Population Demographics

  14. Other Health Care Trends (cont.) An example of a Regional Health Information Organization

  15. Nursing Implications • Increasing demand for nurses • Advancing technologies • Emphasis on care management • Focus on prevention • More care provided outside of the hospital

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