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Health Care Ecosystems

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Submitted By BeatriceW
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Medicare is a federal government payer program for people over 65, for people with certain disabilities, and people with end stage renal disease. The program was started in 1966 by President Lyndon Johnston under the Social Security Act. Medicare is the largest of the government payer program in the United States. Because of this, Medicare has a large impact on licensing, certification and accreditation standards.
Every health care facility is required to be licensed to provide care to patients. Each state has different requirements for a facility to be licensed and they can change annually. In the state of Washington, the Department of Health is responsible for licensure of hospitals. Healthcare facilities are licensed to make sure that the facility meets certain standards of service and quality and that the facility meets with state laws and regulations. After receiving their initial license, a facility will be periodically reviewed to make sure that the standards are continued to be met. If a facility wants to provide care to Medicare patients, it must first be licensed to provide care within the state they are located.
Any health care facility that wants to provide care or services to Medicare patients and be paid by Medicare, must be federally certified in addition to being state licensed. Medicare certification is voluntary. Certification is when an outside agency officially determines if a health care facility meets the Social Security Act's provider or supplier definitions, and whether the entities comply with standards required by Federal regulations (Centers for Medicare and Medicaid Services, n.d.). The facility must be able to demonstrate that it meets all of the Conditions of Participation (CoPs). If a facility is not federally certified, it cannot receive reimbursement for Medicare patients’ care.
Accreditation shows how well a facility is meeting the standards and requirements of licensure and certification. For a facility that provides care and services to Medicare patients, accreditation shows how well the facility is meeting the Conditions of Participation as well as the state licensure and federal certification. Accreditation is not mandatory, but it allows a facility to not have to go through certification.
Clinical Quality Measures, or CQMs, are tools that help measure and track the quality of health care services provided by a health care system (Centers for Medicare and Medicaid Services, n.d.). Measuring and reporting quality of care data to ensure high quality care. Medicare influences clinical quality by offering an incentive program to Medicare facilities that meet certain quality requirements.
As the largest American health insurer, Medicare has the ability to set the standards in which care is given. In order to receive reimbursement from Medicare, a health care provider must meet Medicare’s standards of care. Hospitals, providers, medication and skilled nursing facility all must meet the conditions of participation. If they do not, they are unable to get reimbursed
Medicare reimbursement is set by a formula. Per the CMS.gov website, the formula for Original Medicare (Medicare Fee for Service) is based on a complex set of data. The amounts are set the year before they go into effect and providers are allowed to put in input.
Medicare also influences what medications are used. Medications are listed on the formulary in tiers, and the tiers effect the price of that drug. If a medication is listed on the Medicare Part D formulary, the co pays that the patient pays are less. If a drug is not listed on a Medicare Part D formulary or is at a high tier, then the patient is required to pay a large amount of the cost.
Medicare only limits its own patients’ access to health care. In order to receive care at a specific rate, a Medicare patient must go to a facility that has been certified as a Medicare facility. If the facility is not a certified Medicare facility then the facility is at risk for not being reimbursed for the care or services given and the patient is at risk of having to pay a larger share of the bill. However, as Medicare is the largest medical payer, and the Medicare age population growing, it would make sense that a medical facility would seek Medicare certification.
Medicare licensure, certification and accreditation offer a health informatics professional a variety of roles. All of the steps require data to make decisions and health informatics professionals are well suited to provide that data. Collecting, organizing, reporting and storing data and using it to change how care is given is by providing information for medical quality assurance. (Jobs For The Future, 2012). Ongoing Medicare certification and accreditation requires that health facilities are able to provide information to show that the requirements are being met.
Medicare has a large impact on the health informatics workforce. Parts of the Affordable Care Act (ObamaCare) is making changes to how Medicare pays. It will require that hospitals are able to track if patients return to the hospital for the same treatment within 3 months. New systems will have to coordinate care and track treatment outcomes. (Jobs For The Future, 2012) Also, Medicare is offering a monetary incentive for facilities to submit their information for certification via approved electronic medical records programs (Centers for Medicare and Medicaid Services, n.d.).

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