Provision and Reimbursement of Health Care Services

Provision and Reimbursement of Health Care Services

Grand Canyon University: HLT – 308V

Some of the biggest healthcare trends lately have to do with the Affordable Care Act. Since the Affordable Care Act health insurance marketplaces opened in 2014, there have been a number of changes in insurer participation as companies entered and exited states and also changed their footprint within states. In 2016, insurer participation changed in a number of states due to a combination of some new entrants and the failure of a number of CO-OP plans (fehr, 2018). The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to major changes to individual insurance markets. Both involved new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office reports said that overall these provisions reduced the budget deficit, and that repealing the Affordable Care Act would increase the deficit (fehr, 2018). The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After the law went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.

The act largely retains the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled around a three-legged scheme. Insurers in these markets are made to accept all applicants and charge the same rates regardless of pre-existing conditions or sex. To combat resultant adverse selection, the act mandates that individuals buy insurance and insurers cover a list of “essential health benefits”. However, a repeal of the tax mandate, passed as part of the Tax Cuts and Jobs Act of 2017, will become effective in 2019 (fehr, 2018). To help households between 100–400% of the Federal Poverty Line afford these compulsory policies, the law provides insurance premium subsidies (fehr, 2018). Other individual market changes include health marketplaces and risk adjustment programs.

Trends that are impacting

Healthcare trends that are making impacting us are Clinical and data analytics, big data and clinical evidence will increasingly be utilized to improve patient outcomes. Offering services that help patients collect; analyze and understand their own health will be a new emphasis on patient engagement. We have rolled out a way which is called MyChart; a patient can access their medical records remotely, email the clinical staff, and see lab results, request refills, request medical records to be transferred and so much more. Population health services organizations; all sectors of the industry will be looking closely at the determinants of health. To better manage rising costs, there needs to be added social determinants of health and wellness. Value based payments; there is a shift away from fee for service. To find new ways to lower costs and improve quality of care, value based payment models that are outcomes based are being tested.

Cost transparency; the demand for more transparency in the costs of health care services and products is gaining support from both legislation and consumers. Having patients see every charge through their Mychart; they can immediately contact the billing department with any issues. Total consumer health, health care now encompasses people overall well-being as well as their social and financial environments. Health organizations are focusing on nutrition and physical activity as ways to prevent costly medical problems. We have actually launched a program with the State of Texas where we can do instant evaluation for food security with patients and if they need assistance we can help enroll and get some food stamps.

Future Healthcare Trends that potentially will be impacting

Some future healthcare trends that could be potential impacting would be Telemedicine. Telemedicine leads directing into having organizations needing ways to keep patients’ information safe and secure. The U.S. government’s Report on Improving Cybersecurity in the Health Care Industry identified six key imperatives to tackle (health, 2019) Those six key imperatives are define and streamline leadership, governance, and expectations for healthcare industry. Increase the security and resilience of medical devices and health Information Technology. Develop the healthcare workforce capacity necessary to prioritize and ensure cybersecurity awareness and technical capabilities. Increase healthcare industry readiness through improved cybersecurity awareness and education. Identify mechanisms to protect R&D efforts and intellectual property from attacks or exposure. Improve information sharing of industry threats, risk and mitigations. Task Force Co-Chairs Emery Csulak and Theresa Meadows, “As health care becomes increasingly dependent on information technology, our ability to protect our systems will have an ever greater impact on the health of the patients we serve,” the duo explained. “While much of what we recommend will require hard work, difficult decisions, and commitment of resources, we will be encouraged and unified by our shared values as health care industry professionals and our commitment to providing safe, high quality care (snell, 2017).”

Health care reform will continue to be an impacting trend as government officials constantly making plans for repealing, replacing or modifying the current health care laws, it’s important to have a standardized, consistent approach to compliance in today’s highly regulated health care environment. Healthcare reform will be forever changing especially as times change as political offices change.

A major trend that I have recently witnessed has been mobile health technology. Digital technologies can be of use in improving disease management and data collection. Health care companies should learn to embrace changing technology and evaluate new revenue sources. It goes along with telemedicine which is huge in my disease process of Cystic Fibrosis. Our patient population is immunocompromised and sometimes it is not beneficial for our patients to drive long distance; if we can use telemedicine at a local Emergency Room and get the patient stable it would allow for less of a compromised situation for our patients.

Some areas that we have been focusing on are addressing pharmacy costs. Companies should commit to being transparent and refrain from frequent price increases to help rebuild trust with consumers, physicians, and health insurers and demonstrate goodwill to legislators (ferkol, 2015). Our patients medications such as Pulmozyme costs on average of $60,000 a year, Cayston costs $90,000, Tobramycin is $75,000, the most expensive drugs are the modulator therapy drugs at they cost from $245,000 to $300,000 a year. We have been working with the drug manufacturers to create reimbursement programs, coupons, decreasing the cost, even as far as hoping for a generic formation of the medication. It is very rare to have a patient who can afford these medications.

A bigger trend is the younger generation is very digital aged. We need to focus on having more things available electronically available for our patients. According to Health and Safety Assurance Services (HSAs), patient portals and wellness education materials are key to improving patient engagement (health, 2019). Health care companies should invest in tools and processes to better understand their target market and customer segments and improve the patient experience to engage more effectively with today’s informed health care consumers (health, 2019).

Trends that will make a Positive impact

Falling back on some trends that I feel will leave a positive impact are Telemedicine however they also can potentially be a Risk Management due to security breaches. Some other areas of concern are that patients possibly abusing the system and not seeking medical attention in person when telemedicine should not have been used. This can potentially lead to a catastrophic incident. This is one reason why I feel it fully hasn’t made its way across the healthcare field. It has been increasingly popular with mental health care and general practice care.

I also feel that pharmaceutical costs are a big trend that will continue to be forever changing especially as new drugs are being created the cost of the medications will increase. I feel that this will cause an increase of hospitalizations because patients can’t afford their medications. So patients who don’t take their medications equals increased hospitalizations, clinic visits however this also increases patient debt with facilities because if they can’t afford the medications they can’t afford the hospital visit or clinic visit even with healthcare insurance.


Fehr, R., @cynthiaccox, C. C., & Levitt, L. (2018, November 14). Insurer Participation on ACA

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Ferkol, T., & Quinton, P. (2015, September 15). Precision Medicine: At What Price? Retrieved July 21, 2019, from

Health Care Trends. (2019, February 22). Retrieved July 21, 2019, from

Snell, E. (2017, June 05). Healthcare Cybersecurity Task Force Finds 6 Imperative Areas. Retrieved July 21, 2019, from