Reducing Unnecessary Care Requires Transparency and Leadership

Reducing Unnecessary Care Requires Transparency and LeadershipFebruary, 18 2015 by Vickie Anenberg

The Affordable Care Act (ACA) has changed healthcare facility reimbursement far into the foreseeable future. Gone is the fee-for-service model. Instead, providers face the challenge presented by an outcomes-based model to receive reimbursement without incurring financial penalties.

Reducing unnecessary care is a sensitive topic. What is unnecessary care? Who defines it? Is there really a fix to ensure reimbursement? These are all very valid questions. For administrators, CFOs and directors, the decisions they make can drive the positive financial health of their organizations, or have potentially serious, even if unintentional, negative consequences. It is all a question of medical necessity.

The AMA has defined medical necessity as: “Healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other healthcare provider.”

An article recently posted by the consulting firm Navigant effectively addresses healthcare problems and poses logical solutions. It notes, “Unnecessary care that's not evidence-based—usually associated with excess testing, surgical procedures or over-prescribing—accounts for up to 30% of what is spent in healthcare.”

Further, in probing potential solutions, Navigant suggests four points for serious consideration:

• Documentation is key

• Transparency about medical necessity and unnecessary care is assured

• Payments and penalties will follow

• Physician leadership is vital

At the root of providing quality care, while assuring realistic reimbursement becomes more complex under ACA, there is one constant. Quality care begins with quality staffing. Cross Country Staffing has proven workforce solutions and staffing services that deliver cost-effective, consistently dependable results for healthcare provider organizations of all sizes. Our 40 years of professional staffing experience partnering with more than 2,500 healthcare providers nationwide means Cross Country Staffing is the one firm you can trust to reach optimal staffing levels for delivering quality patient care.