healthcare delivery system

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One approach in achieving the goal of lowering the cost and improving the quality of care is the implementation of managed care, a healthcare delivery system seeking to reduce healthcare costs and improve patient outcomes through a collaboration of health providers to meet the overall health needs of health consumers (Giardino & Jesus, 2020). Cost reduction is achieved through superior quality care that guarantees fewer hospital visits and reduced hospital stays (Giardino & Jesus, 2020).
The current efforts to transform the healthcare industry have felt the contribution of every stakeholder, even those perceived to be losers in the transformation process (Simonds & Echavarra, 2017). Private insurers have developed strategies that have been beneficial to the change process, although many people expected them to control nothing in this transformation (Simonds & Echavarra, 2017). For example, private insurers have entered into agreements with employers and offered discounts for employers contributing a specific premium amount (Simonds & Echavarra, 2017). Such strategies have ensured that more Americans are enrolled in healthcare coverage, which is part of the goals of the transformation (Simonds & Echavarra, 2017).
I think we can all agree that nurses remain critical players in the ongoing efforts to transform the healthcare system in America from the conventional fee-for-service that encourages quantity over quality to the new value-based approach that concentrates on the quality of healthcare offered to patients. This paradigm shift places nurses in a more strategic role of working with other stakeholders to realize the triple aim of reducing healthcare cost per capita, improving healthcare outcomes for a specific population, and better patient care experience (Simonds & Echavarra, 2017). Current value-based models such as managed care are based on a reimbursement model that places the triple aim as a requirement for health reimbursements (Simonds & Echavarra, 2017). Therefore, nurses have an additional role in creating awareness among patients on the need for healthy living, which generally impacts the health of populations that largely dictates reimbursement and the managed care model (Simonds & Echavarra, 2017).
Nurses are active players in the efforts to reduce the rising cost of healthcare in America (Simonds & Echavarra, 2017). They may employ a range of strategies to achieve this goal, such as reducing the number of hospitalization for an individual health consumer (Salmond & Echevarra, 2017). Repeated hospitalization corresponds with increased healthcare costs since patients must spend on each occasion (Simonds & Echavarra, 2017). They can reduce hospitalization by advocating for preventive mechanisms rather than treatment approaches (Simonds & Echavarra, 2017). Nurses can also reduce healthcare costs by improving departmental utilization by minimizing wastages that drive operating costs up (Simonds & Echavarra, 2017).
While studies mentioned above have shown that managed care has resulted in better health outcomes and reduced the cost of care, all stakeholders, including patients, should work together to expedite its full implementation. Part of that effort should be to increase nurses’ roles in healthcare, as discussed above.

Discussion 2
According to Heaton & Tadi (2021), managed care refers to entities in healthcare that aim to reduce costs using financial provisions, preventive medicine, and treatment guidelines. Bird et al. (2015) outline some ways that private insurers are trying to transform healthcare. The first approach is through partnerships. Funds flow in the healthcare setting refers to partnerships where payment is achieved through partnering organizations (Bird et al., 2015). Some common types of funds flow arrangement include purchased services agreement, discrete joint operating agreement, cost-sharing, shared margins for new services, and virtual joint venture (Bird et al., 2015). Nurses have a role in improving quality patient outcomes that are tied to healthcare reimbursement. One way to do that is to adhere to the objectives of the Quality Payment Program as stipulated in CMS.gov (2020). First, nurses can improve patient outcomes through engagement using patient-centered Advanced APM and MIPS guidelines (CMS.gov 2019). Nurses can use the Alternative Payment Model (APM) to reduce costs and improve healthcare quality (CMS.gov 2019). According to Fraher et al. (2015), nurses are instrumental in care coordination. The CMS, through Medicaid, has incentives for states to use community services. With the aging population, such reforms can be used to meet the needs of this population (Fraher et al., 2015). Through care coordination, nurses can take advantage of Medicare incentives for care management. Considering the role of data today, systems can be designed to promote care coordination and lower costs. Nurses can use data in EHRs to assess interventions and care processes that influence patient outcomes (Fraher et al., 2015).

Nurses can use different strategies to advocate for healthcare consumers and reduce the increasing cost of healthcare. In their advocacy roles, nurses can help healthcare consumers reduce the rising costs of healthcare. First, education can be redesigned to prepare nurses to deal with changing population needs, provide care coordination, use EHRs, and work in multidisciplinary teams (Fraher et al., 2015). Nurses can advocate for a redesign of the curriculum and professional development for nurses to promote care coordination. One barrier to preparing nurses for today’s workforce is that they are not trained on emerging models of care. Following recommendations from the Institute of Medicine, nursing education should address the needs of older adults and geriatric care (Fraher et al., 2015). Besides education, nurses can advocate for regulatory changes to allow registered nurses and others to utilize their skills fully. Restrictive state regulations hinder the provision of care and increase costs (Fraher et al., 2015). Nurses can advocate for new policies that permit them to use their abilities accordingly. Although it is a long process, nurses can challenge insurance reimbursement rules that take away from patient care. Changes in education should also include NCLEX, where licensure should reflect changing roles of nurses, including care management, informatics, population health, and coordination (Fraher et al., 2015).