Healthcare Economics and Finance

The United States healthcare system has been implementing the Affordable Care Act for several years. Everyone has recognized that our healthcare system is broken but the bigger question is how do we fix it? Our healthcare system is very complex and unique. It has many stakeholders and multiple different components. As an experienced nurse, you likely recognize that reimbursement systems are currently the tail that wags the dog in healthcare economics (Frakes & Evans, 2006). Prospective payment systems dating back to diagnostic-related groups (DRGs) functioned to "practice medicine without a license" by determining when patients should be discharged from hospital care. The medical community was not effective in overturning these reimbursement stipulations, and healthcare economics has become increasingly burdened by related reimbursement regulation such as resource utilization groups (RUGs) and minimum data sets (MDS). In addition, managed care has infiltrated the healthcare marketplace as described by Curtin (2007). Managed care means capitated systems, covered lives, and risk sharing are reimbursement arrangements that determine the type and levels of services patients receive. Nurses and consumers alike now readily recognize managed care organizations, such as health maintenance organizations (HMOs), preferred provider organizations (PPOs), and medical service organizations (MSOs), from the perspective of the healthcare access they dictate. Reimbursement from third-party payers such as Medicare, Medicaid, and private insurers are certainly not without their share of stipulations that govern the care selections determined by providers (Foster & Clemens, 2005; Hurley & Retchin, 2006). The two largest government stakeholders are the Medicaid and Medicare systems. Other government programs that are included in the federal programs are the Veterans Administration Health Systems and the Indian Health Systems. A DNP nurse advocate must understand the federal stakeholders and the policies that these systems have overcome to develop appropriate health policy to help our nation's patients. What effect has increasing economic controls had on the delivery of healthcare in the U.S. delivery system? What are the driving forces and motivating factors that may bring about a transition from managed care to consumer-directed healthcare (Bauer & Hagland, 2006; Christianson, Ginsburg, & Draper, 2008)?  

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