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Introduction

Federal and state policies that focus on healthcare reimbursement have a direct impact on how services are reimbursed in healthcare facilities. For example, if CMS decides to reduce Medicare payments to hospitals by 4%, the organizations that care for Medicare patients will receive less reimbursement and may have to resort to cutting costs to survive economically. This is why it is so critical that, as nurses, we stay attuned to what our federal and state governments are doing when it comes to legislation that affects healthcare reimbursement.

The United States has an entrepreneurial healthcare system, with a variety of products in the marketplace. However, in the US healthcare delivery system, administrative functions result in huge costs. Compared to the US, countries with fewer varieties of insurance products tend to have much lower healthcare delivery overhead.

The US health insurance market has worked well for the insurance industry but not so well for many patients and clinicians. For example, the Congressional Budget Office (2020) estimates that at any given point in 2019, about 30 million people were uninsured. Tens of millions more were underinsured, and those with coverage were often afraid of losing it. Many medical practices lacked the support that they needed to provide coordinated, safe, effective, outcome-oriented, patient-centered care.

Why Reform?

Arguably—and the debate about healthcare reform did result in many arguments—the US healthcare system was broken and needed to be repaired. Essential care providers faced crushing paperwork, uncertainty regarding payment, and rising healthcare costs. Insurance bureaucracy added yet more paperwork to medical practices, which reduced their time spent with patients. Patients with no or limited coverage often forwent or delayed seeking needed care and treatment. This resulted in patients presenting to emergency departments very ill and thus requiring costly treatment. Healthcare outcomes in the US continued to lag behind many other countries, despite the US spending far more on care.

Two leading indicators of the quality of a country's healthcare system are life expectancy and infant mortality. In 2000, the last year that the World Health Organization (WHO) assessed all countries’ healthcare delivery systems, the US ranked 37th out of 191 countries analyzed (Tandon et al., 2001). Also, other countries’ primary care systems ranked higher than those in the US. In short, the US healthcare system needed a major overhaul.

What Is an Interventional System?

The US is considered an interventional system. Think of an interventional system as being the opposite of a prevention system. Many Americans do not care for their own health in a preventive way—for example, by exercising and eating healthfully—nor do they change their behaviors when faced with a health problem. Instead, they rely on pills and other types of interventions to make them better.

My mom once told me a story that illustrates this perfectly. She was watching a television show with ...

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