The Centers for Medicare & Medicaid Services (CMS) recently released their 2015 quality and financial performance results for Medicare Accountable Care Organizations (ACOs). Their findings suggest that ACOs are striking an important balance between steadily improving the quality of care for Medicare beneficiaries while bringing costs down at the same time. In 2015 alone, over 400 Medicare ACOs generated more than $466 million in overall program savings. 125 of these ACOs qualified for shared savings payments by meeting quality performance standards and their savings threshold. These results are hopeful because they show a trend of ACOs sharing savings. They also indicate that ACOs with more experience in the Pioneer ACO Model and the Medicare …show more content…
And, with the right incentives in place, these savings can also be passed onto the providers themselves. ACOs are either Pioneers or a Medicare Shared Savings Program (MSSP). As the name implies, Pioneers were a small group of large organizations that adopted the ACO model early on. While 32 organizations signed onto the Pioneer program initially, only 12 remained in 2015. The Pioneer ACO Model was designed for organizations and providers already experienced in coordinating care for patients across care settings. The model allows providers to move more rapidly from a shared savings payment model to a population-based payment model on a track related to, but separate from, the MSSP. The Affordable Care Act saw the establishment of MSSP in an effort to foster cooperation and coordination among providers with the goal of improving quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce unnecessary costs. MSSP encourages providers to create new healthcare entities that are held accountable for improving care while reducing delivery …show more content…
Over 91% of participating ACOs increased their overall performance score in 2015 through Quality Improvement Reward points in at least one of four quality measures. What Were the Financial Results? With a larger number of ACOs participating in the MSSP model, it’s no surprise to see a variety of financial results. While 83 ACOs kept costs below their benchmark, they still did not meet the minimum savings and therefore did not qualify for shared savings. A significant number of ACOS generated savings above their minimum savings rate each year. For PY15, 31% of ACOs generated savings above their MSR compared to 28% in PY14 and 26% in PY13. The results also showed that ACOs with more experience in the program performed better. For instance, in 2015, 42% of ACOs that started in 2012 generated savings above their MSR compared to only 37% of those organizations that started in 2013 and 22% that started in 2014. The MSSP program continues to receive a lot of interest from new applicants seeking to join the program as well as from existing ACOs seeking to adopt the program for the period starting in 2017. New and renewing ACOs will be announced at the end of this
Membership Services (MSD) at Kaiser Permanente used to be a modest department of sixty staff. However, over the past few years the department has doubled in size, creating minor departmental reorganization. In addition the increase of departmental staffing, several challenges became apparent. The changes included primary job function, as well as the introduction of new network system software which slowed down the processes of other departments. These departments included Claims (who pay the bills for service providers outside of the Kaiser Permanente network), and Patient Business Services (who send invoices to members for services received within Kaiser Permanente). Due to the unforeseen challenges created by the system upgrade, it was decided that MSD would process the calls for both of the affected departments. Unfortunately, this created a catastrophic event of MSD receiving numerous phone calls from upset members—who had received bills a year after the service had been provided. The average Monday call volume had risen from 1,800 to 2,600 calls per day. The average handling time for each phone call had risen as well—from an acceptable standard of 5.6 minutes to an unfavorable 7.2 minutes. The department continued to be kept inundated with these types of calls for the two years that these changes have been effect.
Cimasi, R. J. (2013). Accountable care organizations: Value metrics and capital formation. (pp. 90-92). CRC Press. Retrieved from http://books.google.com/books?id=EDMTlDWYvmUC&dq=specific service payment bundled&source=gbs_navlinks_s
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. This drives up costs by rewarding providers for doing more, even when it’s not needed. ACOs continue to utilize fee for service by creating incentives to be more efficient by offering bonuses when providers keep ...
Pay-for-performance (P4P) is the compensation representation that compensates healthcare contributors for accomplishing pre-authorized objectives for the delivery of quality health care assistance by economic incentives. P4P is increasingly put into practice in the healthcare structure to support quality enhancements in healthcare systems. Thus, pay-for-performance can be seen as a means of attaching financial incentives to the main objectives of clinical care. However, reimbursement is a managed care payment by a third party to a beneficiary, hospital or other health care providers for services rendered to an insured or beneficiary. This paper discusses how reimbursement can be affected by the pay-for-performance approach and how system cost reductions impact the quality and efficiency of healthcare. In addition, it also addresses how pay-for-performance affects different healthcare providers and their customers. Finally, there will also be a discussion on the effects pay-for-performance will have on the future of healthcare.
In December 2011, Texas Health and Human Services Commission (HHSC) received federal approval of a Medicaid Section 1115(a) Demonstration Waiver, entitled “Texas Healthcare Transformation and Quality Improvement Program,” for the period starting with December 12, 2011 through September 20, 2016. The main objective of the 1115 Waiver is to improve access to and quality of health care by expanding Medicaid managed care programs and promoting health care delivery system reforms while containing cost growth. Specifically, the Waiver created two new pools of funding—Uncompensated Care (UC) and Delivery System Redesign and Innovation Payment (DSRIP) pools—by redirecting funds that were available under the old Upper Payment Limit (UPL) payment methodology. DSRIP funding is used to offer financial incentives to health care providers that develop and implement projects aimed at improving how care is delivered to low-income populations. Specifically, the providers (often referred to as the “performing providers” or “performers”) propose and execute projects like programs, strategies, and investments designed to enhance access to health care, quality of health care, cost-effectiveness of services, and health of the patients and families served.
The Bundled payment is defined as the reimbursement of health care providers on the basis of expected costs for clinically defined episodes of care. It has been considered as a middle ground between fee for service reimbursement and capitation system. Bundled payment has been proposed in health care reforms in the United States as a strategy for reducing health care costs, especially during the Obama administration (Mechanic & Altman 2009). While federal and state health care laws make bundled payments difficult to structure and implement, both the Medicare program and commercial payers have embraced bundled payments as a means for reducing costs, and many providers view bundled payments as an effective market strategy and a gateway to population management and more complex value-based payment arrangements (Moeller & Evans 2010).
Health Maintenance Organizations, or HMO’s, are a very important part of the American health care system. Also referred to as managed care programs, HMO's are combinations of doctors and insurance companies that are formed into one organization. This organization provides treatment to its members at fixed costs and decides on what treatment, if any, will be given based on the patient's or doctor's current health plan. Sometimes, no treatment is given at all. HMO's main concerns are to control costs and supposedly provide the best possible treatment to their patients. But it seems to the naked eye that instead their main goal is to get more people enrolled so that they can maintain or raise current premiums paid by consumers using their service. For HMO's, profit comes first- not patients' lives.
Formed in 1998, the Managed Care Executive Group (MCEG) is a national organization of U.S. senior health executives who provide an open exchange of shared resources by discussing issues which are currently faced by health care organizations. In the fall of 2011, 61 organizations, which represented 90 responders, ranked the top ten strategic issues for 2012. Although the issues were ranked according to their priority, this report discusses the top three issues which I believe to be the most significant due to the need for competitive and inter-related products, quality care and cost containment.
The current health care reimbursement system in the United State is not cost effective, and politicians, along with insurance companies, are searching for a new reimbursement model. A new health care arrangement, value based health care, seems to be gaining momentum with help from the biggest piece of health care legislation within the last decade; the Affordable Care Act is pushing the health care system to adopt this arrangement. However, the community of health care providers is attempting to slow the momentum of the value based health care, because they wish to maintain their autonomy under the current fee-for-service reimbursement system (FFS).
Health Care workers are constantly faced with legal and ethical issues every day during the course of their work. It is important that the health care workers have a clear understanding of these legal and ethical issues that they will face (1). In the case study analysed key legal and ethical issues arise during the initial decision-making of the incident, when the second ambulance crew arrived, throughout the treatment and during the transfer of patient to the hospital. The ethical issues in this case can be described as what the paramedic believes is the right thing to do for the patient and the legal issues control what the law describes that the paramedic should do in this situation (2, 3). It is therefore important that paramedics also
Administrative costs and paperwork associated with health insurance have also been reduced, and some persons who currently do not have health insurance have been able to obtain some financial protection.
The two major components of Medicare, the Hospital Insurance Program (Part A of Medicare) and the supplementary Medical Insurance program (Part B) may be exhausted by the year 2025, another sad fact of the Medicare situation at hand (“Medicare’s Future”). The burden brought about by the unfair dealings of HMO’s is having an adverse affect on the Medicare system. With the incredibly large burden brought about by the large amount of patients that Medicare is handed, it is becoming increasingly difficult to fund the system in the way that is necessary for it to function effectively. Most elderly people over the age of 65 are eligible for Medicare, but for a quite disturbing reason they are not able to reap the benefits of the taxes they have paid. Medicare is a national health plan covering 40 mi...
...(2.06 million) based on these goals. Lastly, Nimsoft must remain aware of what job needs to be done. We must ask questions from different perspectives, continue to adapt, and make sure we are not overlooking potential markets. While the list is lengthy and the work will be difficult, following these steps will guide us in the right direction and prevent us from making the same mistakes those in the industry have already made.
· EVA allows a good way for companies to set a reward system that is not