Jen CarrollCMS Value-Based ProgramsThe CMS Value-Based Program will be an adjustment for some providers who have been rewarded for treating patients in numbers, the more patients they see in a day the more revenue is generated. The structure of Categories 2,3 & 4of the CMS value base program changes that mindset, pay is linked to quality of care not volume of patients treated. Category 2 Fee for service breaks the service provided for the patient into individual units. Payment is based on delivery of care, quality, and efficiency of care delivered. Category 3 relies on shared risk otherwise known as two -sided risk, shared savings payment approach. Effective management of the population, episode of care, and delivery of services are linked
Collaborative partnerships, among physicians and case managers, add value to the patient care by orchestrating care progression and coordination, supportive decision-making and cost-effective choices. The interaction of the case managers with multiple departments in a health system allows open communication, resulting in quality metrics demonstrating value in areas such as length of stay, observations, accounts receivable, and appeals or denials of patient care (Miodonski 2011). For instance, a patient presents with a myocardial infarction and a hospitalist orders an upper gastrointestinal series that is not necessary. The case manager in this particular situation seeks the necessity of the tests, preventing unnecessary testing and additional length of stay, ultimately improving the patient’s care and progression. Although hospital costs are avoided in this example, more importantly the case manager coordinated efficient movement and progression of care resulting in improved quality and accountability (Daniels & Frater 2011). There is no room for confusing managed care with case management, as managed care equals cost containment programs mandated by concrete systems. Case
A multispecialty group practice is one that consists of individual physicians who offer various medical and specialty services in that practice by contracting to a managed care plan. Managed Care Organizations are formed by insurance companies that either own a provider network or create one by arranging with independent providers (Gapenski, 2009). The payment structure used to reimburse providers regardless of services provided falls into the category of either fee-for-service or capitation based. Fee-for-service is the reimbursement according to services provided, either through reimbursing based on the cost of services provided or reimbursing based on rate schedule of services provided. On the other hand, in the Capitation system, providers are paid a fixed amount depending on the number o...
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.
Miller, H. D. (2009). From volume to value: better ways to pay for health care. Health Affairs
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).
Medicare uses the Medicare Physician Fee Schedule to pay physicians and the Outpatient Prospective Payment System to pay hospitals and other outpatient facilities. Recently, the Centers for Medicaid and Medicare Services (CMS) made changes to physician and outpatient payments. The five levels clinic visit codes or five outpatient codes were replaced with a single code. “The Chronic Care Management Fee will go into effect in January 2014 and will be the new form of physician compensation. Bundle Payment is a way for paying for high volume, high cost hospital procedures. Global payment enables providers to reduce unnecessary care and bring down spending under control but creates incentives for providers to restrain the supply of services.
The person pursues healthcare service with great expectations such as quality health care, latest technological interventions and low cost for their service. Nowadays, one of the challenges facing by the health care providers is providing appropriate care and identifying their needs in a cost effective and comprehensive way without compromising the quality of care. Center for Medicare and Medicaid Services (CMS) reported “an rise in healthcare spending from $2.34 trillion in 2008 to $ 2.47 trillion in 2009, the largest one year increase since 1960” (Pickert, K, 2010). “The action to improve the American health care delivery system as a whole, in all of its quality dimensions such as efficiency, effectiveness, equitability, timeliness, patient-centeredness, and safety for all Americans” (IOM, 2011).
Fee-for-service is a retrospective reimbursement system in which providers create a comprehensive list of services they provided to a patient and the materials, supplies, and facilities they used to provide those services and then bill the patient’s insurer (or the patient, if he/she is self-pay) for each item on the list (Cellucci et al., 2014). Traditionally physicians were reimbursed on a fee for service basis. In a fee for service arrangement, physicians were paid based on the numbers of services administered to the patients. Fee for service gave providers an incentive to provided more treatment because payment was dependent on the quantity of care rather than the quality of care. Some of the disadvantages of
...lthcare system is slowly shifting from volume to value based care for quality purposes. By allowing physicians to receive payments on value over volume, patients receive quality of care and overall healthcare costs are lowered. The patients’ healthcare experience will be measured in terms of quality instead of how many appointments a physician has. Also, Medicare and Medicaid reimbursements are prompting hospitals, physicians and other healthcare organizations to make the value shifts. In response to the evolving healthcare cost, ways to reduce health care cost will be examined. When we lead towards a patient centered system organized around what patients need, everyone has better outcomes. The patient is involved in their healthcare choices and more driven in the health care arena. A value based approach can help significantly in achieving patient-centered care.
The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.
Health care professionals must have provide the best quality of care while dealing with patients. Quality of healthcare is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Managed care is a system of care delivery involving complex organizational arrangements between institutions and clinicians, explicit financial incentives, defined access to service, controls on the use of services, 3 coordination and integration of services. (McConnell, C, 2010) Cost balance is health professionals trying to balance the cost while improving the quality of care. Although these health professionals are for improving the quality and cost balance in healthcare, it is taking a strain on them with the rising cost of healthcare,
This system provides annual statics on Medicare payment amounts for institutional providers. A nurse leader can use HCRIS to find other similar institutions with whom to compare reimbursement rates and use this information to make necessary adjustments (“Healthcare Cost Report”, 2016). Lastly, nurse leaders can also use cost-to-charge ratios, volume-based measures, per diem rates, and balanced scorecards to gain better insight of unit reimbursement (Liberty University,
Blum,J.,(2011). Improving quality, lowering cost: The role of health care delivery system: U. S Department of health and human services.
In 2015, the Centers for Medicaid and Medicare Services (CMS) released the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which implements the final rule which offers financial incentives for Medicare clinicians to deliver high-quality patient centered care.5 Essentially, taking the time to learn the patient’s goals and treatment preferences allows for the patient to walk away from the medical treatment or service feeling understood and cared for by the provider.4 Thus, resulting in a better, more comprehensive plan of care. Policy makers are hopeful that the new incentive-based payment system will accelerate improvement efforts.
What are the three or four most important drivers of Microsoft’s business model over the past 10 to 15 years that have accounted for the company’s spectacular results?