Healthcare Model: Accountable Care Organizations
The current focus on new healthcare models is a reaction to long-standing concerns around quality, cost, and efficiency. Accountable Care Organizations model focus on integrated healthcare to promote accountability and improve outcomes for the health of a defined population. The goal of integrated healthcare is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (CMS, 2014). The following paper will analyze an ACO’s ability to change healthcare in the United States.
Analysis of Accountable Care Organizations
The Affordable Care Act seeks to reduce health care costs by encouraging doctors, hospitals and other health care providers to form networks which coordinate patient care and become eligible for bonuses when they deliver that care more efficiently. Accountable Care Organizations (ACOs) make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures. About four million Medicare beneficiaries are now in an ACO, and, combined with the private sector, more than 428 provider groups have already signed up (CMS, 2014). An estimated 14 percent of the U.S. population is now being served by an ACO (CMS, 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 ...
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...e adopting some form of contract that encourages population management and cost minimization (Muhlestein, 2013). ACO continues to only represent a small minority of care delivered in the United States. ACOs are still a work in process and their eventual success or failure is still to be determined, but the Accountable Care Organization’s influence on the American health care system continues. Many ACOs will complete a risk-based ACO contract, and their early results will influence how payers, providers and policymakers experiment with future iterations of Accountable Care. If the results are good, then the ACO model may become the dominant form of health care in the United States over the next decade (Muhlestein, 2013). If the results are negative, Accountable Care Organizations may never gain a permanent place in the United States healthcare delivery system.
Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations. A good example of these challenges was prompted by the Center for Medicare and Medicaid with the release of data and chargemasters from several healthcare facilities. The release of the chargemasters sends a wave shock across the healthcare industry as it depicts a huge price discrepancies among health care providers, and due to this exposure many healthcare organizations attempt to rectify their charges. The main purpose the CMS release the chargemasters was to encourage transparency in hospital’s billing
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
It is generally accepted that the method of payment to physicians affect their professional attitude and behaviour. Consequently, health policy makers manipulate payment system in an attempt to achieve optimal health care for their citizens such as improve accessibility, quality of care, patient’s satisfaction and cost containment. In Ontario, there are a wide range of mechanisms that are used to pay physicians for their services that are funded by both federal and provincial government. According to Canada Health Act annual report (2013), the majority of primary healthcare physicians are funded using the fee for service payment arrangement but of that majority, only less than 30% are compensated exclusively according the fee for service plan. The remaining physicians are funded using one of the following mixed compensation models:
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).
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.
Healthcare in the U.S. has recently been affected by implementation of the Affordable Care Act (ACA) of 2010. The intent is to create a healthca...
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.
The United States (U.S.) has a health care system that is much different than any other health care system in the world (Nies & McEwen, 2015). It is frequently recognized as one with most recent technological inventions, but at the same time is often criticized for being overly expensive (Nies & McEwen, 2015). In 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) (U. S. Department of Health & Human Services, n.d.) This plan was implemented in an attempt to make preventative care more affordable and accessible for all uninsured Americans (U.S. Department of Health & Human Services, n.d.). Under the law, the new Patient’s Bill of Rights gives consumers the power to be in charge of their health care choices. (U.S. Department of Health & Human Services, n.d.).
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).
Yong, Pierre L., Robert Samuel Saunders, and LeighAnne Olsen. The Healthcare Imperative: Lowering Costs and Improving Outcomes : Workshop Series Summary. Washington, D.C.: National Academies, 2010. Print.
The Affordable Care Act (ACA) is a federal that was signed into law by President Barack Obama on March 23, 2010 to systematically improve, reform, and structure the healthcare system. The ACA’s ultimate goal is to promote the health outcomes of an individual by reducing costs. Previously known as the Patient Protection and Affordable Care Act, the ACA was established in order to increase the superiority, accessibility, and affordability of health insurance. President Obama has indicated the ACA is fully paid for and by staying under the original $900 billion dollar budget; it will be able to provide around 94% of Americans with coverage. In addition, the ACA has implemented that implemented that insurance companies can no longer deny c...
Managed care reimbursement models have contributed to risk avoidance by negotiating discounts, discouraging use, and denying payments for charges that appear to be false. Health care reform has increased awareness to the quality of care providers give, thus shifting the responsibility onto the provider to provide quality care or else be forced to receive reduced reimbursements (Buff & Terrell,
The Affordable Care Act, more commonly known as Obamacare, is a new health policy created by the American federal government. Its purpose is to make healthcare more affordable and friendly for the people. Unfortunately in some way that does not prove to be the case. It is becoming apparent that Obama may have made some misleading statements to help get the ACA put into action. The ACA is sprinkled with many flaws that call for a reform such as people’s current plans being terminated, high costs, and at minimum some people’s hours being cut by their employers.
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.
Reforming the health care delivery system to progress the quality and value of care is indispensable to addressing the ever-increasing costs, poor quality, and increasing numbers of Americans without health insurance coverage. What is more, reforms should improve access to the right care at the right time in the right setting. They should keep people healthy and prevent common, preventable impediments of illnesses to the greatest extent possible. Thoughtfully assembled reforms would support greater access to health-improving care, in contrast to the current system, which encourages more tests, procedures, and treatments that are either