Cms Policies Push Alternative Medicare Payment Models

The care delivery enterprise must be re-tooled so that it functions in a fee-for-value reimbursement environment as is has in a fee-for-service reimbursement environment. The Centers for Medicare and Medicaid Services (CMS) is leading the

With the continued transformation of the healthcare system, an increased emphasis on consumerism and quality-based reimbursement will be observed. This could lead to challenges for all managed care stakeholders. One example of an industry change that might occur is that patients’ out-of-pocket costs could increase. The cost of healthcare continues to rise faster than inflation, generating increased incentives for insurance companies to offer plans with high deductibles and small networks. In the article “The Top Changes MCOs Should Expect in 2016” Joel Brill (2015) states that:

Based on the political and economic environments of states and the federal government the methods of health care reimbursement have been required to evolve. With the introduction of the Patient Protection and Affordable Care Act (PPACA) new laws have been set into place that has caused a stringent review of spending on health care. All care provided is being examined for effectiveness, quality, and the actual need of the service. Unnecessary health care functions are being screened and eliminated. The government and other insurance providers have begun to place cost containment measures in place only paying for those procedures that are deemed medically necessary for the illness that the patient is currently afflicted with. This has a direct impact on the monies that the government and insurance providers will reimburse for services. The following paper will look at the major types of reimbursement activates currently in place. The writer of this paper will also speculate on the future of health care reimbursement and how it will affect his current organization.

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

Medicare has changed the way it pays hospitals for services delivered to clients with Medicare. Instead of only paying for the amount of services the hospital offers, Medicare also pays hospitals for providing top quality health care services. The Centers for Medicare and Medicaid Services (CMS), a federal agency that runs the Medicare program, is altering the way Medicare compensates for hospital care by giving rewards to those hospitals that delivers higher quality and higher value service to clients (Medicare.gov, n.d.). At the beginning of October 1, 2012, the Affordable Care Act (ACA) permits Medicare by reducing payments to acute care hospitals with surplus readmissions that are paid under CMS 's inpatient potential payment system (Medicare.gov, n.d.). Medicare has information regarding how the hospital 's quality care affects the disbursements it receives from Medicare. The Hospital Value-Based Purchasing (VBP) Program, created by the ACA,

Quality and financial viability being closely tied is an extremely salient point. Furthermore, the Affordable Care Act has influenced the requirement for high-quality, cost-effective care provision by implementing Value Based Purchasing (Aroh, Colella, Douglas, & Eddings, 2015). In addition, there are presently Centers for Medicare and Medicaid (CMS) quality indicators that effect reimbursement for hospitals (Xu, Burgess Jr, Cabral, Soria-Saucedo, & Kazis, 2015). For example, if a facility does not meet the indicator threshold for catheter associated urinary tract infections, central line infections and/or pressure ulcers their reimbursement is affected. Given that the quality of care provided by a hospital is

The proposal for bundled payments (CCJR) will force hospitals and other health care facilities to change and adapt. The proposal would include medical severity diagnostic-related groups which would help calculate targeted prices for each severity group and each hospital separately. Several controversial components would be included in the proposal. Mandatory participation is one of the key requirements to the proposal. Another controversial component to the CCJR program is that hospitals would be exclusively responsible for the bundled payment program and any financial excess. However, these controversial components are key features to ensuring the proposal’s success which will help patients and providers in the future. Another reason the CCJR proposal will force hospitals to adapt is that the hospitals would be financially accountable for the quality of care. If the hospitals fail to meet three specifically designed protocols for quality, the hospital(s) would be ineligible for savings

The United States can boast of being the country with the best technology in the health industry, the best expertise and also the best infrastructures. However, these services are not readily available to all due to the relative cost and mostly lack of health insurance. In some situations, the health insurance may be available but coverage is limited and with tentacles of restrictive clauses. For years these have been the measure of our healthcare system and long overdue overhaul that became eminent via the Obama Care in 2010 also known as the affordable care act. The rapidly rising health care costs over the decades have prompted the application of business practices to medicine with goals of improving the efficiency, restraining

With new reforms being put in place under the Affordable Care Act such as the pay-for-performance (P4P) also known as “value-based purchasing,” which is intended to help provide maintain and efficient programs to improve health care cost. Healthcare providers, hospitals, medical groups, and physicians are offered incentives for meeting certain performance goals; it also fines for increased costs and medical errors such as incorrect medication or dosages. In two different studies quality of care was found to have improved at P4P hospitals compared to non-P4P hospitals Lindenauer et al. (2007) and Grossbart (2006). However, a study by Werner et al.(2011) found no continuing benefits in quality of care. One measure being advocated for is the Hospital Readmissions Reduction Program (HRRP) to prevent hospital readmissions as a way to improve the quality of care and at the same time cut cost. If patients are readmitted within 30 days after discharges due to conditions like acute myocardial infarction (AMI), heart failure, and pneumonia, fines can be levied such as 1 percent of Medicare payments. Others include the Hospital Value-Based Purchasing (VBP) is based on how well the hospital performs compared to other hospitals or the improvement of their own performance compared to a baseline time. The goal is to encourage better outcomes for patients and improve experience during hospital stays. And the Hospital-Acquired Condition (HAC) Reduction Program motivates hospitals to increase the safety of it patients by cut the number of hospital-acquired conditions and patient safety (Medicare.gov, n.d.) (Kruse, Polsky, Stuart, & Werner, 2012)(Gu et al.,

Centers for Medicare and Medicaid Services (CMS) had adopted the “no-pay” rule in the year 2008 with the objective to encourage hospitals to terminate medical complications (American Medical News, 2012; Stone, et.al., 2010). Under this rule, CMS denies the payment to the healthcare facilities for any extra cost which is involved in treating Medicare patient. This policy has the significant impact on the health care system as the hospital executives need to redefine their priorities and enhance their efforts towards improving patient care.

There are many healthcare payment methods used when processing claims billed by a hospital or provider for services rendered to the patient. Those payment methods include, fee for service, bundled payment, value base pay, capitation and global budget. As stated previously in this discussion, HF is the most prevalent reason for an increase of readmissions rates ranging at 40% (Hobbs, 2016). Subsequently this problem affects how reimbursement is made payable to the hospital or providers. Currently, HF is greater among patients who are MCR beneficiaries and readmission rates for this population range from 22% to 25% (Banoff, 2016). With the substantial increase of readmissions, attracted attention from the Centers for Medicare and Medicaid

cording to Batnitzky, Hayes and Vinall (2014), fee – for – service (FFS) “is the oldest form of reimbursement method, and in this system, healthcare professionals are paid for every service and test they provide” (p. 3.2). While the opposition would argue this form of reimbursement is the catalyst for medical professionals to “pad their wallets” for profits, FFS is would be equivalent to a professional in another field of work to be compensated for the services they render. FFS has remained within the medical pay system because, medical professionals should not be limited in using all resources at their disposal to ensure the correct diagnosis is achieved as, you cannot take a one size fits all approach when providing care to patients. Treatment

The pace of change throughout the healthcare industry has never been greater, due in large part to a growing emphasis on improving patient satisfaction, managing costs, and improving quality of care. This is referred to as the “triple aim” of healthcare reform. In fact, healthcare reform has directly and indirectly driven the development of accountable care models and many other quality initiatives such as episode-based payment and shared risk programs. As a result, hospital revenue is now increasingly tied to measures related to patient satisfaction, health outcomes, and compliance with evidence-based standards of care. For example, one third of Medicare payments to hospitals are now based on quality or value.¹ These include a growing portion

There have been overwhelming efforts to better and extend lives in the US. However, evidence indicates that the outcomes can be improved at lower cost. Many models aimed at achieving this are being piloted throughout the country. In addition to testing, some pockets of adoption exist. The dominant payment system for healthcare providers remains and is based on the fee for service which provides little or no support for numerous innovative and personalized services implemented by healthcare providers. Several potential valuable approaches are poorly reimbursed or are not reimbursed at all. Traditional fee for service payments promotes higher volume and the intensity of duty. To support innovative and cheaper care, providers and health plans have started to develop, implement and evaluate different financial reforms that utilize reimbursement. They award value instead of volume to offer providers more support for providing care which enhances higher quality at reduced cost. Parties to the payment agreement set the value based on the assessment of quality, efficiency, and safety. Penalties and rewards are stated, and the client is paid upon reaching or surpassing set targets. This paper looks into value-based reimbursement, based on patients ' surveys and quality scores by maximizing the value for patients (Mcclellan, 2015).

Health care costs currently exceed around twenty percent and continue to rise where other countries spend less of their funding on health care but have the same increasing trend. An aging population and the development of new treatments are cause for some of the increase. Unrealistic incentives also contribute: third-party insurance companies and governments who reimburse for procedures performed rather than outcomes achieved, and patients bear little responsibility for the cost of the health care services they demand. However, few acknowledge a more fundamental source of increasing costs: the system by which those costs are measured. Honestly, there is almost a complete lack of understanding of how much it costs to deliver patient care,