Disadvantages Of The HVBP Program

The PPACA involves many legislative changes that will affect hospital reimbursement. The PPACA requires every citizen in the United States to get health insurance and those that are noncompliant will face tax penalties. The PPACA requires all states to establish an American Health Benefit Exchange by 2014 to assure that health insurance is affordable to individuals and companies with 100 or less employees. The PPACA establishes a pay for performance program, which is a value-based purchasing (VBP) program in which Medicare pays hospitals based on their performance as compared to how they meet quality measures. Beginning in 2013 using the VBP program, hospitals will be paid based on their performance on many quality measures for acute myocardial infarction, pneumonia, heart failure, surgeries and hospital associated infections.

In 2012, the ACA found an excessive amount of readmissions of patients that were hospitalized within 30 days for the same medical conditions. This factor viewed under the ACA as a quality issue and CMS implemented value-based incentive payments based on performance in a set of quality measures. The plan is to implement a pay for performance (P4P) in formulas used by Medicare to reimbursement providers. “The objective is to link reimbursement to quality and efficiency as an incentive to improve the quality of health care, as well as reduce system-wide costs” (Shi and Singh, 2015). In addition to the P4P, nonprofit hospitals also focus on continual improvement, data and cost containment throughout the organization (Adamopoulos,

This model reimburses hospitals based on quality of care instead of the volume of patients. The quality of care is assessed by patient questionnaires and if hospitals are unsatisfactory penalties may be imposed (Edwoldt, 2012). The value-based system also affects Medicare and Medicaid. It was reported that Medicare readmissions within 30 days of discharge cost 17 billion dollars annually (Edwoldt, 2012). Due to the high costs of readmissions Medicare and Medicaid have implemented a Hospital Readmission Reduction program. A formula is utilized to evaluate readmission rates within 30 days of discharge for any medical reason related to their original admission such as heart failure and pneumonia. Upon review the hospital is potentially penalized. It is important that nurses strive to provide excellence in care despite their beliefs on the ACA. Nurses have the ability to provide a safe patient environment and reduce the risk of hospital associated infections by following hospital protocols such as hand washing.

The advantage of VBPS program is that it promotes and reimburses for all treatments that are planned to help to bring better health outcomes for Medicare patients. This program also plays a part in reducing the rate of unnecessary tests and referrals that are unrelated to treating of patients’ conditions. The program gives incentive rewards to healthcare facilities that are successful in reporting the high quality of cares and better patients’ health outcomes. It also serves as supports and guidelines for healthcare facilities to build needed infrastructures to improve their quality of services (Minemyer, 2016).

Value-based purchasing (VBP) outlined by Roussel et al. (2016) is a payment methodology that rewards quality of care through payment incentives and transparency. Some of the key elements comprise of:

According to L. Horton, LTACHs are funded by commercial insurance, Medicare, and charity (personal communication, March 7, 2014). For claims reimbursed by Medicare, patient satisfaction survey’s or Hospital Consumer Assessment of Healthcare Providers and Systems/HCAHPS help determine the hospital’s reimbursement scores. Value Based Purchasing (VBP) was established by the Affordable Care Act, which implements a pay-for-performance approach to the Medicare payment system (“Linking Quality to Payment,” n.d.). This program can help hospitals evaluate the performance of the services they provide to the public. Part of the VBP plan includes a questionnaire to patients that determines 30% of the weight of the hospital’s reimbursement scores. There are eight measures included in the HCAPS: nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment, and overall rating (Grellner, 2012, p.57).

Healthcare in the U.S is most expensive than any other developed country. The U.S spends far more on per capita as compared to any other developed. U.S scores low on many outcome measures, inefficiencies and wastes and quality measures as compared to other countries. The Patient Protection and Affordable Care Act is developed to strengthen these failures in the health care system. The U.S healthcare is transforming care from volume based reimbursements to value based payments. The healthcare law works around providing more patient centered care and better preventive care. One of the payment reforms with Obamacare is to penalize the hospitals with high readmission rates for the three conditions – Acute Myocardial Infarction, Heart Failures and Pneumonia.

In addition, it also measures the quality of care and patient satisfaction. In 2015, the US Secretary of HHS has announced a goal of 85 percentages of Medicare Fee for Service payments tied to quality or value. In addition, many new payment models are associated with HRRP; for instance, forthcoming Skilled Nursing Facility VBP program and Dialysis Adequacy measure , potentially specifies preventable readmission measures. As the system is moving from quantity to quality, it is beneficial to implement quality of standards to optimize future benefits for the community and Central Health as well. Currently, Central Health has higher readmission rate than national average with an overall rating of 2 out of 5. Penalties incurred due to below standard of care could strain hospital resources to utilize for the betterment of our facility. Furthermore, the incentive structure has concerned Central Health to reevaluate the mode of practice and care provided engaging healthcare providers and patients. Central Health is committed to reducing readmission rates by identifying and sharing best practices for long term benefits. Given the flexibility of penalty under the 21st Cure Act, the initial program will focus on readmission prevention within 30 days of hospital

One major trend in the healthcare environment is the shift from volume based reimbursement towards value based reimbursement. Many provider practices remain on a volume based or fee for service reimbursement plan. This system tends to reward high quantity of services with less regard for the quality or performance of the service. However, with a renewed focus on value, reimbursement plans

HCAHPS survey is a patient satisfaction survey required by CMS (The Centers for Medicare and Medicaid Service for all hospitals in the United States. HCAHPS identified the attributes of affective support, health information, and quick response as the elements of nursing care in the interaction and relationship between patient and nurse that determine patient satisfaction. High score of these elements would increase the hospital competition.

The way we practice healthcare and healthcare organizations are changing due to the pressure to reduce costs, improve the quality of care and to meet rigorous guidelines. This change has forced health care professionals to examine we evaluate our overall performance. Paradise Hospital, Inc. has not had any service improvements since 1995. A physician named Avedis Donabedian (2005) proposed a model for assessing health care quality based on structures, processes, and outcomes. He defined structure as the environment in which health care is provided. This is known as the organizational characteristics such as the measurement of staffing ratios and the number of hospital beds. The process is described as the method by which health care is provided. This represents the communication and interaction seen between doctor and patient. The necessity for the tests and procedures performed. The outcome is defined as the consequence of the health care provided, was there a desirable or undesirable effect.

The passing of the Deficit Reduction Act of 2005 made an additional incentive possible for acute care hospitals who take part in the HCAHPS survey. Since July 2007, hospitals who are subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions need to collect and submit HCAHPS data if they want to collect their full IPPS annual payment. Inpatient Prospective Payment System hospitals that ignore to report the required quality measures, which includes the HCAHPS survey, could get an annual payment update that has a reduction of 2%. Hospitals like Critical Access Hospitals, can also participate in HCAHPS if they want to.

Value Based Purchasing refers to a strategy used by employers and the Federal government to provide excellence in health care. It entails improving healthcare quality in order to improve population health. The program is used by Medicare and what is included is measuring and reporting comparative performance, paying providers based on performance, and designing health benefit strategies and incentives to encourage individuals to provide higher quality care. Leaders should be concerned because although people are working hard to ensure everyone has access to good health care, the problem is keeping it affordable. Also, value-based purchasing is in its early stages, therefore there is lack of data. It is important for leaders to have evidence-based care in order to provide the best preventative care possible.

The major reasons why adding value to patient services at Paradise Hospital, Inc. is important, is because of the various challenges, changes and competition that the health care system faces. These challenges mainly stem from the Affordable Care Act. Under the ACA hospital that perform well or could receive some sort of financial incentive. These incentives are based on both clinical outcomes and patient satisfaction data. The ACA can also penalize hospitals that perform poorly.

To encourage the shift toward service quality, the Centers for Medicare and Medicaid Services has launched four initial value based programs: the Hospital Value Based Purchasing VM) or Physician