How A Buyer Has Numerous Benefit Options For The Procedure At Any Facility

A mixed payment system combined with physician monitoring, will provide physicians with incentives to consider costs and benefits of different treatment options, which will lead to an efficient level and quality of care. (1,2)

Financial Incentives for Primary care: Comparison costs of practices using PCMH model to those that do not and achieved savings (by reducing hospital admissions and unnecessary tests, they can get half $ back. The catch is that they only get the $ if they’ve met a whole checklist of quality measures for preventive care, chronic disease management and so on. Primary Care is rewarded for efficiency without sacrificing quality. Half of savings goes to Geisinger’s own health plan that funds extra services and creates medical homes. The health plan earned 2.5 times its R.O.I. back in the first year.

The goal of the initiative is to increase efficiency of care, improve quality of care, and lower costs. This initiative consists of four different bundled payment models. The first three bundled payment models are retrospective payment arrangements based on patients’ historical data. However, the fourth model is proposed for the future. Centers for Medicare & Medicaid Services (CMS) make a single bundled payment to the hospital for all services during inpatient stays for hospitals, physicians, and other medical professional specialists.

Any proposed policy to improve healthcare must address the current payment method, and the rising cost of healthcare. The common reimbursement method for healthcare services is the fee-for-service payment model. It requires providers to figure-out all incurred costs to render services for patients. Additionally, providers need to determine what is the insurer proposing to pay, which thought to reward quantity over quality. An alternative to this model is using a bundle

As stated above, 11.4% of the population is still uninsured or under-insured. Of these patients, 40% have outstanding medical bills that will most likely go unpaid to the providers (3). This equated to $74.9 billion in 2013 of total uncompensated care across hospital systems and community providers (4). Not surprisingly, hospitals took the brunt of this cost at 60%, equaling $45 billion in uncompensated care. This raises the question of whether providers or other organizations can supplement the already subsidized monthly premiums. In theory, this model would be a win-win for the patient and provider, such that the patient stays covered and the provider is reimbursed for their

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

In comparison to the fee-for-service reimbursement model, bundled payments support, and pay care coordination, while reducing cost among a patient’s provider. A bundled payment compensates all of a patient’s health care suppliers with a sole, fixed, all-inclusive payment that shields suggested clinical services associated to the patient’s treatment, episode, or illness over a well-defined period of time (Association, 2013). These disbursements can be modified and constructed based on the patient’s health status.

This article provides background on previous financial models used such as fee-for-service and the potential costs between practitioners. The article states that in the fee-for-service model of payment many physician operate disjointed care and often rely on patient volume rather than need. It attempts to create a strategy to change physician behavior and incentivize them to work as a team focused on a set of guidelines for a specific episode of care. The article is largely important as to give background information on bundled payments that are already currently happening with the pilot programs brought forth for hospital related health care services. One program is the Medicare Acute Care Episode (ACE) Demonstration for Orthopedic and Cardiovascular

To further explain, Hamel et al. (2015) referred to the Medicare options – Medicare Part A, B, D, Medigap – with the different copay, premiums, and policy which contribute to the fragmented care in the program. Consequently, Hamel et al. (2015) stressed that the complexities and variation in health care delivery might result in poor outcomes and health access limitation to older adults. Hence, Hamel et al. (2015) included the proposals to integrate all the Medical options into a single program with a specific premium, deductible, and policy. Moreover, Hamel et al. (2015) offered to lower the out of pocket cost for beneficiaries to eliminate the Medigap. In this way, Hamel et al. (2015) reasoned that the process of coordinating care, measuring quality, and payment reimbursement will be more

2) Preferred Provider Organizations (PPOs), PPOs allow members to obtain care in network and out of network, but the member have to pay higher premium.

The Belvoir Primary clinic will obtain payment from a variety of payers. Since 45% of the clinic’s enrolled patients have commercial insurance this will be the clinic primary source of revenue. The clinic’s second largest source of revenue will come from Medicare with 35% of the clinics population enrolled in the program. Finally, additional income will be generated from the clinic’s Medicaid beneficiaries and private payers. To maximize profitability, the clinic must capitalize on its PCMH status by identifying new federal, state, and commercial opportunities for revenue. The PCMH model expands current revenue streams by qualifying practices for transition support fees, care coordination/care management fees, shared savings, and pay-for-performance incentives (Gray & Arnovich, 2016).

It seems as though the gaps between patient-care and doctor relationships are being pulled apart and further disintegrated by eliminating “patient-care” and substituting it with “reimbursement”. Most physicians working in private practice today are burdened by diminished reimbursement rates and a growing list of administrative tasks required by insurance companies. In response, many primary care physicians are exploring alternative practice options other than the traditional fee for service. A fee for service is a delivery system where health care providers are paid for each service like an office visit, test, or procedure. A new health care trend which seems to be the growing

In the new exchanges, the price and quality of a health plan will be more important than ever for consumers who are trying to get the best value for their money. Insurers who can find ways to reduce claim costs can offer more attractive premiums. One problem that contributes significantly to health care expenses is the overutilization of services. The chief danger of overutilization is that it results in higher medical costs without any accompanying improvements in quality. To be competitive, health plans must ensure that their expenses actually improve quality. Sound benefit design and a focus on providing high quality care can help diminish this problem. Even for plans where overutilization is not a problem, higher quality care can reduce complications, errors, readmissions, and other unnecessary costs. Better

Instead, customers are encouraged to use providers within the network through offering them reduced rates for service. When a customer uses a provider that participates with the program, they pay less in the form of out of pocket copayments. These discounts are available because the health care providers within the network have contracts with the PPO stating the agreed upon discounted rates the providers will be paid when they provide services for members of that particular PPO (Gapenski, 2013).

The positive outcomes that have resulted due to value base programs have caused the model to gain traction and ignite one of the largest changes in history in the health care marketplace. By linking reimbursements to service quality, insurers such as the Centers for Medicare and Medicaid Services have facilitated a massive leap forward in the performance of United States health care providers. This achievement is a considerable accomplishment in the face of an institution that has received reimbursement from insurers via a fee-for-service model during the last 75 years. Soon, valued based payment models will represent the norm as more insurers support initiatives such as shared savings program, integrated clinical care, and accountable care payment models.