Reimbursement In Health Care

It is commonly believed that the method of physician remunerations affects their professional behavior. As a result, payment systems are therefore manipulated in attempts to achieve policy objectives with the primary aim to improve quality of care, contain cost and maintain recruitment of human resources in underserved areas. (2,1)

One major factor of the Affordability Care Act, which was implemented in January of 2014, targets the manner in which payment is made for services rendered (Chow 2013). For instance, a provider was typically paid for performing a surgery on a patient without considering the quality of care provided. If additional procedures were required to address any complications stemming from the first procedure, the provider would be entitled to additional revenue. This was the fee for service feature that the healthcare delivery system operated under for so many years. The new provision in the ACA will only allow a one lump sum upfront to cover the surgery and any complications that occur after surgery (Chow, 2013).

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 article discusses how the transition from fee-for-service models to value based care will affect the industry both private and CMS. It outlines that there is still uncertainty about how there are still huge concerns in relation to these new reimbursement and care delivery models. This article goes into detail about how the transition to value based care from fee-for –service will affect physicians. It examines early physician training and how physicians must now transition from independent work toward care coordination. It also looks at the need for more primary care physicians and the possible retraining of many physicians to provide more of a disease states focused care. Finally, the article points out that specialist and primary care

Instead of getting compensated for demonstrating valued care to patients. This leads to discouragement from physicians from improving in their practice efficiently. Overall, legal responsibility is viewed as a reinforcer of fee-for-service physician reimbursement. Physician fees must be high enough to pay physicians’ unpredictable and unequally distributed liability insurance premium. However, public and private health insurers could finance liability risks less expensively through other forms of various and self-funded methods. Due to the high cost of malpractice insurance, Medicare redesigned physician payment to pay more for services with higher input costs for certain procedural specialties (Sage,

The inability for patients to maintain timely payments can be an even further hinderance on the quality of life. Lack of payment and delinquency can lower credit ratings and lead to a garnishment of funds. It’s because of these financial troubles that the American people and politicians scrutinized the structure of the American healthcare system. While the America has been a major power and leader in advancement in many aspects for the Western world, the country has not done so in healthcare and could considered behind the times.

Managed care was established in order to manage health care cost, utilization, and quality (Kongstvedt, 2015). In managed care, health insurance is provided through HMO, PPO, and other types of managed care. It has the potential to reduced health care spending and improved the quality of care. However, despite of its success in improving the quality of care through preventive health care services, chronic disease management program, and so forth, many physicians are reluctant to be part of the managed care environment. Some of the reasons are the impact of managed care to physician’s income and autonomy. Under managed care, insurers have decreased the fees paid to physicians. There are different ways how managed care organizations control costs. One of this is through selective contracting with health care providers and hospitals to lower costs. In selective contracting, health care providers agreed to accept lower prices in exchanged for guaranteed volume of patients under managed care plan (Culyer, 2014). This paper will discuss more issues and trends in Managed Care Organizations such as the rise of Medicaid Managed Care spending, the new Medicaid Managed care Rule, and the collaboration of Managed Care Organizations and Accountable Care Organizations to reduce health care spending and improve efficiency of care.

Healthcare in the United States has evolved over the years. The overall goal is to optimize how physicians, hospitals, and other care providers are remunerated focusing on high quality of care provided at lower costs. Currently there two various payment modes for healthcare providers, fee for service and capitated systems. Fee for Service (FFS) modes allow for payment to be made as the service is provided. Under the capitated system, a fixed payment is made in advance and when the patient seeks care, the healthcare provider provides all the services. These models have both advantages and disadvantages. FFS model will be the focus of this paper.

Past payment programs did not adequately pay doctors for time spent with a patient to take a medical history, conduct an examination, or follow up before or after the next appointment. Also, core primary care services, like care coordination or management, and practice infrastruc­ture, including health information technology and patient registries, are sometimes not reimbursed at all. The payment system also failed to provide physicians with incentives to improve care or incentives that encourage clinicians to work together as a team for a practice associated with better health out­comes for patients. In total, the Affordable Care Act invests an estimated $3.5 billion in the primary care provider bonus program from 2011 to 2016. This provides incentive by boosting paychecks and therefor provides better quality healthcare (Abrams, Nuzum, Mika & Lawlor, 2011).

With the cost of healthcare rising at an alarming rate, there are many challenges that can also arise that can range from physician turnover rates to malpractice costs. As a result of this practices are seeking ways to maximize their resources so that they can remain profitable.

All the physicians, hospitals and other medical professionals are paid under free for service by the insurance companies and Medicare. The fee for service includes the reimbursement for each test, procedure and consultation. Combined with a medical system that is not coordinated, this supports overtreatment, including repetitive tests.

United States spend a lot of money on healthcare: for instance, the cost of the office visit, hospital stay, even prescription drugs every year. Lawn states, “….. Those in our audience who work in healthcare know the cost of providing care to the indigent and uncollectible is top of mind for every healthcare administrator” Lawn, J. (2009). Physician received a substantial amount for an office visit through Medicare and Medicaid. Therefore, one of the best ways to cut prices on healthcare is by embracing low-cost primary cares.

This essay examines developing trends in healthcare delivery in the U.S. Until recently, organizations were paid on the basis of transactions, that is, by visits or by procedures. In some markets, however, new payment models are emerging that, instead, base payments on producing outcomes. This transition will no doubt be complex and challenging.

Four models of compensation are described: fee-for-service, capitation, hybrid and fee-for-value. Under the fee-for-service model, physicians are paid for productivity, which encourages physicians to see more patients and perform more procedures

Under payment, an ideal healthcare system will have the challenge of delivering higher quality for lower costs. The system’s payment reform will involve a transition from fee-for-service to global from systems that are value-based important for the achievement of the overall healthcare goals. An ideal healthcare payment system will give a great deal of support to value-driven system of healthcare delivery (Kent, 2013). The fee-for-service payment system will be of great importance to the healthcare system as it will help control the costs of health care.