Summary: The Change To Value-Based Purchasing

Value-Based Purchasing which is part of the Centers for Medicare & Medicaid Services; the program allows healthcare providers to get incentive payments for quality of care they provide to Medicare beneficiaries; for doctors it could mean doing less mean decrease in revenue and lower salary for the doctors. Therefore, value-based care has its pros and cons based who you talk to.

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

Reading and understanding the information that was given in our text book about transforming the healthcare system for improved quality, rely on enhancing the value on healthcare. Their ideas is to improve healthcare in both financial and clinical aspect that could adjust the quality of healthcare. Meanwhile, if hospitals, doctors, and medical team. improve the value base care, it can or may provide better care, better health and lower cost. According to the Aetna the solution is to provide and deliver better health and more

The American human services framework is experiencing a rapid shift that incorporated a movement from fee-for-service payment into value-based payment that rely profoundly upon the provider integration plus care coordination (Santo, 2014). Value- based installment attempt to realign the economic incentive regarding care delivery by integrating doctors pay to value and quality. The FCA and AKS, are regulatory structures that were basically created to handle fraud and abuse claims emerging from the fee- for-service reimbursement framework.

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

Responsible Reform for the Middle Class stated, The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs. One part of the transformation is the creation of value proposition. Value proposition is a promise of value to be delivered. Value is defined as “a fair return or equivalent in goods, services, or money for something exchanged; the monetary worth of something; market price; or the

For instance, patients will receive urgent hospital care and then will not be able to pay back their bills. Another policy affecting provider reimbursements is the change from volume-based care to value-based care. For instance, the Centers of Medicare and Medicaid (CMS) have mandatory reporting guidelines that all healthcare providers have to participate in. These reports were based off volume of care (fee-for service) for the past 9 years, but due to the high costs in healthcare, the CMS is changing over to a valued based care (pay-for

Moreover, we see that some providers are focusing on what providers do and how they get reimbursed rather than what the patient needs, which is a focus that does not prioritize quality of care and therefore does not align with the Triple Aim framework. The problem presented regarding this matter is that the health care system lacks a patient-focused care of medical conditions that puts patients and their health needs first. For example, when we think of provider reimbursement, it is not in the patient’s best interest for the system to only have a simple fee-for-service structure. A structure like this one will only lead to an increase of health care expenses. Also, it fails to incentivize high-value service, which also does not align with the Triple Aim framework health care providers should go by. It is very crucial for the health care system in the United Stated to find a better balance between medical groups reimbursement and patients needs in order to reduce the risk of overutilization.

Why is the healthcare system shifting from volume to value based? Why change the requirements now? Well, the traditional fee for service system allowed providers to receive higher pay based on higher patient admissions (Miller 2009). It is understood that just because more patients come to you for care does not necessarily mean that they are getting the best care. In fact, providers with increased patients may not be able to give each patient the highest level of care due to heavier workloads and increased patient traffic. The fee-for-service system allows providers to receive payments based on the volume and complexity of services they provide (Miller 2009). Higher intensity of care does not equal higher quality care. Hospitals, physicians and other health care providers gain increased profits by delivering more services to more people, which drive health care costs (Miller 2009). Moreover, current payment systems often penalize providers financially for keeping people healthy, like ordering a patient to stay an extra

Mr. Lease indicates that quality in health care is another external influence in the delivery of health care services. The integration of medical services into larger payment groups, when using value-based purchasing and improving coordination of care would increase productivity in health care; making medical services much more affordable and increasing the quality of care (W. Lease, personal communication, July 23, 2010.

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:

Transparency of measures, a type of value-based purchasing, was outlined as a way to require hospitals to make information regarding various areas of quality available to the public. Kavanaugh et. al. (2012) described several of these areas which included incidence of healthcare-associated infections (HAIs), hospital-acquired conditions (HACs), process measures, and patient satisfaction surveys. It would serve as a tool for physicians to know the best places to send their patients when a referral is necessary. This would hold facilities accountable and at the same time help to improve areas of concern.

The hospital reports data to several entities, there is Hospital Compare, Value-based Purchasing, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and National Database of Nursing Quality Indicators (NDNQI), in addition to Press Ganey patient satisfaction surveys.

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.

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.