The Dominant Payment System For Healthcare Providers

The policy issue that I have selected to discuss herein is the pay-for-performance payment model. I feel that this impacts a large number of our population and changes in this regard should be made. This type of payment model aims to use reimbursement to incentivize providers to deliver high quality services. Pay-for-performance model steps away from the traditional manner of reimbursement of fee-for-service, in which providers receive payment on the basis of frequency or volume of the services they provide regardless of outcomes. In contrast,

First implemented in 1985 by Aetna (previously U.S. Healthcare), P4P programs were used to reward top performers and improve outcomes (Bruno, 2012). The incentives were meant to improve the quality of patient care by basing incentives on patient outcomes. Conversely, fee-for-service reimbursements are based on the treatments and set limits on the amount reimbursed for services. Because of these limits, incentives for use of pharmaceuticals and non-invasive procedures can impact how physicians practice.

Over the years there has been a pervasive issue in health care because of the Pay-for-Performance (P4P) Programs. Pay-for-performance is defined as a plan of reimbursement that connects compensation to quality and effectiveness as a motivation to develop the health care quality as well as making a decrease in costs. Hospitals and providers are being encouraged by government agencies and individual health plans to encourage excellence standards. Pay-for-performance methods could cause consequences such as reduction admission to care, add differences care, and weaknesses to improve. There could be an impact of the health care quality and efficiency by providers getting financial rewards if they show better care for patients as well as

With the growing telemedicine trend there is an increased focus on how to reimburse for these types of patient services, which differ from state to state due to each state 's varying laws, regulations and policies. 2 The current healthcare payment structure in the United States is fee-for-service which makes it imperative for healthcare professionals to use correct codes for proper reimbursements with Medicaid, Medicare and private insurance providers.

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.

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,

The change to value based purchasing has bought many challenges to the healthcare industry. With the change to value-based purchasing for payments, it has changed how healthcare organization receive payment and delivery care. The advantage of have value based purchasing is that it improves the quality of care while reducing cost in an effort of aligning patient’s with the right provider and treatment plan (Minemyer, Jun 29, 2016). However, there are many disadvantages, such as it increases the patient volume as counteracting the reduction of procedure volume (Brown, B. & Crapo, 2016). Also it makes providers more responsible for care that is beyond the expected treatment of care needed (Minemyer, Jun 29, 2016). With quality measures tied

The Arkansas Health Care Payment Improvement Initiative (“AHCPII”) is one part of the health care innovations the state has implemented with the aim of “increas[ing] health care quality and reducing the costs of care.” The AHCPII’s intent is to shift Arkansas’s payment system from “one that primarily rewards service volume to one that rewards desired outcomes, particularly with respect to quality and affordability.” Applying to Medicaid, Medicare, and private payers, payment innovation will move away from fee-for-service health care (where quantity all too often trumps quality) to pay for quality. In doing so, the hope is that Arkansas will gain a “new, sustainable model of financing” with the help of a multi-payer leadership and support.

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

Since the advent of health insurance in the 1950s, there have been many models of care that are come to the scene in an attempt to both control cost of care and improve quality of care. Insurance models came into being because the fee for service model used until then was proving to increase cost of healthcare without any measure of quality of services and care provided. Health insurance models have evolved from the basic hospital offered insurance to employer sponsored coverage plans. The US health system is broken both financially and quality wise with more than 20% of gross domestic product being spent on healthcare (Blackstone, 2016).

They will now receive payments from the quality of care they provide to their patients. Those with higher based value will receive higher payments than their counterparts (Berenson 2010). I think this is very important because the healthcare system has been volume driven for so long that quality healthcare has been an issue for quite some time. In addition to value, this would definitely improve quality and efficiency needed for better patient outcomes.

When Medicare was first established, Medicare adopted the payment methods of Blue Cross Blue Shield which meant that the program was paid hospitals on the basis of their own costs and physicians were being reimbursed by the fees that they charged which caused hospitals and physicians to provide care without boundaries (Anderson et al., 2015). This method caused Medicare to dissipate the budget that was established for beneficiaries to utilize. Now, with the ACA being implemented, Medicare had done an overhaul of payment reimbursement. Medicare is now moving toward a volume to value payment initiative that links payment to patient outcomes, experience of care, while giving providers an incentive to limit spending

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.

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.