The Importance Of Value-Based Reimbursement In Healthcare

Healthcare is in a constant state of change with movements that impact rates, access and quality of care. Hospitals have become more competitive due to the rising cost of care delivery and the reduction in reimbursement from payers. This causes difficulty in delivering quality care to all patients, which is being measured by mandated patient perception surveys, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS scores are part of value

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

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 patient centered medical homes (“PCMH”) approach “focuses on keeping people well, managing chronic conditions like diabetes or asthma, and proactively meeting the needs of patients.” According to the Arkansas Department of Health, chronic diseases like cancer heart disease or diabetes affect approximately over fifty percent of adult Arkansans. Yet chronic diseases are often preventable. The high rate of chronic diseases can partly be attributed health insurance coverage—“when people don’t have health insurance they tend to avoid seeing doctors. People

Payment for services will determine the advancement of technology. Research for cures, disease prevention, and new medications are examples that humans value. The involvement of the CMS affects many health care organizations. Even with the new health care reform, costs continue to rise and there remains a lack of access to many.

Though the spending has lessened in recent years ,when compared with other economically developed countries the cost of the health care in U.S is much higher and ranks poorly on quality indicators (Burke & Ryan, 2014).Evidence suggest that patient quality outcomes not generally correlated with variation spending .Beneficiaries are expected and deserved for high quality care within affordable

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

Based on the political and economic environments of states and the federal government the methods of health care reimbursement have been required to evolve. With the introduction of the Patient Protection and Affordable Care Act (PPACA) new laws have been set into place that has caused a stringent review of spending on health care. All care provided is being examined for effectiveness, quality, and the actual need of the service. Unnecessary health care functions are being screened and eliminated. The government and other insurance providers have begun to place cost containment measures in place only paying for those procedures that are deemed medically necessary for the illness that the patient is currently afflicted with. This has a direct impact on the monies that the government and insurance providers will reimburse for services. The following paper will look at the major types of reimbursement activates currently in place. The writer of this paper will also speculate on the future of health care reimbursement and how it will affect his current organization.

To understand this process better, a case study will be referenced as a basis of the discussion of the paper. The study that will be utilized follows a multi-phase implementation of a program to change how to increase the Triple Aims within healthcare systems to deliver services within the community. The 2007 study was designed to evaluate how organizations could improve the quality, access, and reliability of care while being cost effective in providing healthcare services to the community (McCarthy & Klein, 2010). By identifying issues that impede providing these three elements, healthcare providers and organizations can utilize resources to address the issues and improve the patient’s health (McCarthy & Klein, 2010). Organizations can make a positive

Another solution to making a good profit for a healthcare practice is to perform services that provide a good reimbursement rate. For a new for-profit health care organization CCHC advised that the facility seek out the average Medicare, Medicaid, and private reimbursement schedules. When reviewing these schedules a provider can determine where the profit of services lies. From here the provider can perform additional research by conversing with its peers to see what kind of profit ratio they are running in their facility, as well as what particular services provide the best reimbursement rates. This would be a good start for the new practice. As services are being provided, and payments are being sent the provider should take a hard look at the reimbursements being given for services rendered. If it appears that a particular service is bringing in little or no reimbursement, the practice may need to decide whether or not to continue the service.

The fragmented and misaligned state of the U.S. health care system has become a catalyst for payment and delivery system reforms. Traditional fee-for service (FFS) payment structures incentivize high volume rather than high quality care, and lead to the suboptimal provision of medical services across the disjointed provider landscape. Despite various attempts to improve care delivery, health care costs continue to rise. The Accountable Care Organization (ACO) model seeks to reverse these trends by promoting a simultaneous restructure of the payment and delivery systems to incentivize higher quality, lower cost care.

The pace of change throughout the healthcare industry has never been greater, due in large part to a growing emphasis on improving patient satisfaction, managing costs, and improving quality of care. This is referred to as the “triple aim” of healthcare reform. In fact, healthcare reform has directly and indirectly driven the development of accountable care models and many other quality initiatives such as episode-based payment and shared risk programs. As a result, hospital revenue is now increasingly tied to measures related to patient satisfaction, health outcomes, and compliance with evidence-based standards of care. For example, one third of Medicare payments to hospitals are now based on quality or value.¹ These include a growing portion

I enjoyed reading your post. The Center for Medicare and Medicaid Services (CMS) establishment of Hospital Value-Based Purchasing (VBP) Program related to acute care inpatient reimbursement and quality of care has definitely made a drastic change in many health care organizations for better. According to the U.S. Department of Health and Human Services, (2012), the major factors leading United States health care system is quality and performance improvement and it mirror the National Quality Strategic three aims, which are “Better Care, Healthy People/ Healthy Communities and Affordable Care”.

I find the concept of value-based health care delivery systems very interesting. My own experiences being a nurse and patient in the U.S. health care system is that care is often fragmented and confusing for patients to navigate. It may take patients multiple visits to many health care providers before their health care concerns will be properly addressed. With value-based health care the focus is on patient health outcomes versus the number and profitability of health care services provided to patients (Porter & Lee, 2013). Therefore, health care providers will concentrate their scope of practice on certain health areas where they can provide patients higher quality services (Porter & Lee, 2013). Valued-based health care systems

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.