Value-Based Care

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.

In this task, I will look at the seven principles of the Care Value Base. The Care Value Base is a Code of Practice which care workers follow and must apply a level of care to service users according to the Care Value Base. I will look at one particular care setting, which will be a hospital, to investigate how they provide a high quality of care according to the Care Value Base. While on work placement at a hospital, I learnt valuable information on how a hospital follows the guidelines of the Care Value Base when caring for service users.

After years of schooling and hundreds of thousands of dollars in debt, doctors aren’t even able to work on their own terms. “Consumers allegedly have a “right” to what health care providers provide, a “right” to say what will be provided, when, and at what price” (Salsman 2012). Consumers shouldn’t have a “right” to what is provided to them or how much it costs. The government controls pricing and controls who can receive care and what kind. It’s not right that those who are actually working in the medical profession that they have lost control of their businesses.

The lucrative healthcare companies in America have created an immeasurable gap between good healthcare only being for the privileged upper class Americans which has left a horrible effect on the middle and lower class Americans. As modern medicine achieves new heights, the prices of healthcare seem to tread right behind maintaining an unbroken pattern that American classes have grown accustomed to over the past few decades of paying more for less. Leaving many Americans uninsured, underinsured, or even in debt. In a speech Bernie Sanders a U.S. Senator from Vermont spoke at a presidential campaign October of 2015 which he discussed the unruly problematic healthcare trend of price gouging, that is the medical industry getting the most it can from American citizens. In a blog Bernie Sanders states that “46 million Americans today have no health insurance and even more are underinsured with high deductibles and co-payments” (Sanders). 18,000 Americans die every year from preventable illnesses because they cannot cover the cost and don’t go to the doctor when they should. Sanders summed this situation up with this “Health Care is a Right, Not a Privilege” (Sanders). After researching the issue of healthcare, I have come to the conclusion that the American healthcare system is disintegrating due to the ravenousness of modern medical industries, first I will discuss a few reasons to why the healthcare system is failing the modern American

In today’s seemingly ever-changing world of healthcare regulation, medical professionals are burdened with many compliance requirements. On October 14, 2016, the Department of Health and Human Services released its final rule implementing the Quality Payment Program as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Starting January 1, 2017, clinicians who are reimbursed by the Centers for Medicare and Medicaid Services(CMS) are required to participate in the Quality Payment Program (QPP). (Centers for Medicare & Medicaid Services, 2016) The QPP replaced the Sustainable Growth Rate formula with the new payment structure in which clinicians are rewarded for delivering high quality care. There are now two pathways for

According to the Centers for Medicare and Medicaid Services (CMS), health care spending in the United States has grown at a rate of 3.7 percent since 2012 to $2.8 trillion, costing the U.S. 17.9 percent of total its GDP and ranking it number one spending on health care (Martin et al 67; world bank). Despite having the most expensive healthcare per capita, according to The Commonwealth Fund - a private American foundation dedicated to the promotion of a high performance healthcare system - the U.S. ranks at the bottom of the top ten wealthiest nations in terms of “access, efficiency, and equity” (Davis

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

Also, there are few American citizens who are striving for a real cure. The current fashion is to impose incremental reforms. For instance, Congress passed a new program to finance healthcare reforms for some uninsured children. They are also attempting to push bills to make it difficult for HMOs to deprive people of needed care.

The United States spends twice as much per citizen for health insurance as any other country in the entire world, but continues to fall behind other countries when it comes to coverage and quality (Rangel, 2011). There are nearly forty-six million uninsured Americans, and millions more have inadequate coverage. The affordable health care act, was designed to help millions of Americans. But, to Americans it is questionable at best. Obamacare is so fundamentally inconsistent that it is taking Americans in the opposite direction of the necessary reforms needed. The root cause for our health care system include misaligned reimbursement policies and incentives, lack of integrated patient care process, and poorly coordinated patient care treatment (Health Care Delivery System Reform, 2015). America cannot build sustainable health reform on a dysfunctional health care system. The United States needs to get rid of Obamacare and pass a new comprehensive reform that makes health care affordable for families, businesses, and the government.

In recent years, emphasis has been placed on improving the quality of health care services and the overall patient experience. Innovative measures are needed to meet these expectations, while also containing the rising costs of health care. The government has enacted new laws in attempts to provide incentives that base Medicare payments in part on quality. In fact, the Patient Protection and Affordable Care Act of 2010, requires the implementation of value-based purchasing (VBP), which bases Medicare reimbursement rates on the quality of care (Kennedy, Wetzel & Wright, 2013). Hospitals may experience a decrease in revenue initially, however, it is theorized that the increase of transparency and accountability will serve as an incentive for improvements in the overall quality of care provided in the United States.

Value-Based Payments (VBP) is a tactic utilized by purchasers to encourage quality and the value of health care services (Health Care Incentives, 2017). Value-Based Payments offer financial incentives to doctors, hospitals, medical groups, and health care providers (Webb, 2015). The incentive is to provide better care for their patients and to focus on the quality of the care they are providing rather than the number of people they treat. This payment model is being used as a way to keep DSRIP sustainable (NYSDOH, 2015). The VBP Model offers a roadmap, which outlines a five year plan to attaining inclusive payment reform; which includes a shift to 80% VBP through Medicaid managed care plans (The Commonwealth Fund, 2017). This payment reform should be accomplished by the end of DSRIP enactment period of five years (The Commonwealth Fund, 2017).

Instead of paying fully for every service that a hospital provides for a Medicare beneficiary, Medicare now reimburses hospitals with an amount based on how well they reach certain care quality measures which encompass specific health outcomes, patient satisfaction and cost of care. If hospitals are able to reach specific health outcome goals, have high patient satisfaction and provide low cost of care they will be reimbursed a higher amount for their Medicare patients than when they don’t meet those goals. If a hospital does not reach the set quality measures then it misses out on 1-2% (depending on the year) of the reimbursement from Medicare that it would have received if they had met their goals (Federal Register, 2015). This change in payment method is important because it changes the incentives of hospitals when providing care. Under the value-based purchasing program hospitals are economically motivated to provide better quality of care rather than quantity of services. This has many consequences that should counteract the problems seen with the non-quality linked FFS method because it should push the focus of the hospitals towards providing better health outcomes, improving on patient satisfaction and reducing the costs per patient (eg: reducing low-value services) instead of the

healthcare system preforms inadequately and is ranked 37th in the world next to countries who don’t have the advanced medicine or technology like the U.S. which is terrifying. Among the top wealthiest countries we are dead last and highest health expenditures according to common wealth fund. How is it possible that a country like ours that has all the technology in the world fall short in providing health care? The answer – money, America’s health care has become more of a business than a service. America has, become an over medicated country consumed by greed by private practice insurance and physicians. Unlike other countries where it’s a service provided to its citizens everybody is insured, everybody has access to quality health care at a low cost.

With new reforms being put in place under the Affordable Care Act such as the pay-for-performance (P4P) also known as “value-based purchasing,” which is intended to help provide maintain and efficient programs to improve health care cost. Healthcare providers, hospitals, medical groups, and physicians are offered incentives for meeting certain performance goals; it also fines for increased costs and medical errors such as incorrect medication or dosages. In two different studies quality of care was found to have improved at P4P hospitals compared to non-P4P hospitals Lindenauer et al. (2007) and Grossbart (2006). However, a study by Werner et al.(2011) found no continuing benefits in quality of care. One measure being advocated for is the Hospital Readmissions Reduction Program (HRRP) to prevent hospital readmissions as a way to improve the quality of care and at the same time cut cost. If patients are readmitted within 30 days after discharges due to conditions like acute myocardial infarction (AMI), heart failure, and pneumonia, fines can be levied such as 1 percent of Medicare payments. Others include the Hospital Value-Based Purchasing (VBP) is based on how well the hospital performs compared to other hospitals or the improvement of their own performance compared to a baseline time. The goal is to encourage better outcomes for patients and improve experience during hospital stays. And the Hospital-Acquired Condition (HAC) Reduction Program motivates hospitals to increase the safety of it patients by cut the number of hospital-acquired conditions and patient safety (Medicare.gov, n.d.) (Kruse, Polsky, Stuart, & Werner, 2012)(Gu et al.,

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.