Policy, Politics and Global Trends Essay

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

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,

Over the last five years, the United States has implemented a new policy in which Americans will receive their health care benefits. This policy is known as the Patient Protection and Affordable Health Care Act which was implemented in 2010 through United States federal statue and signed into law by President Barack Obama. The intentions of the reform is to insure that all Americans have affordable access to health care benefits without struggling to afford the cost associated. The reform is broken down into nine title sections that affect all aspects of health care and changes that will be associated. In this paper, I will be discussing each of the title sections and how the changes will affect the field of nursing.

Many times, the people who are creating policies or legislation for health care reform are not the “first providers” of the health care system. As the journal article, “Influencing Health Care in the Legislative Arena” stated, “[nurses] are often the first providers to see clearly when and how the health care system is not effectively meeting patients needs;” hence, we need more nurses to take a stance in the legislative arena.

There is a growing trend in the United States called pay-for-performance. Pay-for-performance is a system that is used where providers are compensated by payers for meeting certain pre-established measures for quality and efficiency (What is Pay-for-Performance, n.a.). We are going to be discussing what pay-for-performance is. There are different aspects of pay-for-performance which include; the effects of reimbursement by this approach, the impact cost reductions has on quality and efficiency of health care, the affects to the providers and patients, and the effects on the future of health care.

For anyone who has kept up with the news, the US healthcare system has undergone major changes in recent years. Insurance providers are no longer able to deny someone coverage based on pre-existing conditions. The advent of healthcare marketplaces has changed the way people purchase health insurance. Children can stay on their parents' health insurance plans until 26. Leading the healthcare revolution is InnovaCare Health. This organization is a leading provider of Medicaid and Medicare Advantage plans. InnovaCare Health recently announced it would partner with the Health Care Payment Learning and Action Network. This is a significant private-public partnership that seeks to change compensation models to reflect the quality of care instead of quantity. This new partnership reflects InnovaCare Health's to affect change in compensation sooner rather than later. The current healthcare model focuses on reimbursing physicians based on the number of patients seen or procedures performed. This encourages "treadmill medicine," or a model that focuses on rapid turnover. This can often lead to detrimental effects on patient health. The new quality model would reward physicians based on practice targets. Potential goals include HbA1c goals for patients with diabetes, the percentage of patients who smoke, and hospital stay after surgical procedures.

Since 1992, health cares like Medicare have reimbursed physicians on a fee-for-service basis that weighs their service and expenses and then converts the weights to money (Wilensky, 8). According to Gail Wilensky, “Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy” (Wilensky, 8). Physicians and PAs are having a hard time with health-care reimbursement. It is causing many problems and Congress needs to come up with a solution. ¨This article states several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform

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).

Some simply call it “The Affordable Care Act” and others affectionately call it “Obama Care”. No matter what it is referred to, the objective of the Affordable Care Act was to make healthcare more affordable for people and also to make insurance available to everyone. With this act came the introduction of value based care and performance based payments. The goal of value based care and performance based payments are to transform how medical care is performed and how the payment for medical services is presented and paid. The “Quality Strategy vision” of The Center for Medicare and Medicaid Services (2017), is a way of improving health.

There have been overwhelming efforts to better and extend lives in the US. However, evidence indicates that the outcomes can be improved at lower cost. Many models aimed at achieving this are being piloted throughout the country. In addition to testing, some pockets of adoption exist. The dominant payment system for healthcare providers remains and is based on the fee for service which provides little or no support for numerous innovative and personalized services implemented by healthcare providers. Several potential valuable approaches are poorly reimbursed or are not reimbursed at all. Traditional fee for service payments promotes higher volume and the intensity of duty. To support innovative and cheaper care, providers and health plans have started to develop, implement and evaluate different financial reforms that utilize reimbursement. They award value instead of volume to offer providers more support for providing care which enhances higher quality at reduced cost. Parties to the payment agreement set the value based on the assessment of quality, efficiency, and safety. Penalties and rewards are stated, and the client is paid upon reaching or surpassing set targets. This paper looks into value-based reimbursement, based on patients ' surveys and quality scores by maximizing the value for patients (Mcclellan, 2015).

In the early 2000s, serious deficiencies in quality health care had been highlighted by the Institute of Medicine (James, 2012). Recently, the use of financial incentives to reward for improving quality of care is a growing interest for many. Pay-for-performance programs provide bonuses to health care providers for meeting or exceeding quality measures. However, physicians in the United States have traditionally been paid for quantity versus quality of care (Blum, 2011). Utilizing incentive models, such as patient-centered medical home, pay-for-performance, and the fee-for-service payments are the most commonly used programs. Incentive programs may also reward on improvements that occur over time, such as year-to-year decreases in hospital readmission rates or decreasing hemoglobin A1c values in diabetic patients (Blum, 2011). Hospital can incur financial penalties under the Medicare guidelines for individuals who acquire certain preventable conditions during their hospital stay, such as urinary tract infections from use of catheters and pressure ulcers. However, there is insufficient evidence to support whether or not financial incentives improve quality of primary health care. In addition, it is unclear whether financial incentives could potentially cause harm as they only incentivize based on certain health indicators. Therefore, physicians may spend more time focusing on meeting those indicators while paying less attention to other important issues

Thanks for your informative post, I agree, pay for performance is a reimbursement method aimed at improving the experiences of patients at various health institutions. This method as you mentioned is becoming popular among health care policymakers and health care insurers. it is a method based on incentive paid by health care insurers to providers to encourage the overall improvement of providers’ healthcare services to their patients . The pay for performance is considering a method of reimbursement that has shifted much of the financial risks to the providers of health care. The shift in risks to providers could be a double-edged sword. For one, the method can be credited for allowing physicians accountability for costs containment and wellbeing of their patients to be emphasized within the health arena. On the other hand, P4P could result in physicians enrolling patients with less complicated health problems in the practices, or it could lead to physicians avoiding healthcare facilities in poorer neighborhoods with many chronic ill patients. That said, researchers do not concur that the pay for

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.