Belvoir Primary Clinic Case Study

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 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.

Constance, evidenced based practice (EBP) and quality are important and they are becoming a focus of healthcare payment models that reward for better quality and outcomes. With the repeal of the Sustainable Growth Rate (SGR) legislature and the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the United States has changed the rules around what determines how much health care providers are paid for services. Starting in 2019, providers including physicians and advanced practice nurses (APNs), will receive payments that are adjusted by the cost associated with, and the quality outcomes of the care provided to their patients for services rendered during 2017 (MACRA, 2015). It is important that all care providers

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

On February 2, 2016, the Patient-Centered Primary Care Collaborative (PCPCC) report highlighted 30 primary care PCMH initiatives that measured cost and utilization of services and concluded that PCMH reduces costs and improves health care quality. A senior vice president at the Blue Cross Blue Shield Association mentions that reduction in hospital admissions, emergency room visits and health care costs and

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.

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.

States have chosen to two forms of Medicaid managed care to better deliver healthcare services besides the traditional fee-for-service Medicaid programs; primary case management and traditional health maintenance organizations. “In primary care case management, the state Medicaid agency contracts with a primary gatekeeper entity (e.g., physician, clinic) that coordinates primary and specialty care for Medicaid beneficiaries. For healthcare maintenance type programs, a State Medicaid agency contracts with an existing healthcare maintenance organization, prepaid health plan, or other institutional health care provider who, in addition to proving primary care services, assumes insurance risk of providing covered services. Typically primary case management are paid on a fee-for-service basis plus a monthly case management fee per enrollee, while health maintenance organization plans are paid a capitation rate and are at full financial risk.” (1)

As the shift for HCOs is made to a PCMH model, the financial aspect also has to make a transition to accommodate to the changes. In recent years, there have been implementations of different payment and reimbursement options, health insurance programs, and the establishment of the Affordable Care Act (ACA). Between May 2009 and April 2012, one of the initial PCMH pilot programs was conducted in Colorado, appropriately named The Colorado Multipayer Patient-Centered Medical Home Pilot. More than 100,000 patients within sixteen internal medicine practices participated in the experimental PCMH model, using six different health plans (Harbrecht & Latts, 2012).

“Patient-centered medical home medical home (PCMH) incentive programs are local, state, and public/private payer initiatives that offer payment incentives to participating practices that adopt the function of a PCMH” (American Academy of Family Physicians). The incentives is what drives up the motivation and therefore a successful outcome. Since incentives are provided at varieties of state

It seems as though the gaps between patient-care and doctor relationships are being pulled apart and further disintegrated by eliminating “patient-care” and substituting it with “reimbursement”. Most physicians working in private practice today are burdened by diminished reimbursement rates and a growing list of administrative tasks required by insurance companies. In response, many primary care physicians are exploring alternative practice options other than the traditional fee for service. A fee for service is a delivery system where health care providers are paid for each service like an office visit, test, or procedure. A new health care trend which seems to be the growing

Historically medical providers have been paid under a fee-for-service system in which they receive pay for their service regardless of the patient outcome. Fee-for-service has been thought to generate excessive, unnecessary services that increase profits. Pay-for-Performance is based on the concept of offering “financial rewards to providers who achieve, improve, or exceed their performance on specified quality and cost measures” (Health Care Incentives Improvement Institute, 2015).

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.