Question

Instructions

Before beginning work on this assignment, please review the expanded grading rubric for specific instructions relating to content and formatting.

Risk-Based Reimbursement

For your assignment, a primary care physician is often reimbursed by Health Maintenance Organizations (HMOs) via capitation, fee-for-service, relative value scale, or salary. Capitation is considered as a risk based compensation.

In an effort to understand the intricacies involved with physician reimbursement, particularly in an era of health care reform, identify and interview an expert in the field, such as:

Hospital Administrator

Managed Care Organization (MCO) executive

Health care Consultant

Legal Professional

Assumption: MCOs use risk-based reimbursement for primary care physicians.

Ask the following questions in the interview:

What kind of risk do the MCOs assess?

Does risk-based compensation limit the freedom of primary care physicians in any way in terms of patient care? Why or why not?

How does the capitation model of reimbursement work?

Do physicians generally prefer one model over the other? Why or why not?

Why do HMOs prefer the prepaid, monthly premium?

Is pay-for-performance a better model than existing models of compensation? Are there limitations to it as well?

Feel free to add additional follow-up questions for depth and clarification as you see fit.

Create a 4- to 5-page report in Microsoft Word document, analyzing the responses provided (which should be included as part of the report) using the evidence from the literature to help support or refute the responses provided.

Submission Details:

Name your document SU_HCM4025_W5_A2_LastName_FirstInitial.doc.

Support your responses with examples. Cite any sources in APA format.

Submit your document to the Submissions Area by the due date assigned.

Due Date Sep 12, 2018 11:59 AM

Answer 1

Value based care causes providers to become more accountable for acheiving cost and quality goals, because reimbursement rate depends on it.. There are two types of risk in health care that is upside and downside structure..Primary care physician actual health care costs will be budget based called shared savings..It makes providers in upside--risk models provider will not receive any shared savings and not financially penalized..In downside-risk model providers increase their budgeted costs to refund payers..Here they are getting more shared savings..

Perhaps in bundle payment models provider will meet more financial risk,payers reimburse a set price for episodes of care for joint replacement or heart surgery,but providers can earn savings by lowering the cost of care or lost the actual and budgeted costs..

Providers quality performance and provider compensation bit must meet some efficiency benchmark measures..physicial reimbursement Bhave connection with performance measures..Health care providers are working more appropriate and cost-effective care for patients.. Health IT systems help providers to enroll patients..providers are incentivized to use evidence-based medicine,engage patients,upgrade health IT and use data analytics in order to get paid for their services..when patients receive more coordinated, appropriate and effective care, providers are rewarded..

Capitation payments from MCOs control health care costs..capitation payments control physician at financial risk for services provided to patients..At the same time MCOs measures the utilization in Physicians practice..it will measure the health care quality,having link with financial rewards like bonuses..

Physician involved in primary care network models to receive extra capitation payments for diagnostic test referrals and subspecialty care.. The primary care physician will use this additional payments to pay for these referral..it make them in more risk if the overall cost of referrals goes beyond the capitation payments..

HMOs which reimburse physician on a free-for-service basis are associated with higher rates of hospitalization than those which use capitation..caspirations has the potential to increase patient health risk because there are incentives to reduce services and incentives to defer care beyond the prepayment interval..HMOs arranges health group for prepaid monthly premiums to provide comprehensive care for patients.. There will be small co-payment for each office visit and emergency treatment..