Question

what reimbursement model do you see in current work environment. What are the limitations and benefits associated with that model.

Answer 1

REIMBURSEMENT MODELS

• Healthcare reimbursement models are systems by which healthcare organizations can get paid for the services they provide to patients.
• Some of the reimbursement models are

1. fee for service
2. value based care
3. bundled payments
4. Accountable care
5. patient centered medical home
6. Pathways model
7. health maintenance organizations

FEE FOR SERVICE

• One of the most common reimbursement models in recent years, the fee for service bases patient pricing on the cost of each individual service or product that a physician orders.
• The bill usually includes these products and services and their individual prices listed out so that the patient can pay for all of it.

limitations

• since the provider gets paid more when they provide more services to their patients, it can lead to service inflation, redundancy, and the ordering of unnecessary testing and procedures.
• Due in part to recent attempts to overhaul healthcare regulations, many organizations have begun shifting away from this model

VALUE BASED CARE

• Value based care( VBC) also known as pay for performance is a billing system that is becoming much more common in healthcare organizations these days.
• Government regulations favor this model, so government healthcare programs tend to work more smoothly with this system and its various subtypes
• In this reimbursement model, providers are paid based on the quality of care they provide to their patients, rather than the quantity.
• This eliminates overcharging and service inflation from fee for service models

BUNDLED PAYMENT

• The bundled payment reimbursement model is a subtype of value based care
• This model has become especially popular lately because it simplifies patient bills into one set payment that folds in every service provided for a single episode of care
• When the bills are paid, the payments get split up among the different providers involved in that episode.

ACCOUNTABLE CARE

• Accountable care organizations are also fairly popular form of healthcare reimbursement model, and are yet another subtype of VBC.
• Their purpose is to provide right care at the right time
• Coordination is key in this model and results can be rewarding, assuming, communication and accountability among the providers

PATIENT CENTERED MEDICAL HOME

• Patient centered medical homes( PCMHs) are similar to ACOs in that they involve a group of providers teaming up to provide complete care services to their patients.
• PCMHs provide care focused through five main attributes: comprehensiveness, patient centeredness, care coordination, accessibilty and quality.

PATHWAYS MODEL

• Clinical pathways are a care model that charts an individual's healthcare needs and the treatment options for them over time.
• Providers of multiple disciplines work together to build this plan
• This model also requires patients and providers to work together, as well, so that a patient knows his or her options

HEALTH MAINTENANCE ORGANIZATIONS

• A health maintenance organization is a provider model in which a patient works with a specific organization for both healthcare and insurance
• The HMO generally functions as a network of providers and contracted organizations that work to provide comprehensive care services to the patient
• The patient the pays the care network for services provided, and is given lower cost icentives to continue using the HMO rather than going out of network for service exceptions related to emergency care and urgent care.