Question

You are a health care professional working in a large health system. Several stakeholders approached you and are seeking clarification regarding new reimbursement models they have been hearing about. For this assignment, you will prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.

In your memorandum, include the following:

• Description of the old model, such as capitated payments, fee-for-service, or others.
  • How was quality monitored under these models?
  • How was the quality rewarded under these models?
• Description of the new model, such as value-based, accountable care organizations, or others.
  • How is quality monitored under these models?
  • How is quality rewarded under these models?
• Compare and contrast the traditional and new models.
  • Explain the reasons for the new model. (Examples: rising costs of health care; policy changes; triple aim; etc.)

Support your findings with at least two peer-reviewed sources.

Answer 1

NEW REIMBURSEMENT MODEL

In a recently years we've seen a notable reduction in the growth of Medicare spending compared to prior decades, both overall and per beneficiary. This reduction can be partially attributed to policy changes , such as adoption of new healthcare reimbursement models( aka pay- for- performance reimbursement models). These mosels , created as part of the Affordable care act., Seek to reduce costs by encouraging providers to share responsibility for providing coordinated care that limits unnecessary spending.

Patients benefits from receiving high - quality, coordinated care nad providers through Medicare incentive payments.

TRADITIONAL REIMBURSEMENT MODEL

In the traditional healthcare environment, physician are reimbursed based on the number of service they provide, or the the number of procedure they order. This is known as the " free -for - Service " ( FFS ) reimbursement model. For example , every time we have a doctor's appointment , a surgical consultation , or a hospital stay . We will pay for esach test, procedure , doctor visit , and treatment provided , even though some of these may not be needed, or supported by evidence - based data.

In the traditional healthcare model, many times patients are left confused and frustrated trying to navigate through the healthcare system alone. For example :- patient must manage their own care path , moving from primary care physician , to specialist , and then to surgery center in away that is often complicated and unpredictable.In traditional model there is lack of technology vand the incentives to coordinate patient care across the health care system. So they stay independent , using the fee - for- service payment model , which ultimately drives up healthcare costs.

The shift in healthcare strategy is extremely beneficial to the patient population, because it delivers a connected care experience where patients receive more coordinated, appropriated and effective care , improving the health of individual and their communities.

FEE - FOR - SERVICE ( FFS)

In yhe traditional fee for service payment model private health insurers and government programs ( e.g Medicaid and Medicare) reimburse physician for the number of services provided.Many recognise the FFS model as a quantity based or " excessive cost" payment system. , Incentive doctors to order a high number of test and procedures to generate more income., And encouraging them to Practice" defensive medicine," doing everything possible to help patient by "playing it safe" when evaluating and ordering a treatment.

CAPITATION SERVICE

Under the capitation payment model ,providers are paid a prospective " cap " or per member per month (PMPM ) payment, to provide care for individual enrolled in managing helath plans ( e.g. Medicaid and Medicare) . Providers strive to meet and to exceed defined standard for quality and efficiency , and if successful , then they get to keep and net realized savings below the assigned payment for patient. The capitation model, therfore. ,is recognised as a performance based payment system, enabling providers to focus on value - based care, and financially incentivizing them to give the right quality care at the right time to a greater number of patients.

Quality be monitored

paying close attention to our practice's efficiencies can keep our business operationally and fiscally healthy. Just as our monitor the vital signs of our patients , assessing and monitoring key operational aspects of our practice will help our better understand the status of our's practice's financial health.

QUALITY REWARDING

For Medicare's Merit based incentive payments system , clinical outcomes , resources use , meaningful use, and clinical improvement activities will determine oue final payment.Meeting these requirements ill requires teamwork between many members of the team. Performance data and benchmarking will be the bes rock of the new payment model.

TRADITIONAL AND NEW MODEL

I n the traditional healthcare model, many times patients are left confused and frustrated trying to navigate through the healthcare system alone. For example patient must manage their own care path , moving from primary care physician to specialist and then to surgery center in a way that is often complicated and unpredictable. In addition , patient may see multiple doctor, specialist and surgeon who do not communicate with each other, or do not have access to same important, patient data

The value based model of healthcare shift the emphasis of care from simply reimbursing clinicians on test and services order to rewarding physician from providing appropriate, coordinated care that keeps patient population healthy. Value based care programs are design to deive down health care cost and to improve patient care and population health , by financially rewarding health care providers fir considering overall patient care , cost efficiency, and a patient's outcome.