DQ 1 WEEK 8: Identify stakeholders impacted by health care reform
Several of the Vila Health's stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. 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 response, 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 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 reasons for the new model. Examples include rising costs of health care, policy changes, triple aim, et cetera.
Finally, after reviewing Vila Health's recent problematic patient case, describe how the care provided would be reimbursed under prior models versus reimbursement under newer models. Identify quality issues that will likely impact the organizations reimbursement under new payment models.
The traditional reimbursement model has been used in the healthcare sector for many years. However, specialists have begun to question the credibility and main focus of the traditional models. The traditional models are based on the number of patients that are treated rather than the quality of healthcare services which they should be given. Thus, many institutions, including the government has begun the process of shifting from the old models to newer models which will revolutionize patient care in the country.
The Fee For Service (FFS) payment model is perhaps the most traditional form of payment model within the sector. In this model, the patient will pay for the number of services which a healthcare provider may request. In other words, if a physician requests for an MRI scan, CT scan, blood tests and urine samples, the patient have to pay for each of these services. In the traditional model, the quality of the service was determined by the amount of money a patient was willing to spend on health costs. Thus, the more the healthcare providers were involved, the more money they made (Nguyen, 2016). The healthcare providers were rewarded according to the number of patients they treated.
The newer models are more value-based.This means that healthcare providers focus more on the quality of their services rather than the amount of reimbursement for each patient. In the Affordable Care Act, several models have been proposed including the Accountable Care Organization (ACO) model and the Patient-Centered Medical Home model (Nguyen, 2016). The ACO model acts by grouping the healthcare providers so that they may be able to share responsibility in terms of costs, quality, and communication and patient outcomes. These service providers are from different institutions,but they all come together to ensure that their allocated patients receive the best quality of medical services (Sanghavi et al., 2014). The groups may be composed of nurses, physicians, lab technicians, or other caregivers in the field. Similarly, in the PCMH model, the homes are tasked with the responsibility of funding caregivers. Through these caregivers, patients can be treated in these homes,and their progress monitored even after treatment. The quality of the services is mainly measured by the patient outcomes. Patient outcomes include the readmission rates, the rates of hospital-acquired infections, and mortality rates. In general, the better the patient outcome, the better the quality of the services they received. These new models also have a system where high quality can be rewarded. For instance, the ACO model allows for the caregivers to receive a share of the savings from the services. In addition, facilities receive bonuses or penalties depending on their overall quality performance (Whitman, 2016).
The core difference between the traditional model and the new models is their focus and end goal. The traditional models only paid attention to the number of patients who were treated while the contemporary models emphasize on the quality of the services given by service providers. In other words, the Fee For Service model was volume oriented while the new models are quality oriented (Nguyen, 2016). Secondly, in the traditional model, caregivers treated patients one by one. Thus, there lacked a clear boundary on who was responsible for the patient’s status. However, the new models take a multi-dimensional approach to communication whereby every caregiver who receives the patient is responsible for their status (Sanghavi et al., 2014). Patients are treated holistically rather than on a come-and-go basis.
The need for a shift from the old model was highlighted by the numerous health costs within the entire health system. The services were costly both to the facilities and the patients in terms of insurance coverage. In addition, the old model only focused on making more money than the patients’ status; this led to a system of uncoordinated care, fragmentation,and duplication of services that only proved to be costly in the long-run.
The main quality issues that may affect reimbursement in the new payment models mostly involve the patient outcomes. According to Hospital compare (2018), customers can review the performance of hospitals they would like to approach for services. The hospitals’ performance are mainly measured using patient experiences, timely and efficient care, complications and deaths, number of unplanned visits and the payment and value of care. Thus, facilities should strive to ensure that the performance of each of these sectors is high and meets those at the national level.
Medicare. (2018). Hospital Compare. Retrieved from https://www.medicare.gov/hospital compare/profile.html#profTab=0&ID=330006&loc=NEW%20YORK%2C%20NY&lat=40.7143528&lng=-74.0059731&name=ST%20JOSEPH'S%20MEDICAL%20CENTER&Distn=19.9.
Nguyen, K. (2016). Capitation vs. Fee-for-Service healthcare payment models. Retrieved from https://prognocis.com/capitation-vs-fee-for-service-healthcare-payment-models/.
Sangavi, D. et al. (2014). The beginner’s guide to new health care payment models. Retrieved from https://www.brookings.edu/blog/health360/2014/07/23/the-beginners-guide-to-new-health-care-payment-models/.
Whitman, E. (2016). Fewer hospitals earn Medicare bonuses under value-based purchasing. Retrieved from http://www.modernhealthcare.com/article/20161101/NEWS/161109986.
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