Alternate Payment Systems Flashcards
Triple Aim for Health Care system
- Better health outcomes
- Improved Patient Experience
- Cost Containment
Current US payment model
a maze of payment systems- governmental and private
outpatient systems generally reward volume of care
volume of care has not been shown to be better care in fact shown to be the opposite
Dis-integrated silos of care are typically and usually focused on _____ instead of longitudinal patient centerd care
episodes
providers often deliver care based on _____
incentives
Current US payment mode is focused on
episodic care
CMS: shifting the incentives payment from _____ to _____
volume to values
Why is a shift needed in the US healthcare system
rising health care costs
What part of medicare is expected to rise the most?
Par B- if physicians are getting paid for medicare then they aren’t going to take the insurance- further creating disparities
What was happening in SNFS with PT
PT were ranking patient high on the complexity scale therefore they need to change the RUG system
observation stay
billed as an outpatient treatment
need to warn patients before seeing them because they will be billed by part b fee for service not as a part of their hospital stay
Why is the shift needed in terms of aging populations
people will be aging using more medicare
Fragmented care is _____ and increases patient ____
inefficient and expensive and increases patient safety risk
What is systems thinking?
seek to understand the big picture
observe how elements within a system change over time, generating patterns and trends
recognize that a system structure determines behavior
What are the major reasons for a shift in the payment method
- aging population
- cost
3 Use
4 fragmented care is expensive and inefficient
Value is defined as
health outcomes/ dollars spent
Value based care
a healthcare delivery model that providers are paid based on patient health outcomes
providers are rewarded for helping improve patient health, reduce effects and incidence of chronic disease
Value based care
_____ cost and better outcomes
_____ patient satisfaction and better efficient care
lowers costs and betters outcomes
increases patient satisfaction and better efficient care
Role of affordable care act: CMMI
fee for service payment model needs reform because it rewards volume not value
ACA granted CMMI authority to do what
- lower spending without reducing the quality of care
- improve the quality of care without increasing spending
Medical Homes
team based model of patient care
Rely heavily on PCP/team- comprehensive team makes decisions
Focuses on coordination of the majority of health, illness and wellness care for medicare beneficiaries
Accountable Care Organizations
hospital, doctors and other providers group together and agree to share collective accountability for the quality and cost of care delivered to the patients in their ACO
payments to ACO incorporate financial incentives in the form of shared savings or loses for performance on identified spending and quality metrics
Bundled Payments
focus on discrete episodes of care
EX: joint replacements
overall budget for services provided to a patient receiving a course of treatment for a given clinical condition over a defined period of time
provide incentives for providers to come in under budge for episodes of care
Bundled payment equality risk
may penalize participants serving medically or socially high risk patients
risk for bundled payment may work for wealthy hospitals but not ____
unweathly hospitals
medicare bundled payment for comprehensive joint replacement general model
hospital which the surgery takes place is financially accountable for quality and cost from date of surgery through 90 days
how does payment work for the medicare bundled payment plan
if the hospital spends alot of money they have a penalty if they dont they get a bonus
uchealth began to partner with HH and post acute to get reconciliation payment
To make the medicare bundled payment you must meet the 3 quality measures
- low 30 day hospital re-hospitalization rate
- low rates of complications within 90 days
- hospital consumer assessment of healthcare- high customer satisfaction rate
What is no longer required with the medicare bundled payment
- 3 night hospital stay if the SNF has at least 3 out of 5 star rating on nursing home compare website
- homebound requirement for home health
- telehealth restrictions
medical homes are best for what type of patient
long term medical
childrens hospital
long term social support
accountable care organizations are best for what type of patient
not for long term care
short term major episodes
bundled payments
more coordinated like joint replacement, bipass surgery
hospital coordinates the major acute episode cost
