- Note: This assessment uses the following media as the context for developing the reimbursement model memo. Review this media before you submit your assessment.
Basic understanding of the reimbursement system requires one to appreciate the size and scope of the system, the complexities associated with the system, and the various subsystems and payment rules associated with health care reimbursement and finance. As a dominant player in the health care sector, the U.S. federal government is the largest single payer for health care services. As a result of its size and dominance within the system, any changes made by the federal government regarding its reimbursement of health services profoundly affect those who are rendering the care, including providers, other payers, and the health system overall. In addition to government-sponsored health insurance, various other forms of health coverage, generally tied to employment as a benefit, were introduced in the United States to help offset the expenses associated with the treatment of illness and injury.In an effort to address concerns within the U.S. health system regarding cost, access, and quality, Congress passed the Patient Protection and Affordable Care Act (PPACA or ACA) in 2010, with President Barack Obama signing it into law. Components of the PPACA included making health insurance coverage affordable, expanding Medicaid coverage, and improving quality while controlling costs. To this end, the ACA required the Centers for Medicare & Medicaid (CMS)to promote the concept of the accountable care organization (ACO) through a shared savings plan driven by a triple-aim approach. In addition to the ACO, the ACA required CMS to implement value-based purchasing programs that would reward hospitals for the quality of care they provided to enrollees.As the recipient of the largest share of Medicare funds, the new value-based purchasing approach measures hospital performance using four domains:
- Clinical care.
- Safety.
- Efficiency and cost reduction.
- Patient experience of care (Casto & Forrestal, 2019, p. 274).
Each measure scores the hospital performance achievement as well as their performance improvement.As a health care sector employee, understanding the complex U.S. health care reimbursement system allows one to serve as a reference to internal and external stakeholders, family members, and organizational departments whose needs often require a working knowledge of how the system is financed. In this assessment, you demonstrate your understanding of traditional and emerging health care reimbursement models by composing a memo that outlines the characteristics and differences between reimbursement models. This memo targets relevant stakeholders from the Vila Health media simulation based in St. Anthony Medical Center.
Reference
Casto, A. B. (2019). Principles of healthcare reimbursement (6th ed.). AHIMA Press.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
- Competency 1: Compare current trends and traditional methods of payment in the health care industry.
- Describe traditional payment models in health care.
- Describe current trends in health care payment models.
- Competency 2: Assess health care reimbursement.
- Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
- Explain reasoning for newer models of reimbursement in health care.
- Explain quality concerns affecting reimbursement given a specific patient scenario.
- Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
- Adhere to the rules of grammar, usage, and mechanics.
- Apply APA formatting to in-text citations and references.
Instructions
You will use Vila Health: Investigating a Readmission as the context to address Part 4 of this assessment.Several of the Vila Health’s stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.Support your assertions in the memo with at least three academic sources. This may require you to do additional independent research. You may wish to consult the Health Care Administration Undergraduate Library Research Guide before you begin any additional research.This assessment has four main parts.
Part 1: Traditional Payment Methods
Relevant scoring guide criteria:
- Describe traditional payment models in health care.
- “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
- Identify the traditional payment models.
- What are the key characteristics of these reimbursement models?
- How was quality monitored under these models?
- Adhere to the rules of grammar, usage, and mechanics.
- “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
- “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
- “Mechanics” refers to correct use of capitalization, punctuation, and spelling.
- Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.
Part 2: Current Trends in Healthcare Payment
Relevant scoring guide criteria:
- Describe current trends in health care payment models.
- Identify the current trends in health care payment models.
- What are the key characteristics of these reimbursement models?
- How is quality monitored under these models?
- Explain reasoning for newer models of reimbursement in health care.
- “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.
- Adhere to the rules of grammar, usage, and mechanics.
- Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.
Part 3: Comparison of Models
Relevant scoring guide criteria:
- Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
- Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models.
- Adhere to the rules of grammar, usage, and mechanics.
- Apply APA formatting to in-text citations and references.
This part should likely be between a half and one page long.
Part 4: Quality Concerns
Relevant scoring guide criteria:
- Explain quality concerns affecting reimbursement given a specific patient scenario.
- Specifically address the recent problematic patient case from the Vila Health: Investigating a Readmission scenario.
- Briefly discuss how the care provided would be reimbursed under prior models versus reimbursement under newer models, based on your assertions in Part 3 of your memo.
- Also, identify quality issues that will likely impact the organization’s reimbursement under new payment models.
- Adhere to the rules of grammar, usage, and mechanics.
- Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.
Additional Submission Requirements
- Structure: Structure your submission like a memo, with an additional, APA-style references page. Use the Reimbursement Model Memo template [DOC] provided. You may wish to refer to the following example when developing your memo:
- Length: 2–3 pages, plus a references page.
- References: Cite at least three current scholarly or professional resources.
- Your textbook can be one of the three.
- Format: Use APA style for references and citations only. Refer to:
- APA Style Paper Tutorial [DOCX].
- Additional APA resources located in the courseroom navigation panel.
- Font: Times New Roman, 12 point, double-spaced.
SCORING GUIDE
Use the scoring guide to understand how your assessment will be evaluated.VIEW SCORING GUIDE
- CRITERIANON-PERFORMANCEBASICPROFICIENTDISTINGUISHEDDescribe traditional payment models in health care.Does not list traditional payment models in health care.Lists but does not describe traditional payment models in health care.Describes traditional payment models in health care.Describes traditional payment models in health care and how quality was monitored and rewarded under each model.Describe current trends in health care payment models.Does not list current trends in health care payment models.Lists but does not describe current trends in health care payment models.Describes current trends in health care payment models.Describes current trends in health care payment models and how quality is monitored and rewarded under each model.Explain reasoning for newer models of reimbursement in health care.Does not attempt to explain reasoning for newer models of reimbursement in health care.Attempts to explain reasoning for newer models of reimbursement in health care, but the explanation is inaccurate, illogical, or invalid.Explains reasoning for newer models of reimbursement in health care.Explains reasoning for newer models of reimbursement in health care, and provides relevant examples, supported by current scholarly or professional sources.Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.Does not describe how quality outcomes are rewarded under traditional or current payment models in health care.Describes but does not compare how quality outcomes are rewarded under traditional versus current payment models in health care.Compares and contrasts how quality outcomes are rewarded under traditional and current payment models in health care.Compares and contrasts how quality outcomes are rewarded under traditional and current payment models in health care, and provides relevant examples supported by current literature.Explain quality concerns affecting reimbursement given a specific patient scenario.Does not identify any quality concerns affecting reimbursement given a specific patient scenario.Partially identifies quality concerns affecting reimbursement given a specific patient scenario.Explains quality concerns affecting reimbursement given a specific patient scenario.Provides a comprehensive explanation of quality concerns affecting reimbursement given a specific patient scenario and makes recommendations that are supported by current scholarly or professional sources.Adhere to the rules of grammar, usage, and mechanics.Does not adhere to the rules of grammar, usage, and mechanics.Errors in grammar, usage, and mechanics inhibit readability and comprehension and detract from good scholarship.Adheres to the rules of grammar, usage, and mechanics.Exhibits strict and nearly flawless adherence to the rules of grammar, usage, and mechanics.Apply APA formatting to in-text citations and references.Does not apply APA formatting to in-text citations and references.Applies APA formatting to in-text citations and references incorrectly or inconsistently, detracting noticeably from good scholarship.Applies APA formatting to in-text citations and references.Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
Expert Solution Preview
Introduction:
The Importance of a healthcare reimbursement model in the healthcare sector cannot be overemphasized. A good healthcare reimbursement model facilitates an efficient transfer of funds between payers, providers, and patients to ensure that patients receive quality care without worrying about the cost. In this memo, we will outline the characteristics and differences between traditional and new reimbursement models in healthcare to aid stakeholders within Vila Health to better understand and make informed decisions about health care.
Part 1: Traditional Payment Methods
The traditional payment models in healthcare include fee for service, capitation, and episode-based payments. Under the fee-for-service model, providers are paid for individual services rendered, irrespective of the quality or outcome of care. Capitation is a model where a provider is paid a fixed, per-member-per-month rate for the care of a covered population, regardless of the number of services rendered. Episode-based payments, on the other hand, is a bundled payment model where a single payment is made for all services provided for a specific condition. Quality outcomes during this period were evaluated by reviewing the number of services rendered.
Part 2: Current Trends in Healthcare Payment
Current trends in healthcare payment models include value-based purchasing, the move towards pay-for-performance systems, and accountable care organizations (ACOs). Value-based purchasing rewards quality of care instead of the volume of services provided. Pay-for-performance models reimburse providers based on achieving specific metrics established by the payer, while accountable care organizations (ACOs) reimburse providers based on the overall cost and quality of care given to an assigned patient population. Quality outcomes for new models are usually measured by monitoring the performance outcomes of healthcare providers against established benchmarks.
Part 3: Comparison of Models
The key differences between traditional and current models are the way care is reimbursed and the emphasis on quality. Traditional models reimbursed providers on volume, regardless of the quality of care in the form of fees or capitation. However, emerging models such as Value-based purchasing and ACOs emphasize quality through incentivization. The fewer services needed to provide a quality outcome, the lower the total cost and the higher the provider reimbursement.
Part 4: Quality Concerns
The recent problematic patient case from Vila Health: Investigating a Readmission is an excellent example of the quality concerns affecting healthcare reimbursement. In traditional models, the organization would have been reimbursed based on the patient’s hospital stay’s number of services provided. In newer models, the patient’s overall outcome would be scored and reimbursed based on the outcomes achieved, regardless of the number of interventions needed to achieve those outcomes. This quality metric affects Vila Health’s reimbursement, and to maintain a good score, they must provide high-quality care while maintaining low costs.
Conclusion:
The various reimbursement models all have advantages and disadvantages. While traditional models focused on the number of services provided per patient, emerging models emphasize the need for quality care while helping to control the cost of care. The reimbursement model utilized will impact the revenues generated by the organization significantly. As the Vila Health stakesholders make decisions on fee structures, they need to be aware of the advantages and disadvantages of the different models and decide which one best suits their needs.
