MHA$/598$: Leveraging Results To Build Brand In The Health Sector

Wk $4$ Discussion $-$ Health Care Payment and Reimbursement

I need help responding to the following classmates:

Leandra Ringfield

Hello,

According to research gathered from Medina, $(2019)$ once Congress passed the Medicare Modernization and Improvement Act $($MMA$)$ that restructured reimbursement and if bids for the cost for service was over the average benchmark, then CMS provided the plan a rebate for the difference of cost$.$ However, subsequently the redirect of money did not successfully produce any savings for CMS$.$ Now in contrast there was a slight success because benefits expanded and out$-$of$-$pocket spending decreased. Based on the achievements from ACA, premiums decreased $22\%($from costing $$44$ to $$34).$ Additionally, by having Medicare Star Ratings as a guideline to manage quality, access to care, health disparities and customer service Medicare Advantage $($MA$)$ plans performance improved $($Medina$,2019).$ So overall, the shift in strategy has been successful but it complicated because many smaller providers offices do not have adequate systems to adapt to this collaboration. Recently, I noticed that more ambulatory care facilities or outpatient facilities are demographically more present and more networking facilities are being built to assist with senior care and comorbid conditions. Expanding services, while having more facilities that offer care to senior citizens while accepting MA coverage can be successful as this strategy of care ensures longer life expectancies and healthier people. Meanwhile, issues with evolving and meeting performance goals will occur which is why ongoing evaluation should be more standardized.

The reimbursement strategy that I have witness has been managed care plans where Medicare supplementary coverage or MA coverage offers enrollees benefits that not be covered under their primary insurance coverage. Often times reimbursement is tricky and can be based on the group insurance size far as the claims processing. The reimbursement structure offers low monthly premiums and both in network and out of network benefits but the disadvantage includes high maximum out$-$of$-$pocket cost and sometimes referrals are required because the provider networks are structured like HMO $($Health Maintenance Organization$)$ networks. Although enrollee's have appeal rights it is difficult to receive favorable decisions under HMO plan structures. Whereas, I have witnessed Point of Service $($POS$)$ plans being more flexibility and for example no referrals are needed for specialist visits. Both HMO and POS structured plans both will require prior authorizations for certain services like surgeries or institutional mental health facility

Carletta Brown

The Centers for Medicare and Medicaid Services $($CMS$)$ moved to value$-$based purchasing in $2011$ with the goal of lowering overall CMS payments by matching reimbursement with patient satisfaction and quality outcomes $($CMS$.$gov. n$.$d$.).$ This strategy's effectiveness requires a sophisticated assessment. On the one hand, it has compelled healthcare institutions to give patient pleasure and quality enhancement top priority. Nonetheless, there are obstacles to overcome, like the difficulty of quantifying and assigning results to specific providers and the possible cost burden on smaller organizations.

My organization uses a blend of value$-$based and fee$-$for$-$service $($FFS$)$ reimbursement methods. The most common type of payment is fee$-$for$-$service, in which service providers are paid for each task completed. Furthermore, our company engages in value$-$based agreements with specific payers. These agreements incentivize a focus on preventative treatment and better patient outcomes by tying reimbursement to predetermined quality measures and cost$-$effectiveness. This hybrid model aims to strike a compromise between incentives for providing effective, high$-$quality treatment and the standard FFS framework.

Capitation is a remarkable alternative reimbursement strategy that should be researched. Under a capitation model, regardless of the services rendered, physicians are paid a set amount for each patient. This encourages the use of preventative and economical healthcare. Bundled payments represent an additional approach in which all services associated with a certain treatment or condition are covered by a single payment. The goals of both options are to improve coordination throughout the treatment continuum and save expenses.