Kathy McCarthy, Director of Sales Consulting for Oracle Health Insurance, discusses the topic in today’s post:
The healthcare system is dramatically changing within the United States – both out of necessity and want. In the current economy, the US spending on healthcare is more than any other nation, more even than this country can sustain. With the fastest rate of growth compared to any other nation on gross domestic product, the US does not have the best action plan to solving this dilemma. Consumers are left with higher costs and decreased attention to their care, when the focus should be primarily on their well-being.
The Affordable Care Act (ACA) is putting consumers back in charge of their health by requiring the government to ensure that payers improve outcomes, lower cost and increase access to care. This application of value-based reimbursement will have four plans that will be implemented by 2015.
- Physicians in group practices of 100 or more who participate in Fee-for-Service Medicare will be subject to the value modifier in 2015, based on their performance in calendar year 2013.
- Physicians in group practices of 10 or more provider who participate in Fee-for-Service Medicare will be subject to the value modifier in 2016, based on their performance in calendar year 2014
- For 2015 and 2016, the value modifier does not apply to groups of physicians in which any of the group practice’s physicians participate in the Medicare Shared Savings Program, Pioneer ACOs, or the Comprehensive Primary Care Initiative.
- The value modifier starting in 2017 will affect all physicians who participate in Fee-for-Service Medicare.
The value-based payment models are aligned with better outcomes for the consumers and the healthcare providers are forced to work more closely with their patients.
- Capitation payment is managed by care organizations to control the cost of healthcare. The fixed amount of money per time period is determined on age, how many individuals and services provided in the geographical area.
- Shared Savings Program is services established for Medicare and Medicaid (CMS). This program simplifies communication among providers to improve and ensure optimal healthcare for those using CMS.
- Pay for Performance is an incentive payment used to improve the quality of healthcare through a collaboration of measuring the overall care of the patient, resources used and other factors.
- Bundle Payment is a single payment made to providers or healthcare facilities based on treatments and conditions given. This method was designed to focus on improved care that providers have clear metric to follow in order to maximize their payments.
- Fee-for-Service is a specific reimbursement for an individual service done to a patient. Payment is based on formula and funding levels by what the consumer wants to pay, the cost of service and type of service provided.
As a result, healthcare payers need to have better access to data, tools, efforts and a significant increase in time to carry out the implemented models. Therefore, there will be an emerging need for payers to have agile and open systems to meet the new market demand. Data will need to be merged by payers, in order to provide crucial information that will accurately determine payment.
As the models change so will the need for flexibility and delivery methods. Cloud-based solutions that have insight, agility and operational efficiency will be the game changers. The Oracle Health Insurance Alternative Reimbursement solution supports a wide range of models that formalizes and automates data. Oracle Health Insurance holds accountable details for contracts, products, providers and members to create financial messages.
To learn more, download and read the white paper, Emerging Healthcare Value-based Payment Models for Improving Patient Outcomes and Cost Efficiency.
Don’t forget to keep up with us year-round: