Discussion: payment methods in helathcare

Discussion: payment methods in helathcare ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: payment methods in helathcare Complete the Payment Mode Analysis worksheet. Discussion: payment methods in helathcare Cite at least three scholarly sources in an APA-formatted reference page. Discussion: payment methods in helathcare Submit your assignment. healthcareweek2worksheet.docx conrad.pdf conrad2.pdf University of Phoenix Material Payment Mode Analysis Nurses play a pivotal role in providing care within the boundaries of their organization’s budget. In order to become a leader in the field to improve quality care and reduce cost, you need to understand the nuances of the way health care organizations are paid. Complete the table to analyze each payment mode. Apply what you’ve learned to complete the activity following the table. Payment Mode Name Summary Strengths Weaknesses Fee for Service Pay for Performance Patient-Centered Medical Homes Accountable Care Organizations Bundled Payments Global Budgets Payment Mode Activity If you were the person in each of the following scenarios, which payment mode would you prefer? A 28-year-old with poorly controlled diabetes An elderly individual with multiple chronic conditions A pediatric neurosurgeon A registered nurse Provide a short rationale for each decision. Discussion: payment methods in helathcare Payment Mode Analysis HSN/476 University of Phoenix Material Payment Mode Analysis Nurses play a pivotal role in providing care within the boundaries of their organization’s budget. In order to become a leader in the field to improve quality care and reduce cost, you need to understand the nuances of the way health care organizations are paid. Complete the table to analyze each payment mode. Apply what you’ve learned to complete the activity following the table. Payment Mode Name Summary Strengths Fee for Service Pay for Performance Patient-Centered Medical Homes Accountable Care Organizations Bundled Payments Global Budgets Payment Mode Activity If you were the person in each of the following scenarios, which payment mode would you prefer? • • • • A 28-year-old with poorly controlled diabetes An elderly individual with multiple chronic conditions A pediatric neurosurgeon A registered nurse Provide a short rationale for each decision. Copyright © 2017 by University of Phoenix. All rights reserved. Weaknesses 1 Original Investigation Emerging Lessons From Regional and State Innovation in Value-Based Payment Reform: Balancing Collaboration and Disruptive Innovation D O U G L A S A . C O N R A D , D AV I D G R E M B O W S K I , SUSAN E. HERNANDEZ, BERNARD LAU, and MIRIAM MARCUS-SMITH University of Washington Policy Points: r r r r Public and private purchasers must create a “burning bridge” of countervailing pressure that signals “no turning back” to fee-for-service in order to sustain the momentum for value-based payment. Multi-stakeholder coalitions must establish a defined set of quality, outcomes, and cost performance measures and the interoperable information systems to support data collection and reporting of value-based payment schemes. Anti-trust vigilance is necessary to find the “sweet spot” of competition and cooperation among health plans and health care providers. Provider and health plan transparency of price and quality, supported by all-payer claims data, are critical in driving value-based payment innovation and cost constraint. Context: In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. Methods: As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated The Milbank Quarterly, Vol. 92, No. 3, 2014 (pp. 568-623) c 2014 Milbank Memorial Fund. Published by Wiley Periodicals Inc. 568 Emerging Lessons From Innovation in Value-Based Payment Reform 569 factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. Findings: The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers’ limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. Discussion: payment methods in helathcare Conclusions: From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected “honest broker” that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a “burning bridge” between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur valuebased payment innovation that combines elements of “reformed” fee-for-service with bundled payments and global payments. Keywords: payment reform, innovation, multistakeholder coalitions. C ontrolling the costs and improving the quality of health care are central to payment reform efforts. Currently, however, we have little information about the design, 570 D.A. Conrad et al. implementation, and challenges of payment reform initiatives from an “on-the-ground” perspective. Understanding how markets and organizations are experiencing payment reform thus may help guide future efforts, which is the focus of this article. Payment Reform Over the past 3 decades, policymakers, payers, and insurance companies have tried a variety of payment reforms. These have included the Medicare hospital inpatient prospective payment system,1 followed by the Medicare resource-based relative value scale for physicians;2,3 the growth of capitation contracting with medical groups, integrated delivery systems, and pay for performance;4-6 shared savings;7 bundled payments;8-10 and a risk-adjusted global payment.11-13 Recently the focus has turned to improving value by enhancing quality, reducing costs, and matching payment innovations to the structure of the delivery system. These value-based payments link providers’ reimbursements to the value, rather than the volume, of services. Global Payment Models Medicare Pioneer and Shared Savings Accountable Care Organization (ACO) programs, which establish global population-based budgets for participating organizations, are the most visible ongoing payment reform efforts.14,15 Global payment encourages coordination among providers of acute, postacute, and chronic care. ACO programs share any savings with participating organizations, and Pioneer ACOs also share any losses. Accordingly, the payment model encourages treatment decisions that are both clinically effective and cost-effective. Similarly, some private insurers now use the global payment approach. For example, Blue Cross Blue Shield of Massachusetts implemented a global payment linked to pay for performance, referred to as “Alternative Quality Contracting.”11,16 Those providers facing a downside financial risk clearly have a strong incentive to control costs. Similarly, the Massachusetts patient-centered medical home (PCMH) pilot eliminated fee-for-service (FFS) payments to a group of primary care physicians in favor of risk-adjusted capitation (global payment) to support both Emerging Lessons From Innovation in Value-Based Payment Reform 571 the physicians and the care team, as well as the health information technology necessary for the PCMH.17 Bundled Payments Several sites are testing the Prometheus program, which offers episodebased, bundled payments for 21 medical conditions and procedures, based on both the expected costs of treatment and evidence-based practice standards.10 Blue Shield of California joined with Dignity Health and Hill Physicians to offer an ACO under a global payment system for enrollees in the California Public Employees’ Retirement System (CalPERS).Discussion: payment methods in helathcare 18 Partner organizations agreed to share both the upside and downside financial risks. Similar to Medicare ACO programs, the global payment, combined with shared financial risk, encourages the coordination of care as well as cost-effective treatments. As a result, in 2010, the ACO saved $15.5 million, which it shared with its partner organizations. Value-Based Supplemental Payments Value-based supplements to FFS or bundled payments may serve as a “stepping stone” toward greater accountability.19 For example, Blue Cross Blue Shield of Michigan has a “fee-for-value” incentive program in which physicians are rewarded for both an efficient use of health care resources and increased buy-in.20 WellPoint uses “value-based payments” to supplement FFS reimbursements for primary care providers in PCMHs.21 In this way, payments reward quality and efficiency and are intended to compensate physicians for non-visit-based services, such as maintaining disease registries. Several multipayer PCMH pilots provide a “management fee” (based on panel size) to participating providers.22,23 For example, Horizon Healthcare in New Jersey pays “coordination fees” that vary with the type of patient.24 Promise and Challenges of Value-Based Payment Reform Several studies indicate potential for the global budget approach, particularly when it is paired with 2-sided financial risk, to improve quality as well as reduce the level or growth of spending.16,18 Evidence of the 572 D.A. Conrad et al. effectiveness of marginal incentive payments for value is more mixed, however, and may depend on the size of the incentives.25,26 Many payment reform efforts require significant changes in the care delivery and support systems, for instance, in the data- and claimsprocessing infrastructure, electronic health records (EHRs), and staff roles. But providers’ limited ability to meet infrastructure demands for payment reform has made them resistant and hindered its implementation. Some providers thus favor reforming the delivery system through collaborative processes and changes in payment to support the proposed system redesign.27 Payment reform efforts likewise face challenges in setting the “right” level of payment, namely, payment that rewards the appropriate delivery of care and discourages inappropriate care. Particularly when facing the costs associated with system redesign, providers might perceive the expected benefits of new payments as insufficient. The inevitable presence of payment reform “winners and losers” also will dampen the interest of risk-averse players. Implementation Process Studies of payment reform do not elucidate the process of implementing payment reform, yet knowledge of this process could help inform future payment reform. For example, which stakeholders participate; what strategies are undertaken; what specific facilitators and barriers arise; and what lessons have been learned from various projects? Successful payment reform requires providers and payers to collaborate and coordinate and may be impeded by the many contentious and competitive relationships among stakeholders.10,23,28,29 For example, bundled or global payments require that stakeholders agree on the type of payment and means of sharing risk and payment, as well as the metrics for measuring performance. Discussion: payment methods in helathcare Concerns about potential financial losses and inequitable sharing of risk may keep them from reaching a consensus. Furthermore, stakeholders may have different perceptions of the proposed changes, even those on which they agree.10 Concerns about potential violations of antitrust regulation also complicate collaboration among competitors.30 Conversely, strong payer-provider relationships appear to facilitate the implementation of payment and system changes.31,32 The principal role of payment reform is to realign incentives to promote the desired outcomes. Improving value often requires changing Emerging Lessons From Innovation in Value-Based Payment Reform 573 care processes or even redesigning the system itself. Although many payment experiments are under way, little is known about how health care organizations are aligning their payments with their care delivery models in order to lower costs and improve quality and access to care. Purpose of This Article In this article we explain the challenges, opportunities, and emerging lessons of multistakeholder, value-based payment reform by highlighting projects being carried out in 3 regions (and 6 states) of the United States: New England (Massachusetts, Maine, and New Hampshire), southwestern Pennsylvania, and the Pacific Northwest (Oregon and Washington). We highlight the multistakeholder aspect of our study to distinguish it from other projects focused on the result(s) of individual insurer-provider payment innovations not grounded in a multipayer/multiprovider context. Each of the projects we describe here is led by a coalition (with varying constituencies) whose principal role is to act as a neutral convener, honest broker, and governing mechanism for a set of stakeholders joined in a common objective: value-based payment reform through independently owned and potentially competing organizations. In each state the Robert Wood Johnson Foundation (RWJF) is supporting projects that emphasize value-based payment reform.33 (The RWJF’s funding goals and strategy and detailed project descriptions are presented elsewhere.34 ) Notably, each of these projects has been ongoing for more than 3 years, and each (with 1 exception) is at a “midterm,” but not final, stage of development. Methods We applied guidelines from organizational sociology and qualitative methods for the comparative case studies.35-38 In keeping with the principles of qualitative research, our approach to data collection and analysis was inductive, structured around a set of common questions and allowing for open-ended responses and follow-up probes. Consequently, this article does not offer a conceptual model or test explicit hypotheses. Instead, it articulates lessons learned and implications for policy and practice derived from qualitative analysis. The analysis is both vertical, 574 D.A. Conrad et al. in that it briefly examines the context and detail of each distinct project, and horizontal, in that we search for cross-cutting themes among the projects. While we do not claim generalizability per se for our findings, given the natural limits and self-selected nature of our study sample, we do present themes and implications that can inform clinical and managerial practice and policy in value-based payment reform in diverse contexts and markets. Discussion: payment methods in helathcare The University of Washington’s Institutional Review Board reviewed and approved our study protocols. Our qualitative methodology had 6 steps. First, the evaluation team developed a semistructured interview instrument with open-ended items for the key informant interviews. We obtained each site’s grant application, documents from each project’s public website, and other local, publicly available information about each project. Based on within- and between-site reviews of the documents, we then created a semistructured, 2-part key informant interview questionnaire: general questions for all sites covering context, stakeholders, objectives, approach, logic model, progress, and results; and specific questions addressing payment reform features unique to each site. We also made a list of the key informants at each site based on the documents and the RWJF’s records. Second, we interviewed the key informants in each site over time. In each site the evaluation team conducted 2 sets of in-person and phone interviews with key stakeholders after obtaining written informed consent, first in autumn 2011 and then in autumn 2012. The interviews were conducted by the principal or coprincipal investigator, with a coauthor taking real-time interview notes on a laptop computer. In both years, the interviews were audio recorded, and the audio recordings from the 2011 interviews were transcribed. During each site visit, we also collected background documents that key informants shared with us, such as project reports, information from stakeholder websites and other relevant Internet sites, and regional and state publications. Third, we performed qualitative analysis for each site and each year of interviews following the accepted protocols.39 Before analyzing interview data, the team read and annotated the background documents, interview notes, and transcripts. For each question, we summarized the response and coded insights from the interview and/or background documents. Next, for each site, we reviewed the key informants’ responses and constructed responses to each question. Emerging Lessons From Innovation in Value-Based Payment Reform 575 Fourth, we produced a site report and executive summary for each interview in 2011 and 2012. For each site and year, the lead faculty interviewer and cointerviewer prepared the first draft of the site report and an executive summary, which at least 2 other team members reviewed. Based on their reading of interview notes, transcripts, and audio recordings (recordings were referred to only as necessary, such as when notes were missing or ambiguous), the reviewers made annotations and suggested revisions and comments on the first draft of each site report and executive summary. After all 5 members of the team agreed on the facts, narrative, and interpretation, the lead interviewer wrote a report, which the team also reviewed and again revised the report and executive summary. Fifth, we vetted each site’s report and executive summary with the lead contact for each project, whom we asked to identify any apparent errors of omission or commission and to specify any inadvertent breaches of confidentiality or revelations of proprietary or competitively sensitive information. The team reviewed the critiques of all the sites and revised the documents in accordance with the team’s consensus. Sixth, we compared the responses to each interview question in each site to identify cross-cutting themes represented in at least 2 sites. The evaluation team agreed on the themes and observations. Discussion: payment methods in helathcare In the spring of 2012 and 2013 we evaluated the cross-cutting themes with the sites during a structured webinar. The study’s advisory group, composed of 8 national experts in payment reform, reviewed the updated reports in Years 1 and 2, and they suggested themes and insights relevant to payment reform. We then used their comments and insights for the cross-cutting themes in this article. The Projects in Profile Next we describe each project’s objectives, strategies, facilitators, and barriers that have shaped its implementation and progress, as well as the emerging lessons from each project. Appendix Table A1 presents a detailed summary of objectives, care delivery and payment strategies, and target population for each payment reform project, as well as its leadership, governance, and stakeholders. Appendix Table A2 describes the specific barriers and facilitators for each project, which emerged as the main drivers of the “midterm” learning. Appendix Table A3 576 D.A. Conrad et al. summarizes cross-cutting themes and lessons from these regional and state innovations in payment reform and reflects the methodology just described, along with our conclusions. New Hampshire: Accountability Through Transparency and Informed Design The … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10