Summary: In this article we will discuss Value-Based Purchasing and how it impacts the Pharma industry in particular. According to an issue brief by Deloitte Center for Health Solutions, Value-based pricing for pharmaceuticals: Implications of the shift from volume to value, a shift in risk is occurring in the pharma industry as a result of healthcare legislation, culminating with the Affordable Care Act (ACA).
On April 30, 2014, CMS announced proposed IPPS regulations to become effective January 1, 2015. The ruling covers: Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, Hospital-Acquired Condition Reduction Program, Quality Reporting Programs, and Wage Index – Updated Labor Market Areas. CMS just announced proposed regulations to become effective January 1, 2015. These regulations further the goals of the Affordable Care Act: increasing patient outcomes and reducing healthcare spending. These proposed regulations are Medicare specific and, if approved, will be applicable to general acute care and long-term care hospitals.
Summary: As a result of the ACA and the increase in patients while the physician shortage is magnified, efforts are under way to address the lopsidedness of supply and demand. One of those efforts is telemedicine. The influx in individuals who are recently eligible for insurance coverage has added fuel to the fire in terms of the number of physicians who can provide care. Telemedicine is expanding in popularity and use as a means to address this issue, while also reducing healthcare costs and increasing both accessibility and affordability.
Summary: What is contributing to the rapid expansion of ACOs? What programs are currently being piloted? What are the initial results of current ACOs? What is an ACO? An ACO is a group of healthcare providers who work together and accept accountability for reducing costs and increasing quality of care.
Summary: Accountable Care Organizations (ACOs) are gaining in popularity as a result of the Affordable Care Act. Have you considered the benefits of ACOs from both the patient and provider perspectives? One of the goals of the Affordable Care Act (ACA) is to provide coordinated care which, in turn, increases quality and efficiency within the healthcare field, and reduces costs. ACOs – What is an ACO? ACOs are groups of providers which form an organization based upon the Medical Home (or PCMH) concept. The Medical Home places responsibility for the coordination of care with the primary physician. The primary care physician coordinates with other physicians and providers such as specialty physicians, laboratories and diagnostic imaging, providing a central point for the patient’s medical information.
The pay for performance model of payment has been the preference of health insurance companies for several decades. Previous models made it too easy for money to be paid for services that were not truly needed, were poorly documented or in some cases, were entirely fabricated for the purpose of payment. Pay for performance measures are meant to validate payments to physicians in accordance with The Affordable Care Act by using data mining techniques to keep tabs on physician costs.
The “patient is always right” model has been the primary driving force behind healthcare for the last several decades. But is this the right approach? Classifying patients as “customers” is a slippery slope. While you might be able to barter with a customer at a shop about the price of a necklace, should doctors ever barter with a patient about their treatment? What about when their patient satisfaction scores are drooping low?
Physician practices may be lagging behind hospitals when it comes to implementing coding software. The hesitation to do so is costing them not only efficiency in coding, but reimbursements withheld due to avoidable errors.
Summary: Do you understand Relative Value Units (RVUs) as they relate to Medicare reimbursement? Is your physician compensation model based upon RVUs or a derivative thereof? What is an RVU? RVU stands for Relative Value Unit and is currently used by Medicare to determine the amount of reimbursement to providers. RVUs are basically a way of standardizing and comparing service volumes across all continuums.