Health Care Reimbursement
Part 1 ( need this part on 12/24/2020 by 11Am Health Care Reimbursement and Utilization Management Accountable care organizations (ACOs) are designed to promote value and quality in health care. They use new payment and delivery models that include incentives to improve care coordination and utilization management. With these models, ACOs contract with private insurers and/or Medicare to receive reimbursement, and then the ACO determines how to contract with physicians and other medical providers to provide health care services to patients. Since not all providers are direct employees of ACOs, there are potential challenges with reimbursing the affiliated providers in a way to maximize efficiency, increase quality, and lower utilization. For this Discussion, examine the following scenario and recommend strategies for reimbursement and utilization management. Scenario: Medicare and private payers have expanded reimbursement under Accountable care organizations (ACO). You are the chief financial officer (CFO) of a hospital system that is forming an ACO to participate in these payment models. The ACO seeks to improve care coordination for its patients with chronic conditions. To provide better care management, the ACO is interested in investing in primary care physicians and physicians assistants to provide more intensive care management services. After formation, the ACO will enter contracts with Medicare and private insurers under alternative payment models, including shared savings, bundled payments, and global capitation. The ACO will need to determine how to set up reimbursement payments to ACO providers and consider whether financial incentives are required to ensure ACO providers deliver efficient care. To prepare for this paper: Read the provided scenario. Consider strategies for reimbursement and utilization management, including financial incentives. How might you set up the reimbursement payments to ACO providers, considering the alternative payment models (i.e., fee for service, shared savings, bundled payments, or global capitations)? What utilization management controls might you add to align the interests of ACO providers? Write a one page a cohesive response to the following: As the CFO of the ACO in the provided scenario, recommend strategies for reimbursement and utilization management. Defend your recommendations. Support your response by identifying and explaining key points and/or examples presented in the Learning Resources. Learning resources Getzen, T. (2015). Health economics for the healthcare administrator (Laureate custom edition). New York: Wiley. Chapter 4, Health Insurance: Financing Medical Care (pp. 6990) Chapter 5, Insurance Contracts and Managed Care (pp. 96119) Pink, G. H. & Song, P. H. (2020). Gapinskis understanding of healthcare financial management (8th ed.). Health Administration Press. Chapter 12, Project Risk Analysis Sommers, B. D., Musco, T., Finegold, K., Gunja, M. Z., Burke, A., & McDowell, A. M. (2014). Health reform and changes in health insurance coverage in 2014. Waltham, MA: New England Journal of Medicine. Note: Retrieved from the Walden Library databases. Cost Sharing as a Tool to Drive Higher-Value Care https://class.content.laureate.net/201ec0adcc19a95086265060de0a665f.pdf https://jamanetwork-com.ezp.waldenulibrary.org/journals/jama/fullarticle/2290607 Part 2 ( need this one by 12/26 Supply of Primary Care Workforce To deliver health care services, an ACO needs to create a competent workforce that can provide healthcare to the patients that are in the ACO. Some integrated ACO entities already have employed physicians and mid-level providers that receive salaries from the organization, whereas other non-integrated ACO entities need to invest in external relationships with independent physicians and other providers. Since ACOs do not have managerial control over non-employed providers, additional controls and incentives may be necessary to ensure that efficiency is maximized. ACOs also need to consider the number and mix of specialists (e.g., family practice vs internal medicine) and mid-level providers (e.g., physician assistants and nurse practitioners) in delivering primary care services that can promote value. Maximizing value requires appropriate workforce decisions on supply and incentives to encourage providers to minimize costs. For this Assignment, examine the Week 4 Assignment document and consider the efficiency in the supply of health services. To prepare for this Paper: Review the scenario and Week 4 Assignment document provided to you by the Instructor. Based on the financial data, conduct a financial projection (revenues, expenses, and profit) that analyzes the efficiency of the supply of health services. The Assignment: In a 2- to 3-page Word document that includes tables and/or calculations, make recommendations on the following: 1) number of physicians and nurse practitioners needed; 2) reimbursement method: salary or fee-for-service; 3) recommendations for financial incentives to address the challenges of supplier-induced demand and how to ensure efficiency. Interpret the net profit from the ACO contract based on your recommendations. Explain the rationale behind your recommendations, including the impact made by your financial calculations.