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Reimbursement Models

Develop a two-page memo to help relevant stakeholders at Vila Health’s St. Anthony Medical Center better understand traditional and emerging reimbursement models.

Introduction

Note: This assessment uses the following media as the context for developing the reimbursement model memo. Review this media before you submit your assessment.

Basic understanding of the reimbursement system requires one to appreciate the size and scope of the system, the complexities associated with the system, and the various subsystems and payment rules associated with health care reimbursement and finance. As a dominant player in the health care sector, the U.S. federal government is the largest single payer for health care services. As a result of its size and dominance within the system, any changes made by the federal government regarding its reimbursement of health services profoundly affect those who are rendering the care, including providers, other payers, and the health system overall. In addition to government-sponsored health insurance, various other forms of health coverage, generally tied to employment as a benefit, were introduced in the United States to help offset the expenses associated with the treatment of illness and injury.

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In an effort to address concerns within the U.S. health system regarding cost, access, and quality, Congress passed the Patient Protection and Affordable Care Act (PPACA or ACA) in 2010, with President Barack Obama signing it into law. Components of the PPACA included making health insurance coverage affordable, expanding Medicaid coverage, and improving quality while controlling costs. To this end, the ACA required the Centers for Medicare & Medicaid (CMS)to promote the concept of the accountable care organization (ACO) through a shared savings plan driven by a triple-aim approach. In addition to the ACO, the ACA required CMS to implement value-based purchasing programs that would reward hospitals for the quality of care they provided to enrollees.

As the recipient of the largest share of Medicare funds, the new value-based purchasing approach measures hospital performance using four domains:

  1. Clinical care.
  2. Safety.
  3. Efficiency and cost reduction.
  4. Patient experience of care (Casto & Forrestal, 2019, p. 274).

Each measure scores the hospital performance achievement as well as their performance improvement.

As a health care sector employee, understanding the complex U.S. health care reimbursement system allows one to serve as a reference to internal and external stakeholders, family members, and organizational departments whose needs often require a working knowledge of how the system is financed. 

In this assessment, you demonstrate your understanding of traditional and emerging health care reimbursement models by composing a memo that outlines the characteristics and differences between reimbursement models. This memo targets relevant stakeholders from the Vila Health media simulation based in St. Anthony Medical Center.

Reference

Casto, A. B. (2019). Principles of healthcare reimbursement (6th ed.). AHIMA Press.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

  • Competency 1: Compare current trends and traditional methods of payment in the health care industry.
    • Describe traditional payment models in health care.
    • Describe current trends in health care payment models.
  • Competency 2: Assess health care reimbursement.
    • Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
    • Explain reasoning for newer models of reimbursement in health care.
    • Explain quality concerns affecting reimbursement given a specific patient scenario.
  • Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
    • Adhere to the rules of grammar, usage, and mechanics.
    • Apply APA formatting to in-text citations and references.

Instructions

You will use Vila Health: Investigating a Readmission as the context to address Part 4 of this assessment.

Several of the Vila Health’s stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.

Support your assertions in the memo with at least three academic sources. This may require you to do additional independent research. You may wish to consult the Health Care Administration Undergraduate Library Research Guide before you begin any additional research.

This assessment has four main parts.

Part 1: Traditional Payment Methods

Relevant scoring guide criteria:

  • Describe traditional payment models in health care.
    • “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
    • Identify the traditional payment models.
    • What are the key characteristics of these reimbursement models?
    • How was quality monitored under these models?
  • Adhere to the rules of grammar, usage, and mechanics.
    • “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
    • “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
    • “Mechanics” refers to correct use of capitalization, punctuation, and spelling.
  • Apply APA formatting to in-text citations and references.

This part should be at least one paragraph long, but probably no more than half a page.

Part 2: Current Trends in Healthcare Payment

Relevant scoring guide criteria:

  • Describe current trends in health care payment models.
    • Identify the current trends in health care payment models.
    • What are the key characteristics of these reimbursement models?
    • How is quality monitored under these models?
  • Explain reasoning for newer models of reimbursement in health care.
    • “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.
  • Adhere to the rules of grammar, usage, and mechanics.
  • Apply APA formatting to in-text citations and references.

This part should be at least one paragraph long, but probably no more than half a page.

Part 3: Comparison of Models

Relevant scoring guide criteria:

  • Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
    • Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models.
  • Adhere to the rules of grammar, usage, and mechanics.
  • Apply APA formatting to in-text citations and references.

This part should likely be between a half and one page long.

Part 4: Quality Concerns

Relevant scoring guide criteria:

  • Explain quality concerns affecting reimbursement given a specific patient scenario.
    • Specifically address the recent problematic patient case from the Vila Health: Investigating a Readmission scenario.
    • Briefly discuss how the care provided would be reimbursed under prior models versus reimbursement under newer models, based on your assertions in Part 3 of your memo.
    • Also, identify quality issues that will likely impact the organization’s reimbursement under new payment models.
  • Adhere to the rules of grammar, usage, and mechanics.
  • Apply APA formatting to in-text citations and references.

This part should be at least one paragraph long, but probably no more than half a page.

Additional Submission Requirements

  • Structure: Structure your submission like a memo, with an additional, APA-style references page. Use the Reimbursement Model Memo template [DOC] provided. You may wish to refer to the following example when developing your memo:
  • Length: 2–3 pages, plus a references page.
  • References: Cite at least three current scholarly or professional resources.
    • Your textbook can be one of the three.
  • Format: Use APA style for references and citations only. Refer to:
  • Font: Times New Roman, 12 point, double-spaced.

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