Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance
Guide to Value-Based Reimbursement:
Profiting from Payment Bundling,
PHO Shared Savings, and Pay for Performance
In healthcare's post-reform volume-to-value world, payor reimbursement strategies are tipping in favor of providers who can deliver the clinical and financial goods. In the mix are bundled payments, shared savings, pay for performance and bonuses — with some going so far as to restructure organizations for maximum gain.
The Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance explores emerging models of episode-based payments, physician-hospital organizations and physician bonus structures.
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Highlights from the 60-page guide include the following:
- Jay Sultan, associate vice president and chief product portfolio architect for TriZetto®, provides perspectives on payment bundling, including definitions of key elements, advice for payors and providers, what's ahead in bundled payments for primary care, and examples of the payment model at work in one organization.
An advisor to participants in CMS's Acute Care Episode (ACE) demonstration, an earlier test of episodic payments, Sultan also describes a bundled payment collaboration between two surgical groups that has not only reengineered every aspect of care but also generated significant savings for the groups.
Next, deconstructing the physician-hospital organization (PHO) model are:
- Healthcare Strategy Group thought leaders Travis Ansel, MBA, manager of strategic services, and Greg Mertz, MBA, FACMPE, director of consulting operations. The two guide healthcare executives through the seven critical areas of PHO development, from defining the PHO mission to creating a data environment conducive to registry use, analytics and active patient management.
Also described are the changing payor environment and incentives available to providers, offering practical considerations for creating a culture of collaboration with the PHO and engaging both providers and employers in this emerging model.
- And on the subject of physician pay-for-performance and realistic bonus structures, Julie Hobson, RN, BSN, manager of provider engagement, performance and partnership at Highmark Inc., describes the evolution of Highmark's program to meet today's healthcare market realities.
Highmark's 6,300 enrolled primary care physicians can earn bonus payments across six measure sets a broad spectrum of measures from clinical and quality measures to prescribing habits, access to care and level of technology use.
In addition, practices can also qualify for a bonus payment based on development or improvement of a Best Practice evidence-based quality improvement project.
Q&A section answers 35 queries on the reimbursement strategies presented in this resource.
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