Volume to Value: Payment Reform and Alternative Payment Models

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As our world and health care climate progress, one thing is becoming blatantly evident. There needs to be change. The old ways of doing things just aren't cutting it anymore. For patients, payers, and providers alike. Because of this, in recent years we as a nation have begun the process of innovation and research towards making that change on a global scale and here's why:

Whether a patient visits with his or her physician for 15 minutes or 45 minutes, the health center is reimbursed the same amount - this is causing massive issues in quality of care for patients, often times leading to misdiagnosis, reoccuring visits, and more time spent in health centers in order to diagnose the problem correctly. 

Under suggested Alternative Payment Model (APM) solutions, reimbursements reflect value of care provided to patients. This is key. This means that instead of physicians getting paid the same amount of reimbursement per visit, the value of care provided to the patient will determine the level of reibursement the provider recieves.  This also depends greatly on how well the center is meeting the "Triple Aim" (Lower per capita cost, Better Patient Experience, and Increased Population Health Outcomes). These measures will work to incentivize health care in a way that works to promote overall population health globally and in contrast demonize fee-for-service care based solely on face to face visits.

With that being said, oppurtunities for innovation can in turn, arise and prosper such as Telehealth services. Medical care providers have had the capability to do this for a while now, but it wasn't until just recently that we've begin to see this really pick up. Patients that can't necessarily make it in to the office, or perhaps just need to speak to their primary care physician outside of office hours, would be able to have access to their medical provider via these services. This would highly improve quality of care in multiple aspects. 

So nationally, what exactly are we doing:

Currently, the Medicare Access and CHIP Reauthorization Act (MACRA) provides a 5% annual lump sum payment to physicians who participate in qualified APMs at certain threshold levels, and it exempts them from the new Merit-based Incentive Payment System or MIPS. Participation in other APMs, or participation in qualified APMs at levels below the MACRA thresholds, will allow physicians to improve their MIPS scores.

How can medical societies develop an APM:

The AMA encourages medical societies to use a simple 5-step process for developing the types of APM proposals that will work effectively for physician practices and that Medicare and other payers can implement under MACRA:

  • Establish a committee of physicians who are willing to spend the time needed to develop 1 or more APMs.
  • Identify specific opportunities to improve patient care that are likely to result in specific types of spending reductions, and identify the specific barriers in existing payment systems that make it difficult for physicians to implement these improvements in patient care.
  • Identify the payment changes needed to overcome these barriers. Not all APMs actually overcome the barriers, and some have unintended consequences that can create new problems for physicians.
  • Analyze whether the benefits for patients and the savings for payers and patients are sufficient to justify any costs associated with appropriate payment changes.
  • Design a payment model that removes the barriers to improving care so that physicians can improve outcomes for patients and achieve savings for payers.

Payment Reform and Value-based care are at the heart of the Delaware Center for Health Innovation’s (DCHI) efforts towards making Delaware one of the top five healthiest states in the nation. With the goals of being in top 10% of states in health care quality and patient experience, bringing the growth of health care costs in line with GDP growth, and improving the provider experience, DCHI is working in conjunction with public and private stakeholders to advance outcomes in Delaware by 2020. For more information please visit us at https://www.dehealthinnovation.org/.

**Articles are intended to foster meaningful discussion about the opportunities and challenges driving healthcare reform**

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