Accountability in Healthcare
This assignment will be at least 1500 words. Address each bulleted item (topic) in detail including the questions that follow each bullet. There should be three (3) sections in your paper; one for each bullet below. Separate each section in your paper with a clear brief heading that allows your professor to know which bullet you are addressing in that section of your paper. Include a “Conclusion” section that summarizes all topics.
This week you will reflect upon accountability in healthcare and address the following questions:
- Briefly define an Accountable Care Organization (ACO) and how it impacts health care providers:
- How do ACOs differ from the health maintenance organizations (HMOs) of earlier years
- What role does health information technology (HIT) play in the newer models of care?
- What is the benefit of hospitals partnering with primary care providers?
- How does bundling payments contain healthcare costs?
- How does pay for performance (P4P) improve quality care?
- Briefly discuss the value-based purchasing program?
- How do value-based purchasing (VBP) programs affect reimbursement to hospitals?
- Who benefits the most from value-based reimbursement and why?
- How does the VBP program measure hospital performance?
Length: 1500-2000 words in length
Structure: Include a title page and reference page in APA format. These do not count towards the minimal word amount for this assignment. Your essay must include an introduction and a conclusion.
References: Use the appropriate APA style in-text citations and references for all resources utilized to answer the questions. A minimum of two (2) scholarly sources are required for this assignment.
Accountability in Healthcare
Accountability in healthcare entails putting the best interest of the client first and being able to justify one’s actions. It is crucial for healthcare stakeholders, mainly the healthcare providers and hospitals, to be held accountable. The discussion of the paper focuses on various efforts by stakeholders and strategies used to increase accountability in the healthcare industry. They include Accountable Care Organizations, Health Maintenance Organizations, bundled payment, pay-for-performance, and value-based purchasing programs.
Definition of an Accountable Care Organization and How they Impact Healthcare Providers
An Accountable Care Organization (ACO) refers to a group of hospitals, doctors, and other healthcare providers that work together voluntarily to provide high-quality care to Medicare patients. In an ACO, payments or reimbursement to health care providers are tied to the value and quality of care that the patients receive and not volume. ACOs improve care by coordinating the delivery of health care, increasing effective utilization of health information technology, and increasing the involvement of patients and their families in decision making (Nickitas, Middaugh, & Feeg, 2019). Different types of ACOs, which include those in Medicare, Medicaid, and those commercial insurance markets, have shown promising progress over the years. Health care providers are impacted in the way they deliver care to patients. ACOs require that a healthcare provider coordinates with other providers through communication and in working as a team. This increases accountability among the healthcare providers while improving the quality of care provided to patients. The healthcare providers also have to partner with patients and families in developing treatment and care plans for patients. ACOs encourage providers to work as a team and improve the quality and safety of care (Summers et al., 2015).
How ACOs Differs from Health Maintenance Organizations
ACOs are comprised of clinicians that contract with insurers, while HMOs are insurance groups that enter a contract with the clinicians. An HMO is made up of media insurance providers who limit coverage of care provided to patients through healthcare providers that are under contract with the network. The purpose of an HMO is to fix the price or cost of healthcare by focusing on the overall welfare of the patient and preventive care and by covering in-network health facilities and physicians. ACOs, on the other hand, are committed to leveraging better and more efficient and effective healthcare practices for the benefit of the patient. Another key difference between ACOs and HMOs is the focus of care delivery. ACOs focus on delivering patient and family-centered high-quality care. ACOs invest in initiatives that foster partnerships between healthcare providers and patients at all levels of care. The partnership is reflected in shared decision-making, care planning, management, and involvement of patients and families in practice and quality improvement projects (Summers et al., 2015).
Role of Health Information Technology in Newer Models of Care
The focus of newer models of care is the delivery of quality and safe care while reducing costs. Quality care is characterized by various components such as data sharing, effective communication, care coordination, and shared decision making. These components require increased access to accurate and complete health care data and information. HIT plays various roles, such as facilitating communication among multiple providers. Electronic health records are part of the HIT and reduce errors in communication by facilitating the storage of accurate and complete patient medical history and medical records. HIT provides access to information as professionals can access information through handheld devices and can reference any data efficiently. HIT also increases patient-centered care by fostering communication and interaction between providers and patients through online portals, emails, and text messaging. HIT also facilitates remote monitoring of patients reducing the time and resources required for patients to access care and for providers to deliver care. According to Wienert (2019), HIT increases the performance of healthcare services, saves costs, improves the quality of care, and increases the involvement of patients as effective partners in their care.
The Benefit of Hospitals Partnering with Primary Care Providers
Partnerships between hospitals and primary care providers can improve the quality of care to patients. The partnership can lead to better management of acute episodes as the primary care providers will build on a well-known medical and social history of the patient. Better management of health conditions leads to shorter hospitalization periods and better patient experience. Patients with chronic illnesses will benefit from better management of their conditions. The partnership between hospitals and primary care providers increases patient follow-up reducing preventable readmissions. The hospitals will benefit from reduced preventable hospital readmissions. The readmissions increase health care costs incurred by the hospitals as they are not reimbursed. The hospitals also benefit from increased patient experience and satisfaction through better ratings. According to Nickitas, Middaugh, and Feeg (2019), hospitals can control the market for their services, patient admission and have greater leverage when negotiating rates with the insurers.
How Bundling Payments Contain Healthcare Costs
Bundling payments is a payment approach where multiple health care providers are reimbursed by an insurer a single sum of money for all the medical services related to a specific episode of care as opposed to reimbursement for each service (Nickitas, Middaugh, & Feeg, 2019). Bundling payment reduces healthcare costs using various mechanisms that include reducing unnecessary physician services, promotion of more judicious utilization of health care resources during patient hospitalization, and reduction in post-discharge expenses. Health care providers are more accountable since they bear the liability of any costs that exceed the bundled payment. This discourages the delivery of unnecessary care, such as unnecessary diagnostic tests and medical procedures. The approach encourages quality care as opposed to quantity of care. Bundled payment acts as an incentive for healthcare providers to reduce costs by eliminating unnecessary services.
How Pay for Performance Improve Quality Care
The pay-for-performance approach has been adopted widely, with the main goal of improving the quality of healthcare provisions. The approach provides the healthcare providers with an opportunity to have their reimbursement increased if they achieve specific quality benchmarks. The approach provides financial incentives to healthcare providers, doctors, and hospitals to achieve ideal patient outcomes and specific performance scores. The approach utilizes financial incentives to increase adherence to clinical guidelines and best practices, which improves clinical outcomes and the quality of care. The approach allows healthcare payers to redirect financial resources to encourage better clinical practice. The pay-for-performance approach facilitates control of costs by aligning hospitals and physicians, and other healthcare providers (Nickitas, Middaugh, & Feeg, 2019). Since the approach aligns the compensation of the employees with their work contribution, the employees are more likely to meet the set goals while increasing efficiency. They offer health care utilizing the best resources, including tools and information, to meet expectations and receive a greater reward. In return, the quality of care provided improves.
The Value-based Purchasing Program
The value-based purchasing program can be described as an incentive program established by the Centers for Medicare and Medicaid Services and rewards hospitals that provide high-quality care to patients who are beneficiaries of Medicare. The program was established first as part of the ACA and was implemented in the 2013 fiscal year. Statutory requirements for the program are outlined in the Social Security Act, section 1886 (o). Hospitals that perform in the program have to be assessed in four areas that include clinical care, safety, care coordination, efficiency, and cost reduction. Hospitals that perform better than the baseline for each selected quality and clinical measure are awarded achievement points. The scoring information is used to determine whether the facility receives a penalty or a financial bonus. The program penalizes poor-performing hospitals while rewarding higher-performing counterparts (Lee et al., 2020).
How the Value-based Purchasing Programs Affect Reimbursement to Hospitals
The value-based purchasing programs increase or decrease hospital reimbursement depending on their performance. The primary goal of the program is to improve the safety and experience of patients by basing Medicare reimbursement on quality rather than quantity of health care provided. Hospitals are rewarded based on their performance. The bonus payments are raised through a 2% reduction in all payments. Since the budget is neutral, the 2% reduction has to be paid by the hospital participating in the program. The highest performing facility earns a bonus that is more than the payment reduction, while other facilities receive minimal payment or fail to earn a bonus at all. Hospitals that fail to meet the required performance are penalized as they have to be pay back the 2% reduction but do not earn the bonus (Centers for Medicare and Medicaid Services, 2021).
Who Benefits Most from the Value-based Reimbursement and why
The patient is the most obvious beneficiary of the VBP since the primary goal of the program is to deliver value to patients. Patients experience better outcomes across all areas of healthcare. The program encourages the entire healthcare system to solve the needs of patients rather than addressing the presenting illness. Performance improvement tools used by hospitals include updated protocols, better management control, and better support systems for clinical decision-making. The tools not only increase accountability of health care providers in diagnosis but also coding and learning new systems crucial for achieving targets of performance that include efficiency, patient experience, and technical outcomes (Lee et al., 2020).
How the VBP Measure Hospital Performance
According to the Centers for Medicare and Medicaid Services (2021), VBP measures hospital performance using components that include patient safety, mortality and complications, patient experience, healthcare-associated infections, and efficiency and cost reduction. A hospital may earn two points for each measure. One point is for achievement, while the other is for improvement. The scores are based on the hospital’s performance in comparison with other facilities and the improvement made by the hospital in comparison with previous performance.
Various strategies are used to increase accountability in the healthcare industry to improve performance and increase the value of care delivered to patients. These include ACOs, HMOs, bundled payment, pay-for-performance, and value-based purchasing programs. Although various approaches are used, the aim of the strategies is to improve the quality of care and improve outcomes through improved performance and outcomes.
Centers for Medicare and Medicaid Services. (2021). The Hospital Value-based Purchasing (VBP) Program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing
Lee, S. J., Venkataraman, S., Heim, G. R., Roth, A. V., & Chilingerian, J. (2020). Impact of the Value‐Based Purchasing Program on Hospital Operations Outcomes: An Econometric Analysis. Journal of Operations Management, 66(1-2), 151-175. https://onlinelibrary.wiley.com/doi/abs/10.1002/joom.1057
Nickitas, D. M., Middaugh, D. J., & Feeg, M. D. (2019). Policy and Politics for Nurses and Other Health Professionals: Advocacy and Action. (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers.
Summers, L., De Lisle, K., Ness, L. D., Kennedy, B.L., & Muhlestein, D. (2015). The Impact of Accountable Act: How Accountable Care Impacts the Way Consumers Receive Care. https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.nationalpartnership.org/our-work/resources/
Wienert, J. (2019). Understanding Health Information Technologies as Complex Interventions with The Need for Thorough Implementation and Monitoring to Sustain Patient Safety. Frontiers in ICT, 6, 9. https://www.frontiersin.org/articles/10.3389/fict.2019.00009/abstract