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.

Accountability in healthcare

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?

The following specifications are required for this assignment:

Length: 1500-2000 words; answers must thoroughly address the questions in a clear, concise manner

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.

Format: Save your assignment as a Microsoft Word document (.doc or .docx).

Accountability in Healthcare Essay Sample

Definition of an Accountable Care Organization (ACO) and its Impacts on Health Care Providers

            An Accountable Care Organization is defined as a group of doctors, hospitals, or other healthcare providers who join to provide coordinated and high-quality care to Medicare patients (Centers for Medicare and Medicaid Services, 2022). An ACO has a significant impact on healthcare providers as it places financial responsibility on the providers to improve patient management while minimizing unnecessary expenditures (Moy et al., 2022). An ACO mainly focuses on avoiding duplication of services and preventing medical errors. An ACO is structured to incentivize providers to be more efficient as it offers bonuses when providers keep healthcare costs down (Moy et al., 2022). Providers must also attain specific quality benchmarks. Such expectations drive the providers to carefully manage their patients with chronic conditions by focusing on prevention to increase the utilization of healthcare services and reduce healthcare costs. Healthcare providers become more accountable for the quality of healthcare services offered. The providers also coordinate more to improve the quality of care and outcomes while keeping the costs down.

 How ACOs Differ from The Health Maintenance Organizations (HMOs) of Earlier Years

            Healthcare costs have been a major concern that has led to the establishment of various agencies, including ACOs and HMOs. Although both ACOs and HMOs were established to reduce healthcare costs, they differ in structure, the role of physicians, size, payment, access, and quality. The structural and conceptual difference between the two is that HMOs are insurance groups that contract the clinicians, while the ACOs are clinicians’ groups that contract with the health insurers (Falkson & Srinivasan, 2021). HMOs were allowed to implement explicit mechanisms such as charging higher fees and incentivizing patients to seek care within the network. On the other hand, ACOs’ beneficiaries are free to hose providers outside the network (Lin et al., 2020). In ACOs, the financial responsibility is placed on the provider with the quality measurement as a determinant of pay rates. Although some HMOs were used to evaluate patient outcomes, there was no direct responsibility of the providers to their patient’s health since they were not evaluated on the overall effectiveness. ACOs are usually small, local, single integrated with primary care physicians as team members, while HMOs are usually large and have fragmented agreements with primary care physicians acting as the gatekeepers.  

Role of Health Information Technology (HIT) in the newer Models of Care

            Newer models of care are focused mainly on quality care and cost-effectiveness. For example, value-based care, which has emerged as a potential replacement for fee-for-service, bases reimbursement on care quality rather than quantity. Current patient care delivery models are based on offering quality care and improving patient outcomes. HIT has been essential to all stakeholders affected by the newer models of care, including physicians, patients, insurers, quality assurance entities, hospitals, researchers, and other stakeholders. HIT has been essential as it has improved the collection of real-time data, data storage, retrieval of stored data, data analysis, and data sharing. HIT has increased operational efficiencies by improving documentation and information accuracy (Isola & Al Khalili, 2022). HIT has also increased coordination through interoperability, which enhances data sharing between stakeholders. With HIT, more informed decisions are made, timely actions are taken, and proper plans are formulated. Stakeholders can access accurate and complete data in providing quality and cost-effective care by minimizing errors in healthcare processes and procedures.

Benefits of Hospitals Partnering with Primary Care Providers

            Partnerships are usually created to promote joint efforts toward common goals and objectives. Partnerships between hospitals and primary care providers offer various benefits to stakeholders involved, including the primary care providers, the patients, and the hospitals. One of the benefits to hospitals is increased efficiency and cost-effectiveness. Primary care providers are usually the patient’s firstcontact in hospitals, and they play an indispensable role in disease prevention and management. Partnering with primary care providers offers stability to hospitals through the retention of primary care providers preventing shortages. Partnerships will likely yield strong relationships based on mutual agreements, with each party leaping benefits. A hospital is likely to benefit from a proper staff ratio of primary care providers. The partnership increases patient access to healthcare services and improved outcomes characterized by improved quality care and increased patient safety. The hospitals benefit from the availability of skilled and competent staff members. The partnerships offer primary care providers job security and enable primary care providers to achieve their independent goals.

How Bundling Payments Contain Healthcare Costs

            Bundling payments have been proposed as a strategy to reduce healthcare costs. Bundling payments can be described as a payment structure where clinicians and healthcare providers treating a patient for the same or related health conditions are reimbursed an overall sum rather than being paid individually for tests, procedures, and treatment. The providers are also rewarded for preventing errors, complications, and duplicating tests and treatment, outcomes achieved through care coordination. The providers are, therefore, accountable for the quality and costs of care. Bundling payments contains healthcare costs since providers assume the risk as they cover costs beyond the target price for each care episode and costs related to any complications and hospital readmissions (Agarwal et al., 2020). On the other hand, the providers share in savings if they incur costs below the target price while maintaining the expected standards. Therefore the providers are motivated to keep costs below the target price, reducing healthcare costs.

How to Pay for Performance (P4P) Improves Quality Care

            Pay-for-performance is a strategy designed to improve quality care through financial incentives. The strategy provides financial incentives to healthcare providers and hospitals to achieve optimal outcomes for patients. Healthcare providers are given a bonus when they meet or exceed the agreed performance or quality measures. Some pay-for-performance programs impose penalties when providers do not achieve the standards. For example, the Medicaid program does not reimburse providers for preventable hospital-acquired conditions. Healthcare providers are kept on their toes to provide quality care to gain bonuses and avoid penalties. Therefore, P4P improves quality care by increasing adherence to best practices (Kyeremanteng et al., 2019). Healthcare providers are more likely to utilize evidence-based practice to improve patient outcomes. They are more likely to adhere to clinical guidelines, organizational protocols, and procedures and integrate research evidence to improve outcomes and prevent medical errors. Such efforts improve the quality of care delivered to patients.

The Value-Based Purchasing Program

            The value-based purchasing program can be described as an incentive program that rewards hospitals providing Medicare beneficiaries with high-quality care (Centers for Medicare and Medicaid Services, 2021). VBP is a mechanism where the CMS ties acute care hospitals’ financial payment adjustments to the performance. The program was initially established as part of the Affordable Care Act. It was implemented in U.S. hospitals in the 2013 fiscal year. The program encourages hospitals to improve care quality, patient experiences, efficiency, and safety of care received by Medicare beneficiaries. Hospitals that participate in the VBP program are usually assessed in specific performance areas, including patient safety, efficiency, cost reduction, patient experience, mortality and complications, and healthcare-associated infections (Centers for Medicare Medicaid Services, 2021).

 How Value-Based Purchasing (VBP) Programs Affect Reimbursement to Hospitals

            The value-based purchasing programs adjust hospital reimbursements under the Inpatient Prospective Payment System (IPPS). The IPPS is the largest share of Medicare spending. The program withholds the hospital’s Medicare payment of 2%, which is the specified amount. The total amount reimbursed or earned back by a hospital depends on the actual amount earned based on the actual range and distribution of all the participating or eligible hospitals’ Total Performance Scores (TPS). A hospital can earn back a percentage that is less, equal, or more than the applicable reduction expected for the program year (Centers for Medicare and Medicaid Services, 2021).

Main Beneficiary of value-based reimbursement

            Patients are the main beneficiary of value-based reimbursement since they are the ones that are significantly impacted by the model. Patients are at the center of value-based reimbursement. They spend less for better outcomes and are satisfied with their care. Healthcare providers focus on necessary tests and treatment for patients and work towards reducing medical errors and increasing patient satisfaction with their care. The CMS encourages hospitals and healthcare providers to improve the safety and quality of acute inpatient care by adopting and integrating evidence-based standards and protocols, eliminating adverse events and medical errors, increasing care transparency, and changing hospital processes to improve patient experiences (Catalyst, 2017). Integration of the following aspects in clinical practice improves patient outcomes. Patients receive the best care from hospitals and providers. For example, they do not experience medication errors that may have a setback in their recovery. They receive evidence-based interventions that are effective in addressing their health issues.

How does the VBP Program Measure Hospital Performance

            The program’s financial incentives comprise a redistribution of funds held from hospital payments and penalties for poor performers. The model assumes that lower-score facilities offer low-quality care (Centers for Medicare and Medicaid Services, 2021). Hospital scores depend on the hospital’s performance in each area, including patient safety, efficiency, cost reduction, patient experience, mortality and complications, and healthcare-associated infections. Each performance area is assigned 25% ‘weight’ used in calculating the total performance score of a hospital. Achievement, consistency, and improvement points are all considered in assessing a hospital’s overall performance. Achievement points are awarded to hospitals that perform better than the baseline in each measure. Improvement points are awarded when a hospital improves upon the previously reported measure, while consistency points are awarded when performance is at or above the 50th percentile in HCAHPS patient satisfaction scores. Total scores determine whether a hospital receives a bonus or penalty.

Conclusion

            The discussed aspects, including ACOs, bundling payments, pay-for-performance, health information technology, and value-based purchasing programs, focus on improving care quality while reducing healthcare costs. The programs, partnerships, groups, and initiatives focus on accountability on the side of healthcare professionals and hospitals. The strategies adopted by healthcare stakeholders improve the quality of care by placing the financial responsibility on healthcare providers to ensure that patients receive essential treatment intervention.

References

Agarwal, R., Liao, J. M., Gupta, A., & Navathe, A. S. (2020). The Impact of Bundled Payment on Health Care Spending, Utilization, And Quality: A Systematic Review: A systematic review of the impact on spending, utilization, and quality outcomes from three Centers for Medicare and Medicaid Services bundled payment programs. Health Affairs39(1), 50–57.

https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00784

Catalyst, N. E. J. M. (2017). What is value-based healthcare? NEJM Catalyst3(1). https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0558

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

Centers for Medicare and Medicaid Services. (2022). Accountable Care Organizations (ACO): What is an ACO?

https://www.cms.gov/medicare/medicare-fee-for-service-payment/aco#:~:text=What%20is%20an%20ACO%3F,care%20to%20their%20Medicare%20patients.

Falkson, S. R., & Srinivasan, V. N. (2021). Health Maintenance Organization. In StatPearls [Internet]. StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK554454

Isola, S., & Al Khalili, Y. (2022). Protected Health Information. In StatPearls [Internet]. StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/books/NBK553131

Kyeremanteng, K., Robidoux, R., D’Egidio, G., Fernando, S. M., & Neilipovitz, D. (2019). An analysis of pay-for-performance schemes and their potential impacts on health systems and outcomes for patients. Critical Care Research and Practice2019. https://www.hindawi.com/journals/ccrp/2019/8943972/

Lin, S. C., Yan, P., Moloci, N., Lawton, E., Ryan, A. M., Adler-Milstein, J., & Hollingsworth, J. M. (2020). Out-of-Network Primary Care, not Specialty Care, is Associated with Higher Per Beneficiary Spending in Medicare ACOs. Health affairs (Project Hope)39(2), 310. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7213776/

Moy, H. P., Giardino, A. P., & Varacallo, M. (2022). Accountable Care Organization. StatPearls [Internet].

https://pubmed.ncbi.nlm.nih.gov/28846320

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