Accountability in Healthcare

Accountability in Healthcare

Introduction

The healthcare system in the United States is becoming more costly with every passing day. This has negatively affected the access to healthcare services by individuals from low socioeconomic backgrounds. Even though the costs of care are high, healthcare services are not of optimal quality. Patients should consider shifting from volume-based healthcare services to value-based models. Healthcare organizations must be accountable and take responsibility for the services they offer to their patients. Healthcare professionals can be accountable by using interprofessional collaboration, leveraging technology, and using value-based payment programs.

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Accountable Care Organizations (ACOs)

ACOs are a network of physicians, hospitals, and other healthcare workers who coordinate care and reduce healthcare costs for reimbursement purposes (Wilson et al., 2020). ACOs must be obligated to meet quality performance standards and lower Medicare spending by certain percentages to quality incentives due to cost-sharing. ACOs impact how healthcare professionals offer their services since they have to implement quality improvement programs and reduce the costs of their healthcare services to get incentives from Medicare. Healthcare professionals must focus more on preventive healthcare services and reduce hospital visits and hospitalizations (Wilson et al., 2020). This can result in lower reimbursement rates and low revenue since the traditional payment systems are incentivized to order more diagnostic tests and procedures.

ACOs improve patient outcomes, quality healthcare services, better patient engagement, and reduced out-of-pocket spending (Wilson et al., 2020). Healthcare professionals share in cost savings by implementing successive preventive healthcare services. The result of ACO is a healthy population.

ACOs vs. HMOs

Health maintenance organizations  (HMOs) are network insurance plans that offer healthcare services to a defined population at fixed prices (Tabriz et al., 2017). ACOs and HMOs are similar in that they have a network of physicians and promote healthcare management to lower healthcare costs. These two organizations, however, have some differences. Unlike HMOs, ACOs are not insurance organizations, and the healthcare providers are incentivized for care coordination (Wilson et al., 2020). The primary care providers in ACOs rely on other healthcare professionals, such as pharmacists and nurse practitioners, to track appointment compliance, manage drug schedules, and track lifestyle changes.

In ACOs, patients can go to physicians of their choice. Patients not happy with their services can go to other providers (Wilson et al., 2020).  This is not the case in HMOs since patients can only see physicians within the HMO network (Tabriz et al., 2017). Participation in HMOs is not voluntary, and there are enrollment provisions that patients must meet. HMOs have gatekeepers who have to pre-authorize patients before seeing specialties (Tabriz et al., 2017). This is not the case in ACOs since there is no gatekeeping and pre-authorization. Patients do not need any approval before consulting other physicians.

Role of HIT in New Healthcare Models

Newer healthcare models such as ACOs need healthcare professionals to share healthcare information. Health information technology (HIT) can be used to help in the collection, analysis, and exchange of data. ACOs can use HIT to share healthcare information among healthcare professionals, patients, and other healthcare organizations (Rural Health Information Hub (RHIB), 2021). This sharing of information can help to improve the coordination of care. ACOs can also use Hit to collect and integrate data from sources like clinical, financial, and operational (RHIB, 2021). This data can be used to improve the efficiency of healthcare services.

HIT can be used to manage population health and support patient safety by using electronic health records, which can reduce medication errors (RHIB, 2021). ACOs can use HIT to maintain the security of healthcare information through passwords and encryptions. This will comply with the HIPAA regulations. HIT used in ACOs includes patient registries, EHRs, data aggregation software, and regional health information organizations (RHIB, 2021). HIT will help improve patient safety and reduce healthcare costs.

Benefits of Hospitals Partnering with PCPs

Poorly coordinated care between primary care providers and hospitals can lead to high healthcare costs, poor patient outcomes, and medical errors (Lockhart et al., 2019). There should be efforts to improve care coordination after discharge. A partnership between PCPs and hospitals can reduce excessive readmissions since there will be transitional care after the patients are discharged from hospitals (Lockhart et al., 2019). The benefits of collaboration are important in the United States healthcare system. The US healthcare system consists of a network of healthcare providers, insurance payers, and programs that deliver healthcare to patients. There is little focus on the coordination of care. The partnership will reduce fragmented care since primary care physicians will be available to offer care to the patients with the information they get from hospitals (Lockhart et al., 2019). This will improve the efficiency of healthcare services and reduce the costs associated with constant hospitalizations.

Bundling Payments

Bundled payments are designed to promote value-based care by giving incentives to healthcare professionals to promote coordination of care and efficiency of healthcare services while enhancing healthcare quality and lowering healthcare costs (Catalyst, 2018). In bundled payments, the cost of episodes of care is predetermined care, and the target price for an episode of care is predetermined. Healthcare organizations can share the savings they make or the losses based on the differences between the costs of care they provide and the predetermined price. (Catalyst, 2018).

Healthcare providers bear the risks since they cover any healthcare costs beyond the predetermined cost for episodes of care and those due to hospital readmissions and complications of treatment. Bundled payments improve healthcare quality while lowering healthcare costs. It controls healthcare costs by ensuring that healthcare providers have reduced the costs of their healthcare services to ensure they do not bear losses for extra costs,

Pay for Performance (P4P)

Pay-for-performance is a strategy that can reduce healthcare costs and improve the quality of healthcare. P4P is a payment strategy that improves healthcare quality by offering financial incentives to healthcare providers (Catalyst, 2018). P4P ensures that clinicians adhere to the best clinical guidelines to deliver high-quality healthcare to their patients. Healthcare professionals and organizations are reimbursed based on patient satisfaction, best practices, and healthcare outcomes.

Hospitals will thus implement programs that will ensure they increase the quality of healthcare services and qualify for reimbursements. There are two types of P4P reimbursements for hospitals. In the first model, hospitals are rewarded based on their performances across efficiency, quality, and process measures (Catalyst, 2018). In the second model, hospitals will be penalized for below-par performances, saving health payers costs (Catalyst, 2018). Healthcare organizations are thus incentivized to protect their reputation since the performance metrics are publicly revealed.

Value-based Purchasing Program

The value-based purchasing program (VBP) was established by the Affordable Care Act (ACA) (Chee et al., 2016). This program pays hospitals for the actual performance of quality measures instead of just reporting the quality measures. This program is primarily implemented in acute-care facilities. VBP can reward or penalize facilities that do not meet the performances and efficiencies established. VBP ensures that there are possible replacements for chargeable healthcare services so that care is provided to patients (Chee et al., 2016). The hospitals are paid depending on the healthcare services they offer. The payments can be made annually or depending on plans set aside for paying the hospitals.

How does VBP affect Reimbursements?

Reimbursements can only be achieved after a hospital has filed a long-term claim. The funding reimbursement process is done by lowering operating payments by 2%, while the remaining funds are redistributed to facilities depending on their scores (Chee et al., 2016). Hospitals are paid for treating patients enrolled in Medicare. All hospitals can earn some percentages withheld by CMS depending on their scores on the quality identified. This program can be identified as a zero-sum game. Hospitals can earn back their money if they perform well, while those who do not do well are penalized, hence losing financial resources. All measures that are part of VBP must be posted on the CMS website for a year to allow patients and potential clients to compare.

Who Benefits Most from VBP

Patients are the ones who benefit the most from VBP. VBP encourages healthcare facilities to enhance the safety and quality of healthcare services. Patients spend less on healthcare with improved outcomes (Chee et al., 2016). Some chronic conditions like diabetes and hypertension are costly to manage. VBP ensures few physician visits, diagnostic tests, and medical prescriptions, and they spend less on prescription drugs. In VBP, providers have to improve their efficiencies, enhancing patient satisfaction (Chee et al., 2016). Quality of patient care and patient engagement increases when the focus is on the value of healthcare. Providers implement strategies that ensure patient safety. This includes reducing medical errors that may cause patient harm (Chee et al., 2016). Hospitals also adopt evidence-based care guidelines, which ensure that patients have the best healthcare outcomes. In VBP, hospitals there is a healthier population since more focus is put on preventive medicine and reduced costly hospitalizations.

How VBP measures Hospital Performances

The VBP measures four domains of performance.  Each aspect represents 25% of the final score calculated to rank all the hospitals in Medicare (CMS.gov, 2021). The clinical care aspect measures the evaluation of death in the thirty days after hospitalizations for a specific medical condition (CMS.gov, 2021). This is measured as a survival rate, with higher percentages being better. Patients who get quality healthcare services are likely to have improved outcomes. The second domain measures the “patient and caregiver-centered experience of care/care coordination.” This domain is based on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey. This survey inquires from patients over 18 years concerning their hospital experiences (CMS.gov, 2021). The aspects measured include communication with physicians, communication with nurses, hospital staff responsiveness, the hospital environment’s quietness and cleanliness, communication about drugs, discharge information, the transition of care, and hospital rating (CMS.gov, 2021).

The safety domain assesses healthcare activities affecting patient well-being. These domains are hospital falls, bedsores, adverse events, and nosocomial infections (CMS.gov, 2021). The final domain measures healthcare costs (CMS.gov, 2021). The costs of healthcare services measured are lab tests, physician fees, home care services, and rehabilitation.

Conclusion

Accountability is essential in healthcare. Healthcare organizations and professionals must thus implement strategies such as technology and coordinated care to ensure their safe, quality, and affordable healthcare services. Many healthcare delivery models in the US are value-based,  including P4P, VBP, ACOs, and HMOs. These models can leverage information technology to ensure that their services are efficient, reduce healthcare costs, and increase patient satisfaction. The different models have different benefits and limitations. Patients must choose the model that works for them to ensure the best healthcare services at affordable prices. All in all, these value-based programs are good for the costly healthcare system in the United States.

References

Catalyst, N. (2018, February 28). What are bundled payments? NEJM Catalyst – Practical Innovations in Health Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0247

Catalyst, N. (2018, March 1). What is pay for performance in healthcare? NEJM Catalyst – Practical Innovations in Health Care Delivery. https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0245

Chee, T. T., Ryan, A. M., Wasfy, J. H., & Borden, W. B. (2016). The current state of value-based purchasing programs. Circulation, 133(22), 2197-2205. https://doi.org/10.1161/circulationaha.115.010268

CMS.gov. (2021, February 18). Hospital value-based purchasing. Centers for Medicare & Medicaid Services | CMS. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing

Lockhart, E., Hawker, G. A., Ivers, N. M., O’Brien, T., Mukerji, G., Pariser, P., … & Baker, G. R. (2019). Engaging primary care physicians in care coordination for patients with complex medical conditions. Canadian Family Physician, 65(4), e155-e162. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467654/

Rural Health Information Hub (RHIB). (2021). Need for health information technology in ACOs – Rural care coordination toolkit. Rural Health Information Hub. https://www.ruralhealthinfo.org/toolkits/care-coordination/2/accountable-care-organizations-model/need-for-hit

Tabriz, A. A., Nouri, E., Vu, H. T., Nghiem, V. T., Bettilyon, B., Gholamhoseyni, P., & Kiapour, N. (2017). What should accountable care organizations learn from the failure of health maintenance organizations? A theory-based systematic review of the literature. Social Determinants of Health, 3(4), 222-247.https://iranjournals.nlai.ir/handle/123456789/724515

Wilson, M., Guta, A., Waddell, K., Lavis, J., Reid, R., & Evans, C. (2020). The impacts of accountable care organizations on patient experience, health outcomes, and costs: A rapid review. Journal of Health Services Research & Policy, 25(2), 130-138. https://doi.org/10.1177/1355819620913141

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Assignment:

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 healthcare 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 do 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?

Assignment Expectations

Length: 1500-2000 words

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.