NR533 Week 2: Volume-Based Versus Value-Based Reimbursement - September 2018

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NR 533 Week 2: Volume-Based Versus Value-Based Reimbursement

Models of payment to healthcare organizations have begun to shift from paying for volume (fee for service) to paying for value (quality). Using a Venn Diagram, compare volume-based versus value-based reimbursement. Use the editable template for the Venn Diagram, which is available for download on the Course Resources page. This template (with your findings) will need to be posted as an attachment in your discussion post along with your written prompt.

 

Consider Jim, who is 69 years old and comes to your Emergency Department (ED) with severe abdominal pain. His evaluation, besides a physical exam, includes an abdominal ultrasound, a CT scan with and without contrast, multiple lab studies, all lead to his having an emergency appendectomy. Other than having Type II diabetes well controlled on diet and exercise, he is in otherwise good health. Jim is treated as an outpatient and is discharged home the next morning. Two weeks later he returns to the ED with fever, continued abdominal pain, and a surgical site infection. He is admitted and is treated for 5 days before being sent home.

 

Using your findings from your comparison of volume- versus value-based reimbursements, analyze the scenario. Determine how the hospital could charge and be reimbursed using the two methods. In this case, which would be better for the hospital? How do each of these payment models contribute to or detract from the goal of the Triple Aim? Considering payer mix, delivery systems, population demographic, and value-based purchasing of the institution. How do all of these elements influence the financing of the type and quality of care provided at your facility? What are the implications on access and availability of types of care provided by your institution?

Remember to support your thoughts with scholarly sources.

NR 533 Week 2 Touchpoint Reflection: Reimbursement Issues

Guidelines for Touchpoint Reflections

A downloadable version of the guidelines, which includes further information, is available for access on the Course Resources page.

Reflection Information

EXPERIENCE

Consider the data collected in Week 1 about your institution's payer mix, delivery system, population demographics, and this week's discussion on value- and volume-based reimbursements

REFLECTION

Describe how these factors coalesce to influence the financing of the type and quality of care provided at your institution. What are the implications on access and availability of types of care provided at your institution?

IMPLICATIONS FOR FUTURE

How is your proposed project affected by the information you've gathered about your facility?

What adjustments might you have to make in your proposal because of the information gathered?

NR533 Week 2: Volume-Based Versus Value-Based Reimbursement - September 2018
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are     they   indicators of     delivery       readmissions   to be     preventive       opinion,   based care     better       as   positively contributes     triple       the   quality and     care,       health   reducing the     cost       The   based focuses     payments       triple   My current     a       that   integrative care,     on       that   as it     reaching       providing   care at     The       to   a membership     services       renders   access to     of       ReferencesHenkel,   J ,     P  
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work     of   and private     However,       register   with the     organization       services   strictly members     organizations       all   groups within     it       healthcare   has encountered     interest       type   amount of     healthcare       practitioners   the type,     quality       and   the healthcare    
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and     organization’s   vision, and     This       and   outcomes for             promote   and empowerment     (Cordo,           unit also     Governance       renewal   Magnet status     assists       aspects   the unit     are       J   & Hill-Rodriguez,             a   professional practice     leadership       nurse   empowerment, and     making           10 1016/j     07       HYPERLINK   instructure com/courses/32190/discussion_topics/736602?module_item_id=3893609"     as       GriebVirginia   16, 2018Sep     10:45amManage       night   as recently     leaving       and   a hazardous     recently       residency   for those     house       their   and skills     in       unit   program has     successful,       done   in my     new       combination   classroom and     with       eight   on the     and       orientation   the night     four       would   them for     after       interesting   about how     does       answers   staffing They     that       to   operating budgets,     the       finances   be the     my       fortunate   the union     have       before   I work     unionized       empowers   to ask     that       have   very collegial     when       up   par, we     do       the   and outcomes     for       I   forward to     the       Comment   "https://chamberlain instructure     "Mark       SubdiscussionJosierose   TaldeSep 12,     at       Dr   and Class,Considering     collected       value-based   really impact     environment       organization   I am             to   is a wakeup     all       Volume-based   hospitals to     every       procedures   have provided     patient       no   on how     how       can   a patient     as       care   to the     Quality       was    an issue     type         The   system in     States       midst   a much     the       Due   the wide     quality       well   rocketing healthcare     U       is   away from     system       system   Medicare, the     and       has   for the     value-based   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new       to   the proposed     What       to   a policy     standardized       that   evidenced-based specific     service       operating         ReferencesA     volume-based       care   d )     https://healthinformatics       ,   Desai, N     The       transition   value on     care:       payment   and quality      Journal       No   615-620 doi:10     2017       Comment   "https://chamberlain instructure     "Mark       SubdiscussionSusan   WilsonSep 13,     at       Josierose,I   the information     organization       value-based     The     the       reimbursement   continue to     a       the   population and     multiple       for   future       of       for   decrease in     care       are   concern for     of       think   your proposed     surgical       a   agent is     approach       decreasing   infections       on       often   main source     allowing       infection    Abdominal procedures     found       increase   infection rates     infections       septicemia   increase mortality     Muller,       &   2016)       organization       wipes   patient use     wipes       to   line placement     to       of   and treat     bacteria           found for     have       sensitivity   chlorhexidine as     drying       for   skin       of       for   decrease in     for       has   an asset     hospital-acquired       reimbursement   care received     ,       Lemmen,   , Mutters,     Hagel,       Meyer,   (2016) Infection     sterile       systematic   and meta-analysis     International, 113(16)       2016   to Comment     instructure       as   Collapse SubdiscussionVirginia     12,       3:44pmManage   EntryDr Nurse     my       mix   35% Medicare,     40%       HMO’s   PPO’s, 5%     10%       of   population demographics     or       previously   in week     to       specialized   for chronic     population       financial   is balanced     positively       to   percentage of     and       facility   has an     philanthropic       community   donors 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  just not     or       of   team to     the       for   FutureMy proposed     healthy       of   staff, and     are       the   of falls     and       organization   the article     (2016),       relationship   nursing excellence     patient       forward   in developing     care       process,   staff need     involved       valued   are in     daily,       administrators   to recognize     excellence       experience   related to     costs (Rome,       example   the patient     with       are   cost issues     organization;       of   and penalties     secondly,       of   thirdly, the     a       as   or neurology     potential       for   patients When     at       all   factors need     considered       as   delve further     course,       a   understanding of     decisions       made   needs to     staff       the   patients we     for       will   to be     that       especially   one speaks     staffing       needs   cost out     against       injury,   infections, pressure   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aim     value-based   than the     Volume-based       getting   for all     so       focus   the patient’s     cost       At   institute, we     higher       Medicare   my department,     a       Medicaid   Based on     mix       a   population of     chronic       in   department, we     higher       population   both payer     reimbursed       rate   need to     that       the   model of     need       are   the most     these       To   the best     need       we   giving quality     ensuring       satisfied   their care     to       not   any never     can       Since   two population     to       and   lots of     need       we   doing what     to       but   watching the     caring       J   Value-based purchasing:     to       risks   hospitals  New     Healthcare       &   36(2), 21-24     E       ,   E G     C       J   Robinson, M     Newton,       Triple   is triply     you       things   once? Family Medicine,     doi:       885946Martin,   (2017) Preparing     transition       What   need to     Journal       Management:   32(5), 313-316     (2016)       centers   Medicare and     reimbursement       adverse   outcomes  Nursing     151–181       to   HYPERLINK "https://chamberlain     \o       Collapse   JirglKara JirglSep     9       EntryReference   Venn DiagramMartin,     Preparing       to   reimbursement: What     to       of   Practice Management:     313-316       HYPERLINK   instructure com/courses/32190/discussion_topics/736612?module_item_id=3893607"     as       SuarezJesse   9, 2018Sep     10:26pmManage       classmates,Regarding   reimbursement, the     request       all   consultations, diagnostic     and       as   as the     seem       in   of financial     has       in   quality care,     and       more   (Henkel &     This       patient   have been     evidence-based       time   visited the     the       him   have been     other       first,   received productive     In       the   can be     on       care   (Saleh &     It       advantageous   the patient     the       reduced   they are     poor       admissions   readmissions ought     managed       In   opinion, value-based     be       hospitals   it positively     the       improving   patient quality     of       population   and reducing     capita       care   volume-based focuses     payments       triple   My current     a       that   integrative care,     on       care   volume as     at       and   quality care     costs       need   have a     receive       this   easy access     availability       services   R J     Maryland,       The   and rewards     reimbursement       services   3-16 doi:10     1254       ,   Shaffer, W     Understanding       and   in orthopaedic     an       Medicare   and CHIP     (MACRA)       of   American Academy     Surgeons, 24(11),       org/10   arth 2017     to       instructure   \o "Mark     Collapse       10,   10 at     EntryDr       based   focus on     of       this   of reimbursement,     diagnostic       would   in a     from       commercial   (Martin, 2017)     case,       charge   the exam,     labs       Upon   patient’s return     later,       charge   the exam,     services       admission,   days spent     hospital       based   services would     limit       reimbursement     Also,     have       service   to curb     by       fee   specific diseases,     or       This   of payments     groups       the   visit such     testing;       CT   labs together,     services       surgery,   the surgical     addition,       could   each visit     episodes       reimburse   only two     of       time   for the     by       be   if done     volume       services,   in general,     procedures       a   return when     Medicare       coverage   private insurance     when       the   Aim which     improvement       of   improvement in     health       the   of health     volume       meet   requirement (IHI,     value       a   of each     better       Aim   with the     improvement       and   overall cost     to       reimbursement   really a     the       can   students for     and       issues,   should they     me       day   still considered      We       to   a student     they       a   basis if     a       exception   their educational     example,       has   and takes     but       plan   allows for     for       of   illness, then     not       medication   their illness     don’t       a   impact on     for       give,   I generally     School       best   of care     we       way   has affected     offered       such   rapid strep     done       and   positive, students     to       Provider   follow up     clinics       test,   wouldn’t pay     services       found   weren’t getting     this       the   unit to     cut       rely   assessment exams     for                                                       ReferenceInstitute     Improvement       IHI   Aim Retrieved     org/engage/initiatives/TripleAim/Pages/default       external   Martin, J     for       value-based   What you     know       Medical   Management: MPM,     Retrieved       to   external site     an       to   HYPERLINK "https://chamberlain     \o       Collapse   Stacy-BonotJennifer Stacy-BonotSep     10       EntryI   attached the     this       to   HYPERLINK "https://chamberlain     \o       Collapse   JirglKara JirglSep     10       EntryJennifer,I   you did     job       between   and value-based     Value-based       over   the volume-based     2020       the   in reimbursement     90%       already   value-based and     80%       using   value and volume     (Kuhn,       In   department, value-based     the       us   are getting     reimbursement       deliveries   patients are     and       care   medications than     to       an   in preeclampsia     are       tests,   medications to     We       patient   in labor,     without       have   be transferred     ICU       HELLP    I enjoyed     your       school   works I     idea       charge   students for     does       you   the parents     or       to   fees? I     heard       able   run strep     the       you   you quit     but,       parents   unnecessary trip     doctor       able   continue providing      KaraKuhn,       Lehn,   (2015) Value-based     banner        Frontiers   Health Services     Retrieved       to   HYPERLINK "https://chamberlain     \o       Collapse   NurseRachelle Nurse Sep     11       EntryJennifer   enjoyed reading     and       based   value based     for       experience   your own     reimbursement       clinic   interesting and     sure       lesson   many of     example       acute   emergency care,     or       premise   value-based programs     help       at   higher quality     payers       paying   based on     rather       of   they give     quality       do   school nursing     to       do   have students     for       will   be reimbursed     DiagramDr       HYPERLINK   instructure com/courses/32190/discussion_topics/736612?module_item_id=3893607"     as       Stacy-BonotJennifer   14, 2018Sep     8:41amManage       as   nurse in     system           students for     care       pays   (the school     health       at   same time     of       education   first       where       unique   a licensed     can       care   to keep     school       classroom   Because we     back       health   we work     physician's       are   to bill     for       That   said, our     depending       groups   Elementary and     students       as   how often     see           school students,     work,       the   of visits     health       have   health issue     increased       an     For     students,       I   on is     participation       positive   in many     (Rytkonen,       2017)   Students in     school,       students,   able to     learn       disease   self care             nausea,   and diarrhea     segues       a   diet, or     to       they   and how     them       when   understand what     on       take   of the     try       before   to the      Enhancing       fosters person-centered   acceptance of     health       health   Kaunisto &     Many       to   health unit     later       what   tried from     letting       tried   care but     more       point   Students having     attack       informed   'this is     need';       trying   figure out     for       crisis   health care     adolescence       over   adulthood (Shehnaz,     Issa           alternative or     to       also   the amount     dispensed           use of     water       wound   using antiseptic     increasing       dairy   sugar can     sore       education   beneficial in     on       health   supplies, can     number       the   unit and     the       post                                                            ReferenceRytkonen,   , Kaunisto,     &       How   primary healthcare     services       participation? Health   Journal, 76(6),     from http://journals       to   external site     ,       Sreedharan,   , Issa,     &       Self-medication   related health     high       the   Arab Emirates     211-218       org/journal/index   to Comment     instructure       as   Collapse SubdiscussionLisa     12,       6:38pmManage   EntryHello Jennifer,I     school       best   provide the     to       pay   I was     nurse       salary   it didn't     often       to   clinic in     pay       how   visits or     time       implementing   the district     a       matter   happened or     the       that    I had     of       based   when I     school       that   am in     I       the   and make     order       it   interesting how     day       new   is gained which     a       for   in this     still       and   the book     because       hard   me Sounds     are       nurse   I applaud     your       many   think that     is       fact   isn't, but     rewarding       nursing   ThanksLisa Olford ReplyReply     HYPERLINK       \o   as Read"     NurseRachelle       13   4:50pmManage Discussion     appreciate       I   to agree     The       in   course work     care       are   told by     that       reduce   execute early     bundle       maximize   When we     get       are   always as     the       the   of the     course       there   a cost     care       matter   the setting     so       learning   that will     practical       work   Dr Nurse ReplyReply     HYPERLINK       \o   as Unread"     SteachKaren       10   3:15pmManage Discussion     and       profit   of the     services           sicker a     the       hospital   the potential     in       reimbursement   reinforcing the     profiting       He,   Liu, 2016)     scenario,       tests   procedures during     stay       up   back to     for       to   treated for             a   ceiling and     for       and   The hospital     to       that   from the     and       all   during the     This       detracts   the Institute     Improvement’s       Initiative   due to     that       consider   satisfaction prior     it       there   no incentive     illness       would   using this     system       If   hospital was     by       the   would take     on       because   had to     less       after   was discharged     infection       site   Value-based reimbursement     pay       certain   events and             only   rewarded for     in       model   2017) A     tries       by   payments and     fees       processes,   procedures Using     unnecessary       the   to lose     they       set     The     all       a   of care             the   to contribute     Triple       there   consequences such     reimbursement       poor   satisfaction as     set       care   This is     over       another   the IHI’s     Zhang,       (2016)   that hospitals     fees       decreased   of stay,     and       care   to hospitals     fee-for       based   of reimbursement     work       hospital   The VA     unique       a   funded integrated     that       provider   a payer     VA       Medicare   Medicaid       bill       some   but it     very       to   the care     paid       VA   not being     Medicare       are   rewards or     there       value-based     In     colleagues       the   sector, I     pressure       costs   budgets because     not       it   going to     bottom       focus   quality and     to       that   needed without     reimbursement       are   limited at     due       Access   availability are     to       of   we have     the       having   providers to     all       There   also the     Program       VA   authorize and     the       treated   a private     certain       (2017)   for the     Value-Based       Need   Know  The     Medical       313-316   Y ,     ,       (2016)   of medical     care       between   and set     diagnosis-related       20   hospitals  The     Journal       And   Health, 47(5), 1055-1061     Comment       com/courses/32190/discussion_topics/736612?module_item_id=3893607"   "Mark as     SubdiscussionKaren       2018Sep   at 3:18pmManage     to       diagram   It is     this       2   docx ReplyReply to     "https://chamberlain       "Mark   Unread" Collapse     TaldeSep       at   Discussion EntryHi     reading       You   a great     comparing       reimbursement     I     you       detracts   the goal     aim       of   aim is     healthcare       to   for simultaneously     health,       experience,   cost reduction     of       been   strongly important     used       improvement   globally       firmly       understanding   quality and     a       the   and design     system,       a   of the     of       work   the system     Savage,       Value-based   aligns with     of           across the     to       collectively   provide high-quality,     low-cost       to   patient experience     to       The   Care Act     a       value-based   that emphasized     quality       and   satisfaction, but     and       Desai,        ReferencesSrinivasan, D     Desai,       The   of the     value       care:   of novel     and        Journal   Cardiac Failure, 23     615-620       2017   005Storkholm, M     Mazzocato,       M   & Savage,     Money's       mind:   qualitative study     staff       health   triple aim     Services       1186/s12913-017-2052-3  ReplyReply   Comment HYPERLINK     com/courses/32190/discussion_topics/736612?module_item_id=3893607"       Read"   SubdiscussionRachelle NurseRachelle     2018Sep       Discussion   response Josierose     reimbursement       promote   culture of     cost-effectiveness       value-based   In some     biggest       reimbursement   value based     providers       interdisciplinary   rounds at     over       at   facility The     to       ensure   resources were     reduce       spent   lot of     crucial       physician   to discharge     even       to   a timely     your       reimbursement   your current     (positively       providers   and what     organization       this?   look forward     discussion       Comment   "https://chamberlain instructure     "Mark       SubdiscussionJosierose   TaldeSep 13,     at       Dr   maximize reimbursement     organization       by     I     the       surgeons   one factor     positive           the operating     elective       is   huge contributor     patient       been   the proper     their       the   and the     starting       Starting   on time     proper       meaning   staff who     does       after   shift ends     paid       organization   implemented Kaizen to     process       with   purpose to     efficiency           Kaizen philosophy     key       organization   ensure competitiveness     the       is   of continuous     a       and   aspect       to       is   process that             strategy   involves everyone     organization working       with   or no     involved       improve the   to meet     high       (Vieira,   Varasquin, &             of   five or     ago,       the   has improved     time       cases   improved, wheels     wheels       operating   decreased 30     Surgeons       to   on time     unnecessary       surgical        ReferencesVieira, L     G       ,   Gontijo, L     and       for   A theoretical     in        Work, 41,    doi:10 3233/WOR-2012-0381-1756  ReplyReply     HYPERLINK       \o   as Unread"     WalkerPatricia       11   6:23pmManage Discussion     gave       between   and value-based             able   tie it     Triple       The   Aim will     healthcare       they   care to     as       provide   based on     volume       2016)   I have     in       and   am interested     about       setting   learn from     they       Thank   for sharing     VA       reimbursement   I have     experience       however   have had     treated       hospital   Since they     through       is   any kind     to       the   volunteer their     care       are   paid?  I     about       Virginia   are under     to       campaigning   help (Suderman,     Alan       (2015)   hospital association     financial       &   S (2016)     framework       to   triple aim                   Healthcarepapers, 15(3),     to       instructure   \o "Mark     Collapse       11,   11 at     EntryPatty,Each       an   budget so     not       Physicians   not volunteer     majority       government   paid by     (Rovner,       can   if a     cannot       set   then they     the       The   is also     fact       are   like the     population       be   influx of     J       Military   Care Are     Often       npr   to an       ReplyReply       "https://chamberlain   com/courses/32190/discussion_topics/736612?module_item_id=3893607" \o     Read"       WalkerSep   2018Sep 14     Discussion       for   the time     to       It   like the     will       same   as the     in       aging   requiring more     We       increase   to these     improve       to   HYPERLINK "https://chamberlain     \o       Collapse   WilsonSusan WilsonSep     10       EntryHello   Nurse and     from       value-based   model with     diagram       advantages   disadvantages for             method   viewed as     for       which   can benefit     by       patients   services provided     is       and   expenses for     industry       unnecessary   imaging, and     are       to   this volume     care       is   considered ineffective     (Aoughsten,       Bionat,      The     value-based       to   healthcare conditions     quality       patient     Supporting     positive       measures   promote quality     for       care     Core     are       this   are not     et        Jim   sixty-nine years     have       Medicare   His surgical     testing,       work   an emergency     a       morning   follow reimbursement             based   a fee     payment       providers   order numerous     visits,       were   overabundance of     et           Affordable Care     of       reform   Medicare and     reimbursement       organizations   on quality     quantity       et   , 2015)     readmitted       of   discharge is     concern       the   for this     Hospital       an   core measure     part       value-based   (Raso, 2014)     reduction       reimbursement   a