MDNews - North Alabama

SPECIAL FEATURE Riding the Reimbursement FOR HOSPITALS AND PHYSICIAN PRACTICES THAT ARE AHEAD OF THE HEALTH CARE REFORM CURVE, BUZZWORDS LIKE "QUALITY" AND "EFFICIENCY" MAY SIGNAL THE BEGINNING — NOT THE END — OF PROFITABLE REIMBURSEMENT. Waves W HEN IT COMES to health care reform, the fear of waning reimbursement is the perennial elephant in the room. With reimbursement in the midst of a major overhaul, physicians are being faced with a choice between ignoring the sea change or clinging to new quality metrics and technologies in an effort to stay afl oat. Changing Incentives The established reimbursement model, fee-for-service (FFS), pays health care providers in proportion to the services rendered to a Medicare or Medicaid patient. Providers are incentivized to provide necessary services only after a given health condition has become critical, rewarding both hospitalization and readmission. In a value-based model, providers' reimbursements are refl ective of outcomes and other quality measures. Popular iterations of this model include bundled payments and pay for performance (PFP). In this arrangement, incentives are aligned with the quality and cost effi ciency of the care given. "Fee-for-service is a volume-based model driven primarily by admissions," says Carol Cassell, M.D., client services executive at IT provider CTG. "Lately, health care organizations have recognized the need to align hospitals and physicians with a reimbursement model that embraces appropriate care at the right time, in the right place and at the right cost." Physicians Facing Challenges Value-based payment sounds utopian on paper, but it presents a number of challenges for hospitals and physicians deeply ingrained in the former model. One fear inherent to a transition from FFS to PFP is that service lines once primary sources of profi t may become fi nancially unviable. Providers would then have to take a fi nancial blow while they waited months — or possibly years — for reimbursement to reach even. Physicians are also wary of the burden of tackling large structural change in the midst of caring for patients. Hospitals and physi- cian groups will have to transition to ICD-10 and implement an electronic medical record by October 1, 2013, to escape further reimbursement adjustment — not only for Medicare patients, but for all patients covered by the Health Insurance Portability and Accountability Act. The manpower and training required to meet reimbursement deadlines may force physicians into a juggling act that would pit reimbursement against patient care. "During this transition period, health care providers must be careful not to boost compliance at the expense of patients' needs," says Susan Merrill, epidemiological informaticist at health care technology provider ICW. "Value-based reimburse- ment has not been well tested on a large scale, and there are still many unknowns." The Centers for Medicare and Medicaid Services has initiated

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