The Changing Landscape of Reimbursement for Healthcare Services

The Necessity for Changes in Reimbursement Models

Politicians and economists agree that our healthcare system is going broke and can no longer sustain itself financially. Much of the focus has been on Medicare, but all aspects of healthcare are being affected. This poster will present the evidence identified to increase costs of health care, proposed reimbursement models under discussion, and anticipated impact on therapy and diagnostic services. The ultimate goal is to control and reduce the cost of health care while increasing quality.

The Medicare Payment Advisory Commission, the Institute of Medicine, and the Centers for Medicare and Medicaid Services agree that the current reimbursement system encourages excessive services and excessive reimbursement

Evidence cont’d Proposed Reimbursement Models

•Value based purchasing• Aligns payment to delivery of services

and quality of care (read: outcomes)•Episodic / periodic payments

• Single payment for date of service or several dates of service

•Bundled payments• Single payment for combined services

and supplies, or• Grouping several procedures into one

new procedure code•Medical home model

• PCP becomes coordinator and health care manager for patient

• PCP paid to review •Incorporate functional scale for accountability and measure of intervention effectiveness (e.g., International Classification of Function)

Impact on Graduate Student Training

•Distinguish between “graduate school protocol” and customized protocol based on clinical question / issue•Greater emphasis on clinical judgment in diagnostics and therapy•Focus on patient-centered care and incorporate patient / family goals•Measure outcomes for activities of life (not ADLs, but activities of life)•Focus on quality of life in addition to resolving a particular health or functional problem•Incorporate best practices into training regimen (Evidence-based versus consensus-based health care)

Robert C. Fifer, Ph.D. University of Miami Mailman Center for Child Development

Value of Health Care

Research and Education Support

Impact on Health Care Services•Eliminate incentive to “do more to be paid more”•Require knowledge of cost of service delivery•Justify each procedure diagnostically or therapeutically•Therapy: Abolish tradition 2-3 therapy sessions per week•Therapy: Maintain quality with fewer services•Therapy: What additional resources can be had without increasing overhead•Do what is needed, then stop•Develop alternative delivery systems (e.g., telehealth services)

Evidence Motivating Changes in Healthcare Reimbursement

Health Care Costs for American FamiliesSource: Milliman Medical Index

Country Health Care Rank

Per capita spending rank

France 1 4

Italy 2 11

Spain 7 24

Austria 9 6

Japan 10 13

Norway 11 16

United Kingdom

18 26

Switzerland 20 2

Germany 25 3

Canada 30 10

United States 37 1

Additional Factors Affecting Costs1.Fee for Service model2.Race and ethnicity3.Socioeconomic status4.Uninsured (51 mil.) and under-insured (60 mil.) => ER as primary care service5.Pharmaceuticals6.Language disparities between patient and provider7.Hospital readmissions for same diagnosis8.Malpractice suits causing defensive medicine9.End of life care (15% Medicare budget devoted to last 2 months of life)

“We practice according to how we are paid.” Peter Hollmann, MD, Chair, AMA CPT Editorial Panel

Per Capita Health Care Spending Among OECD Nations

Out of Pocket Expenses for Family of Four

WHO World Health Rankings vs. Spending

Value will be patient-centered, focused on three main factors, and divided by cost of service. All services will be evaluated for retention or elimination.