As healthcare providers (including physicians and advanced practice nurses [APNs]) evaluate healthcare reform’s various payment options, they need to assess the impact these changes will make on who gets paid, how they get paid, and how much they get paid for doing which things. Such entities and practices as accountable-care organizations (ACOs), payment bundling, patient medical homes, and gainsharing are prominent among the various options. Although many pilot projects already are underway in the private sector, providers need to evaluate them, look for best practices—and get onboard as quickly as possible.
The new payment proposals can be condensed into five separate approaches:
- Paying more for some services. New payment systems may pay for certain services—or ways of delivering services—that are not currently reimbursed today. Or they may offer higher reimbursement than in the past.
- Basing payment on quality. To a greater extent, reimbursement for a service may depend on the quality of the service; for instance, pay for performance, nonpayment for services required to treat complications, limited “warranties,” nonpayment for services that fail to meet minimum quality standards, and quality-based tiering of reimbursement.
- Bundling separate services into one payment. Gone are the good old days of unbundling charges. New payment systems emphasize a single combined payment for two or more services provided by single or multiple providers.
- Comparative reimbursement—and/or bundling reimbursement of multiple providers. New payment systems may make payment dependent on the number of services or the cost of services delivered by other providers. This will include such areas as shared savings/gain sharing, bundling multiple providers into a single episode payment, and virtual bundling.
- Paying to support specific provider structures, systems, and locations. The new payment systems may pay more for certain kinds of infrastructure or practice structures—or for physician practices located in particular geographic areas or serving specific types of patients. In addition, each of these categories will be accompanied by changes in payment methods, including:
- condition/severity adjustment
- outlier adjustments
- quality and resource-use measures and performance targets
- patient attribution rules
- insurance benefit designs (including value-based benefits and wellness incentives).
Providers don’t need to be employed by hospitals or join large group practices to succeed under the new rule, but it helps—a lot. The goal is to manage costs, improve quality, and increase access. This is impossible for a lone wolf to achieve, so look to networked entities that span the spectrum of care. And make no mistake about it: Nurses, especially APNs, will be an integral part of these new payment systems!