Value based purchasing is a payment model that offers financial incentives to healthcare providers and organizations when they meet certain performance measures. This model also penalizes healthcare providers for poor outcomes, medical errors, or increased costs. Managed Care Organizations (MCOs), Accountable Care Organizations (ACOs), and Bundled Payment Care Improvement (BPCI Advanced) are prospective value-based purchasing programs aimed at improving healthcare quality and reducing costs. Hospitals and physicians participate in these programs with the goal of getting the right care to the right patient at the right time.
In this Discussion, you will consider what happens with these systems as they relate to nursing home care. Nursing home administrators are facing a reduction in the demand for skilled nursing rehabilitation (SNF) beds, while physicians in an ACO or a gain-sharer in a BPCI program are looking at discharging patients with home care or outpatient resources to reduce cost. All these programs are affected by re-admission penalties.
Most businesses are constantly looking to reduce cost. In healthcare, often the necessity to reduce cost means a reduction in utilization. Consider how this compares to a retail market where reduced demand reduces cost by consumer choice. How much influence does the consumer have on the change in healthcare economics? Is it the payer (Medicare), the provider (the physician), or the patient?
Consider the following scenarios:
Scenario 1: You are a rehabilitation director in a nursing home. Your administrator has given you the directive that, to participate with a Medicare MCO and become a preferred provider for a hospital BPCI or comprehensive care for joint replacement (CJR) program, you need to reduce the length of stay for the short-term rehab patients from 20 days to 10 days for DRG 470: Total knee replacement. To compound the problem, you see that the usual 400 total knee patients you get annually has been reduced to 160 patients.
Scenario 2: You are the manager of a large orthopedic practice who participates in the BPCI program. Your practice does 400 total knee patients each year. Medicare has set pricing for a Total Knee Replacement patient at $28,415 per patient for a 90-day episode of care. Current practice is that all patients automatically go to a skilled nursing facility (SNF) for 20 days. Based on current research the goal is for 60% of your patients to go home with home care and those going to a SNF to stay for 10 days so the BPCI program will be profitable.
To Prepare:
- Review the Learning Resources for this week.
- Select one of the two scenarios to focus on for this Discussion.
- Reflect on the scenario, and consider redesign measures you might recommend. For example, consider length of stay, reducing readmissions, attracting new business, care redesign, patient satisfaction, and physician engagement.
By Day 4
Post a comprehensive response to the following:
- Describe at least three care redesign strategies you might recommend to the scenario.
- Justify why you selected these three care redesign strategies and explain how you would implement the redesign strategies you recommended.
- Be specific, and provide examples.
- Be sure to support your Discussion with a reference to course materials or a reference within the last three years.
