According to Kyeremanteng, et al., there is no conclusive evidence that a pay for performance model provides any better value for money than traditional models (2019). Many pay for performance plans reward providers certain services required of more complex patients. “Studies and actual cases have indicated that they harm and reduce access for socioeconomically disadvantaged populations because, despite risk adjustments, providers who treat a larger share of low-income patients will not perform as well on P4P measures and therefore are incentivized to avoid treating them (NEHM, 2018). When a provider meets the quality standards of the pay for performance plan, they are reimbursed more than those who do not meet the set quality standards and with quality standards being difficult to determine, reimbursement rates may be impacted negatively.
Resource-based relative value scale (RBRVS) is a system that considers the cost of physician services in different settings, skill and training necessary, time to provide the service, and the risk it involves. Once these factors are determined, comparisons are made based on the resources needed, and each health service is assigned with a relative value unit or RVU. Reimbursement is based on the RVU, the geographic location, and a conversion factor (Casto, 2018).
Based on an RBRVS method, more complex services, or those requiring more resources, are reimbursed at a higher rate, thus providers are rewarded or have incentive to perform these services. Being compensated higher for more difficult or more invasive treatments can encourage the overuse of such services.
Not all patients have health insurance and there are different choices available to those individuals. Some options may be Medicaid, utilizing a financing option, paying out of pocket, or, in some cases, charity care.
Medicaid, originally known as the Medical Assistance Program, is a state and federal government program that offers healthcare for those with low-income. Eligibility requirements differ by state, though for each state to receive federal funds they must include certain groups (Casto, 2018). One must live in the state where they are applying to receive Medicaid and usually have income and asset tests. There are many health programs available and applying for Medicaid is a fairly easy process. Applications can be found online or at a local Department of Human Services office. Once an application has been received, eligibility requirements will be determined.
Financing may be an option for those that do not have the resources to pay for their healthcare at the time of service. This allows the patient to receive the treatments needed but to pay for them over time. Agreements can be made with healthcare providers directly or through a healthcare financing company such as CareCredit. Though beneficial for those patients requiring immediate care, there can be added costs due to interest rates or late fees, (Lamberti, 2020).
Uninsured patients may elect to pay for a medical service out-of-pocket, or self-pay. Many healthcare providers offer a reduction in fees for those that fall into this category, though payment prior to treatment is often required (Lamberti, 2020). Some health providers take a 50% discount off their regular fee while others will honor the amount on the CMS fee schedule.
According to Lamberti, when a patient’s income is 300% of the federal poverty level providers are required to perform “medically necessary” treatments under charity care (2020). Qualifying for charity care is a challenging process and healthcare organizations will often utilize health navigators or social workers to assist in the process. Relying on these specially trained professionals to assist in charity care determination is strongly recommended as detailed documentation regarding income, government assistance, or any other social service benefits would be required. Once qualified, healthcare organizations often partner with charity organizations such as March of Dimes or the Ronald McDonald House.
Providing and being compensating for quality care is a balancing act shared by all providers of health care today. The options for reimbursement can be confusing and explaining them in more detail, as done here, can be beneficial. Regardless of which model under which reimbursement is rendered, the goal should be delivering quality patient care with integrity; performing treatments and testing when necessary and keeping t
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