Develop a two-page memo to help relevant stakeholders at Vila Health's St. Anthony Medical Center better understand traditional and emerging reimbursement models.
Note: This assessment uses the following media as the context for developing the reimbursement model memo. Review this media before you submit your assessment.
Vila Health: Investigating a Readmission.
Basic understanding of the reimbursement system requires one to appreciate the size and scope of the system, the complexities associated with the system, and the various subsystems and payment rules associated with health care reimbursement and finance. As a dominant player in the health care sector, the U.S. federal government is the largest single payer for health care services. As a result of its size and dominance within the system, any changes made by the federal government regarding its reimbursement of health services profoundly affect those who are rendering the care, including providers, other payers, and the health system overall. In addition to government-sponsored health insurance, various other forms of health coverage, generally tied to employment as a benefit, were introduced in the United States to help offset the expenses associated with the treatment of illness and injury.
In an effort to address concerns within the U.S. health system regarding cost, access, and quality, Congress passed the Patient Protection and Affordable Care Act (PPACA or ACA) in 2010, with President Barack Obama signing it into law. Components of the PPACA included making health insurance coverage affordable, expanding Medicaid coverage, and improving quality while controlling costs. To this end, the ACA required the Centers for Medicare & Medicaid (CMS)to promote the concept of the accountable care organization (ACO) through a shared savings plan driven by a triple-aim approach. In addition to the ACO, the ACA required CMS to implement value-based purchasing programs that would reward hospitals for the quality of care they provided to enrollees.
As the recipient of the largest share of Medicare funds, the new value-based purchasing approach measures hospital performance using four domains:
1. Clinical care.
3. Efficiency and cost reduction.
4. Patient experience of care (Casto & Forrestal, 2019, p. 274).
Each measure scores the hospital performance achievement as well as their performance improvement.
As a health care sector employee, understanding the complex U.S. health care reimbursement system allows one to serve as a reference to internal and external stakeholders, family members, and organizational departments whose needs often require a working knowledge of how the system is financed.
In this assessment, you demonstrate your understanding of traditional and emerging health care reimbursement models by composing a memo that outlines the characteristics and differences between reimbursement models. This memo targets relevant stakeholders from the Vila Health media simulation based in St. Anthony Medical Center.
Casto, A. B. (2019). Principles of healthcare reimbursement (6th ed.). AHIMA Press.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
· Competency 1: Compare current trends and traditional methods of payment in the health care industry.
. Describe traditional payment models in health care.
. Describe current trends in health care payment models.
· Competency 2: Assess health care reimbursement.
. Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
. Explain reasoning for newer models of reimbursement in health care.
. Explain quality concerns affecting reimbursement given a specific patient scenario.
· Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
. Adhere to the rules of grammar, usage, and mechanics.
. Apply APA formatting to in-text citations and references.
You will use Vila Health: Investigating a Readmission as the context to address Part 4 of this assessment.
Several of the Vila Health's stakeholders are seeking clarification regarding new reimbursement models they have been hearing about recently. For this assessment, prepare a two-page memorandum outlining the differences between the new reimbursement models and prior, traditional models for stakeholders.
Support your assertions in the memo with at least three academic sources. This may require you to do additional independent research. You may wish to consult the
Health Care Administration Undergraduate Library Research Guidebefore you begin any additional research.
This assessment has four main parts.
Part 1: Traditional Payment Methods
Relevant scoring guide criteria:
· Describe traditional payment models in health care.
. “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
. Identify the traditional payment models.
. What are the key characteristics of these reimbursement models?
. How was quality monitored under these models?
· Adhere to the rules of grammar, usage, and mechanics.
. “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
. “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
. “Mechanics” refers to correct use of capitalization, punctuation, and spelling.
· Apply APA formatting to in-text citations and references.
This part should be at least one paragraph long, but probably no more than half a page.
Part 2: Current Trends in Healthcare PaymentRelevant scoring guide criteria:
· Describe current trends in health care payment models.
. Identify the current trends in health care payment models.. What are the key characteristics of these reimbursement models?
. How is quality monitored under these models?
· Explain reasoning for newer models of reimbursement in health care.
. “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.· Adhere to the rules of grammar, usage, and mechanics. · Apply APA formatting to in-text citations and references. This part should be at least one paragraph long, but probably no more than half a page.
Part 3: Comparison of ModelsRelevant scoring guide criteria:
· Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
. Develop a concise comparison of the key similarities and differences of the reimbursement process between traditional and current models.· Adhere to the rules of grammar, usage, and mechanics. · Apply APA formatting to in-text citations and references.
This part should likely be between a half and one page long.
Part 4: Quality ConcernsRelevant scoring guide criteria:
· Explain quality concerns affecting reimbursement given a specific patient scenario.
. Specifically address the recent problematic patient case from the Vila Health: Investigating a Readmission scenario.
. Briefly discuss how the care provided would be reimbursed under prior models versus reimbursement under newer models, based on your assertions in Part 3 of your memo.
. Also, identify quality issues that will likely impact the organization's reimbursement under new payment models.· Adhere to the rules of grammar, usage, and mechanics. · Apply APA formatting to in-text citations and references. This part should be at least one paragraph long, but probably no more than half a page.
Additional Submission Requirements
· Structure: Structure your submission like a memo, with an additional, APA-style references page. Use the
Reimbursement Model Memo template [DOC]provided. You may wish to refer to the following example when developing your memo:
· Length: 2–3 pages, plus a references page.
· References: Cite at least three current scholarly or professional resources.
. Your textbook can be one of the three.
· Format: Use APA style for references and citations only. Refer to:
APA Style Paper Tutorial [DOCX].
. Additional APA resources located in the courseroom navigation panel.
· Font: Times New Roman, 12 point, double-spaced.
Subject: Reimbursement Models in Healthcare (BHA-FPX4009 -Assessment 1)
[Provide a brief introduction (preview of the main theses of your paper) here and delete all statements within brackets, such as this paragraph, and replace with your discussion. Also, before you begin, review the “Scoring Guide” and understand the difference between “Distinguished,” “Proficient,” “Basic,” and “Non-Performance.” These “Scoring Guides” are used to grade the assignment. This is why each Template is set up with headings (below) that correspond with the “Scoring Guides” for this specific assignment. Please leave the Headings (below) in the paper.]
Traditional Payment Methods
[Explains traditional payment methods in health care, such as fee-for-service or capitated payment].
Current Trends in Health Care Payment
[Explains current trends in health care payment, such as value-based or accountable care organizations. Explains reasoning for newer models of reimbursement in health care and provide relevant examples].
Comparison of Models
[Compare and contrast how quality outcomes are rewarded under traditional and current payment methodologies in health care and provide relevant examples].
[Describe quality concern affecting reimbursement given a specific patient scenario].
[Summarize the main themes of your paper],
[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capped, Vol# italicized(Issue#), Page numbers.
Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online Journal Name, Vol# italicized(Issue#), 159–192. https://doi.org/10.1000/182
Lastname, W. (2009). If there is no DOI use the URL of the main website referenced. Article Without DOI Reference, Vol# italicized(Issue#), 166–212. http://www.mainwebsite.org
NOTE: The above references are SAMPLES ONLY. For more information and example related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE CITATIONS.]
7/31/22, 10:24 PM
Reimbursement Models Scoring Guide
https://courserooma.capella.edu/bbcswebdav/institution/BHA-FPX/BHA-FPX4009/210100/Scoring_Guides/a01_scoring_guide.html 1/1Reimbursement Models Scoring Guide
CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
Describe traditional payment models in health care.
Does not list traditional payment models in health care.
Lists but does not describe traditional payment models in health care.
Describes traditional payment models in health care.
Describes traditional payment models in health care and how quality was monitored and rewarded under each model.
Describe current trends in health care payment models.
Does not list current trends in health care payment models.
Lists but does not describe current trends in health care payment models.
Describes current trends in health care payment models.
Describes current trends in health care payment models and how quality is monitored and rewarded under each model.
Explain reasoning for newer models of reimbursement in health care.
Does not attempt to explain reasoning for newer models of reimbursement in health care.
Attempts to explain reasoning for newer models of reimbursement in health care, but the explanation is inaccurate, illogical, or invalid.
Explains reasoning for newer models of reimbursement in health care.
Explains reasoning for newer models of reimbursement in health care, and provides relevant examples, supported by current scholarly or professional sources.
Compare and contrast how quality outcomes are rewarded under traditional and current payment models in health care.
Does not describe how quality outcomes are rewarded under traditional or current payment models in health care.
Describes but does not compare how quality outcomes are rewarded under traditional versus current payment models in health care.
Compares and contrasts how quality outcomes are rewarded under traditional and current payment models in health care.
Compares and contrasts how quality outcomes are rewarded under traditional and current payment models in health care, and provides relevant examples supported by current literature.
Explain quality concerns affecting reimbursement given a specific patient scenario.
Does not identify any quality concerns affecting reimbursement given a specific patient scenario.
Partially identifies quality concerns affecting reimbursement given a specific patient scenario.
Explains quality concerns affecting reimbursement given a specific patient scenario.
Provides a comprehensive explanation of quality concerns affecting reimbursement given a specific patient scenario and makes recommendations that are supported by current scholarly or professional sources.
Adhere to the rules of grammar, usage, and mechanics.
Does not adhere to the rules of grammar, usage, and mechanics.
Errors in grammar, usage, and mechanics inhibit readability and comprehension and detract from good scholarship.
Adheres to the rules of grammar, usage, and mechanics.
Exhibits strict and nearly flawless adherence to the rules of grammar, usage, and mechanics.
Apply APA formatting to in-text citations and references.
Does not apply APA formatting to in-text citations and references.
Applies APA formatting to in-text citations and references incorrectly or inconsistently, detracting noticeably from good scholarship.
Applies APA formatting to in- text citations and references.
Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.
7/31/22, 9:06 PM Sample Memo // Purdue Writing Lab
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TO: Kelly Anderson, Marketing Executive
FROM: Jonathon Fitzgerald, Market Research Assistant
DATE: June 14, 2007
SUBJECT: Fall Clothes Line Promotion
Market research and analysis show that the proposed advertising media for the new fall lines need to be reprioritized and changed. Findings from focus groups and surveys have made it apparent that we need to update our advertising efforts to align them with the styles and trends of young adults today. No longer are young adults interested in sitcoms as they watch reality televisions shows. Also, it has become increasingly important to use the internet as a tool to communicate with our target audience to show our dominance in the clothing industry.
XYZ Company needs to focus advertising on internet sites that appeal to young people. According to surveys, 72% of our target market uses the internet for five hours or more per week. The following list shows in order of popularity the most frequented sites:
Google Facebook Myspace EBay iTunes
Shifting our efforts from our other media sources such as radio and magazine to these popular internet sites will more effectively promote our product sales. Young adults are spending more and more time on the internet downloading music, communicating and researching for homework and less and less time reading paper magazines and listening to the radio. As the trend for cultural icons to go digital, so must our marketing plans.
It used to be common to advertise for our products on shows like Friends and Seinfeld for our target audience, but even the face of television is changing. Young adults are tuning into reality television shows for their entertainment. Results from the focus group show that our target audience is most interested in shows like American Idol, The Apprentice, and America's Next Top Model. The only non-reality television show to be ranked in the top ten most commonly watched shows by males and females 18-25 is Desperate Housewives. At Blue Incorporated, we need to focus our advertising budget on reality television shows and reduce the amount of advertising spent on other programs.
By refocusing our advertising efforts of our new line of clothing we will be able to maximize the exposure of our product to our target market and therefore increase our sales. Tapping into the trends of young adults will help us gain market share and sales through effective advertising.
Attachments: Focus Group Results, January- May 2007; Survey Findings, January - April 2007
This is a sample memo; facts and statistics used are fictional.
7/31/22, 9:04 PM Vila Health:
Investigating a Readmission
Vila Health ® ActivityInvestigating a Readmission
A Delay in Payment
The First Visit
Introduction You are a reimbursement analyst at St. Anthony Medical Center. Reimbursement for a patient case is overdue, and you’ve been assigned to find out what problems, mistakes, or omissions might have caused the delay.
A Delay in Payment It looks like you have email from Troy Holland, Director of
Patient Services at the hospital. Click on the icon to read it.
Email From: Troy Holland, Director of Patient Services
Subject: Case #1149923
7/31/22, 9:04 PM Vila Health: Investigating a Readmission
We're having some trouble getting reimbursement on the
above patient case, and I'd like you to look into it and �nd out
what's going on.
The patient presented at the ER last month with symptoms of
tingling sensation in the face, blurred vision, and other
symptoms that suggested an epileptic seizure event. He was
discharged, but 24 hours later, he was back – and this time, he
was diagnosed as having an ischemic stroke.
Can you investigate this? Obviously, we need to get that
payment reconciled, but I'd also like to know if there are any
quality issues regarding the care the patient received that led
to the delay in payment. Let me know if there are, so that we
can get them addressed and keep this from happening again.
The First Visit A patient presented at the ER with symptoms that indicated an
epileptic seizure. Select each conversation to continue.
Registration Desk Registration Specialist: What's your date of birth, sir?
Patient: September 17, 1957.
["6/17/57" entered into Hospital Records]
Registration Specialist: And do you have insurance?
Patient: Yes, Blue Cross Blue Shield.
[Hospital Records list patient's insurance as "Anthem"]7/31/22, 9:04 PM Vila Health: Investigating a Readmission
Examination Room Doctor: Symptoms include tingling sensation in the face, 'not
feeling good,' confusion, and muscle pain.
Patient: My face feels numb and I can’t see very well.
Doctor: I see that you have a history of epilepsy and seizures. I
think you’ve had an epileptic episode. We’ll make sure you’re on
the right dose of seizure medication, and send you home with
some meds for the muscle pain.
[Medical Device Report: 780.31, Febrile convulsions (simple),
Records Check When you dig into the records for both visits, you �nd the
following information. Investigate the scene to continue.
Letter from Insurer We are the payer for patient 1149923. We have received two
bills for this patient with dates of service that are 24 hours
apart, and we are concerned with the quality of care the
patient received on the �rst visit. As a result we are requesting
medical records from the patient’s �rst and second visits to
your Emergency Room.
Physician Supervisor Yikes. The nurse’s notes say that about 17 hours after
discharge from the ER, the patient returned with a severe
headache, increased slurring in speech, and tingling in his right7/31/22, 9:04 PM Vila Health: Investigating a Readmission
Physician Whoops. Looks like discharge planning included a 24-hour
follow-up call to make sure the patient scheduled a primary
care visit, but I don’t see any record of that call being made.
Nurse I don’t see any orders for diagnostic testing on the �rst visit,
and it doesn’t look like they even sent him to the observation
unit before sending him home.
Conclusion You have completed the Vila Health: Investigating a Readmission activity.
Delays in reimbursement can be costly for a health care
Re�ection Questions What problems did you observe that might lead to delays in reimbursement — or even nonreimbursement or �nes?
This question has not been answered yet.7/31/22, 9:04 PM Vila Health: Investigating a Readmission
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