Value-Based Care: Reimbursement Models

COURSE 4 of 7. This course is designed to help you build high-level knowledge of the current medical coding and payment mechanisms of most U.S. healthcare services, referred to as fee-for-service. You will explore why the fee-for-service model has contributed to higher costs in the U.S. healthcare system without clearly improving health outcomes. You will examine the importance of coding to reflect chronic conditions and other diagnoses accurately and how value-based care and payments utilize these measures and data. As you learn about a model to replace fee-for-service, you’ll encounter a range of payment options considered to be value-based that utilize a framework from the Health Care Payment Learning and Action Network (HCP-LAN). To build on those options, you will learn how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. In the summative assignment, you will demonstrate your knowledge by comparing fee-for-service and value-based contracts, using specific examples to explain and justify the importance of documentation and coding, and identifying ways that risk-adjustment and patient satisfaction are incorporated into value-based care contracts. CME Accreditation The American Academy of Family Physicians (AAFP) has approved this course for Continuing Medical Education Prescribed Credits. Visit the FAQs for important information regarding 1) Term of approval and 2) Accreditation and Credit Designation statements.

• From Fee-For-Service to Value-Based Payments
• In this course, you will build high-level knowledge of the current medical coding and payment mechanisms of most U.S. healthcare services, referred to as fee-for-service. Then you will explore why the fee-for-service model has contributed to higher costs in the U.S. healthcare system without clearly improving health outcomes. As you examine a model to replace fee-for-service, you’ll encounter a range of payment options considered to be value-based. To build on those options, you will explore how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. This module is an introduction to and exploration of value-based payment models utilizing a framework from the Health Care Payment Learning and Action Network (HCP-LAN). As a preparatory step to that introduction and review, the module starts with a high-level review of current fee-for-service payments, coding for those payments, and the problems resulting in increased healthcare costs and lower-than-expected quality in the U.S. Remember, as you read or hear terms or concepts that are new to you, have your digital (Word doc) or analog (paper) notepad handy to write them down. At any time, you can use your favorite search engine to learn more. Be a self-directed learner!
• Quality and Risk Adjustment in Value-Based Payments
• In the previous module, you examined the importance of coding to reflect chronic conditions and other diagnoses accurately. You also explored how value-based care and payments utilize these measures and data. As you explore the four categories of the HCP-LAN alternative payment models (APMs)—also known as value-based payment arrangements or value-based contracts – the acronym of the latter is also VBC. As with other acronyms, you will learn to read VBC in context to determine if we are talking about care or payments/contracts. The focus of this module is on two key aspects of value-based payment models: 1) The need for, and methods of, risk-adjustment in value-based contracts, and 2) Quality scores and patient satisfaction measures, which are critical parts of value-based care and contracts. At the end of this module, you will examine how those elements are utilized in value-based contracts. Remember, as you read or hear terms or concepts that are new to you, have your digital (Word doc) or analog (paper) notepad handy to write them down. At any time, you can use your favorite search engine to learn more. Be a self-directed learner!
• Course Project: Making This My Own
• In this course, you have examined how the fee-for-service model emerged from current medical coding and payment mechanisms and why this model has contributed to higher costs in the U.S. healthcare system. In the videos and discussion postings relating the quest to replace the fee-for-service model, you explored a range of value-based payment options and how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. Whether you are currently working in a healthcare provider or payer organization or aspiring to work in either, it is paramount that you be able to synthesize, reframe, and put into practice knowledge gained from this course. Even more important is to recognize that the responsibility for applying this knowledge is shared by providers and payers, as ultimately it is the provider-payer partnership that leads to successful value-based care.