Assignment 01: Reimbursement Models Grid

|Accountable Care Organization (shared savings) |Primary Care Medical Home |Bundled Payment |Partial Capitation |Full Capitation | |Strengths and Weaknesses |-Providers are accountable for total per-capita costs.
-Patient “lock-in” is not required.
- Reinforced by other reforms that promote coordinated, lower-cost care. |-Supports coordination of care between physicians.
-Does not require accountability for total per capita cost |-Promotes efficiency and care coordination.
-Does not require accountability for total per capita cost |- Combines FFS and prospective fixed payment, providing “upfront” payments that can be used to improve infrastructure and process.
- Accountability only for services/providers.
- May be viewed as risky by many providers. |- Provides “upfront” payments for infrastructure and process improvement and makes providers accountable for per-capita costs.
- Requires patient “lock-in.”
- May be viewed as risky by many providers. | |Strengths for Primary Care |YES - Provides incentive to focus on disease management.
- Additional support by adding medical home or partial capitation payments to primary care physicians. |YES – Changes care delivery model for primary care physicians, allowing for better care coordination and disease management |YES, indirectly – Bundled payments result in greater support for primary care physicians |Yes – Partial Capitation allows for infrastructure and process improvement, creating a new model for primary care delivery. |Yes- it provides “up front” payment and changes the care delivery model for primary care physicians | |Promotes Coordination Among All Participating Providers |Yes – Significant incentive to coordinate among participating providers. |No – Specialists, hospitals and other providers are not incentivized to participate in care coordination. |Yes – Depending on how the payment is structured and whom it includes, it can improve care coordination. |Yes – Strong incentive to coordinate and take other steps to reduce overall costs. |Yes – Strong incentive to coordinate and take other steps to reduce overall costs. | |Eliminates Payment Incentives to Increase Volume |Yes – Incentives are based on value, not volume. |No – There is no incentive in the medical home to decrease volume |No – There are strong incentives to increase the number of bundles and to shift costs outside the bundle. |Yes – Strong efficiency incentive to the degree that prospective fixed payment is weighted in overall payment |Yes – Very strong efficiency incentive | |Promotes Accountability for Total Per Capita Cost |Yes – In the form of shared savings based on total per-capita costs. |No – Incentives are not aligned across providers. No global accountability. |No – for payments outside the bundle. No accountability for total per-capita cost. |Yes – Strong efficiency incentive to the degree that prospective fixed payment is weighted in overall payment. |Yes – Very strong account- ability for per-capita cost. | |Requires Providers to Bear Risk For Access Cost |Limited risk – Possible
Risk -sharing in some models, but the model does not require providers to take risks |No – No risks for providers who continue to increase volume and intensity. |Yes, within the episode – Providers are given a fixed payment per episode and bear the risk of costs within the episode being higher than the payment. |Yes – To the degree that prospective fixed payment is weighted in overall payment. |Yes – Providers are responsible for costs that are greater than the payment. | |Requires “Lock-in” of Patients to Specific Providers |No – Patients are assigned based on previous care patterns. There are incentives to provide services within participating providers. |Yes – In order to give providers a PMPM payment, patients must be assigned. |No – Bundled payments are for a specific duration or procedure and do not require patient “lock-in.” |Likely – Depending on the model, patients might need to be assigned to a primary-care physician. |Yes – To calculate appropriate payments, patients must be assigned. | |