Alternative Payment Models: Where are we now?
Well being Care Cost Studying and Motion Community (HCP LAN) is devoted to shifting the well being care system from volume-based, fee-for-service reimbursement, to different cost fashions (APM). Whereas there are a lot of various kinds of APMs, broadly, all of them shift extra monetary threat to suppliers whereas additionally linking reimbursement to high quality of care. The truth is, HCP LAN has the aim of getting 100% of reimbursements for conventional Medicare and Medicare Benefit fall beneath two-sided threat APMs and 50% of business and Medicaid reimbursements fall-under two-sided threat APMs by 2025.
HCP LAN defines APMs as falling beneath one among 4 sorts:
Of their 2020-2021 report titled APM Measurement: Progress of Various Cost Fashions, HCP LAN makes use of information from 2019 and 2020 to look at whether or not APM are gaining market share. From 2019 to 2020, we do see some shift in direction of extra APM and capitation cost, however FFS funds held regular at 39.3% of reimbursements. It shouldn’t be shocking that reimbursement buildings didn’t change a lot since 2020 was the peak of the COVID-19 pandemic.
Charges of use of APM additionally diverse throughout payer sorts. Conventional Medicare had the best use of APMs (i.e., reimbursements within the HCP LAN classes 2, Three or 4), and business insurance coverage had the bottom (see determine beneath). Word that international capitation was pretty unusual throughout most payers (3%-6%) apart from Medicare Benefit the place 21.8% of funds have been made through international capitation.
HCP LAN additionally surveyed payers and located that 87% believed that APM exercise will improve sooner or later. Probably the most curiosity was in bundled cost (47%) and shared financial savings (21%) APM sorts. Of observe, about half (44%) of respondents believed that APMs would lead to elevated supplier consolidation.
Whereas payers are enthusiastic about elevated monetary certainty APMs would carry, suppliers have issues. The highest Three challenges for implementing APMs have been:
- Supplier willingness to tackle monetary threat
- Supplier skill to operationalize APM
- Supplier curiosity/readiness
APM have a variety of apparent engaging options, but additionally challenges as nicely. Clearly, linking reimbursement to high quality of care and worth is a laudable aim. Nevertheless, estimating worth is best in a static setting the place anticipated outcomes and prices are identified with cheap certainty. Because of COVID-19, there was vital uncertainty over prices each because of the price of COVID-19 straight and its affect on treating different illnesses. It goes with out saying that international pandemics make implementing APMs difficult. Equally, as new therapeutic improvements enter the market, high quality might enhance however so might price; as therapy paradigms shift notions of worth–and corresponding APM buildings–might have to evolve over time.
