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Value-based reimbursement
Value-based reimbursement is the payment model for medical services that is gradually replacing the traditional fee-for-service model for payers and healthcare organizations. The goal is to cut rising healthcare costs by switching from a model based on quantity to value-based reimbursement, which is based on quality.
Value-based reimbursement is considered a way to cap costs and spread financial risk among providers, while encouraging coordination of care, disease prevention and better management of chronic conditions. This is seen as a threat to the survival of clinical labs, which expect to see far fewer tests ordered by healthcare providers.
In partnership with THE DARK REPORT, the Clinical Laboratory Management Association is working to help labs navigate these revenue-threatening changes. “As fee-for-service reimbursement gives way to bundled reimbursement and per-member-per-month payment, labs will only be successful if they add value to physicians by helping them diagnose disease earlier and more accurately,” says CLMA President Paul Epner.
Medicare, the largest payer in the U.S., has recently been ordered by the Department of Health and Human Services to link 30 percent of fee-for-service payments to quality or value through alternative payment models, such as accountable care organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.
An ACO, for example is a group of doctors, hospitals and health care providers who work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. In addition to this, through the widespread use of health information technology, the health care data needed to track these efforts is now available.
HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.
Predicting the End of Fee-for-Service Medicine
HOW DISRUPTIVE WILL THE END OF FEE-FOR-SERVICE MEDICINE be to the lab testing industry? I ask this question because we are about to leave the era of fee-for-service (FFS) medicine and move into the era of value-based and bundled reimbursement. Since World War II, FFS has been the overwhelmingly domi…
ACO Numbers Increase, Now Cover 10% of Nation
CEO SUMMARY: A recent report by a consulting firm that tracks the ACO industry indicates that, as of the end of 2012, ACOs of all types involved—in some manner—between 25 and 31 million patients. Moreover, Medicare and private ACOs are located in regions where 45% of the population of…
Lawyers Share Insights about ACO Contracting
CEO SUMMARY: Most pathologists have yet to be involved in any substantial contractual negotiations that would allow them to assume a significant role in accountable care organizations (ACOs). Instead, hospitals and health systems are putting the building blocks in place by acquiring physi…
2012’s Top Ten Lab Stories Predict More Challenges
CEO SUMMARY: It’s been a year with more lows than highs, when viewed through the lens of THE DARK REPORT’S “Top Ten Lab Stories of 2012.” The end of the TC grandfather clause, new policies for prostate biopsy billing, and a dramatic 52% cut to 88305- TC fees were widely reported. …
Shaw & Adelman Successful Support of Lab Networks Need Hospital Leadership
CEO Summary: In the second installment of our exclusive two- part interview, the executive directors of two regional laboratory networks formed in the 1990s (one in Michigan and one in Washington State) share their assessment of why their respective lab networks have performed strongly ov…
2011’s Top 10 Lab Stories Point to a Busy 2012
CEO SUMMARY: Given the specific news stories that make up THE DARK REPORT’S list of the “Top Ten Lab Stories for 2011,” it might be said that 2011 was a rather quiet year overshadowed by anticipation of the coming reforms mandated by the Accountable Care Act of 2010. For the clinica…
Tougher Financial Times Ahead for Lab Industry
THE YEARS 2008 THROUGH 2010 WERE TOUGH ECONOMIC TIMES for all healthcare providers, including clinical laboratories and pathology groups. Moreover, although the deepest recession in 30 years was declared over by mid-2009, many hospitals continue to struggle financially and the national unemployment r…
Time to Think About ACOs And Medical Homes
CEO SUMMARY: In less than nine months—on January 1, 2012—the new health reform legislation mandates that Medicare commence value-based purchasing. Medicare must also begin contracting with accountable care organizations (ACO). Experts say these two developments will initiate …
Payers Move to Pre-Authorize Expensive Genetic Tests
CEO Summary: Pre-authorization of expensive genetic and molecular tests is fast-becoming a priority for most of the nation’s health insurers. For clinical labs and pathology groups that don’t respond, this trend is a threat. On the other hand, because payers need all the skil…
Elevating Lab Testing At Policymaking Table
CEO SUMMARY: With the help of contributing clinical laboratories, the CDC has launched an ambitious effort to gather data, apply evidence review methods used in clinical studies, then identify and publish best practices in laboratory medicine. The goal is to advance the value of …
CURRENT ISSUE
Volume XXXII, No. 6 – April 21, 2025
Now that a federal judge has vacated the FDA’s LDT rule, The Dark Report analyzes the judgement and notes the various steps the FDA could take in response. Also, lab testing at pharmacies is proving to be less successful than was once anticipated.
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