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Defining Successful Transition: Payer Perspective

  • Angelo P. Giardino
Chapter

Abstract

The payer perspective is shaped by the transactional nature that defines the benefit management responsibilities at the core of what a health-care insurance organization exists to do. The most prominent transactions are around payment for services delivered by a health-care provider to adolescents and young adults with special health-care needs (AYASCHN). Payers are defined by their governance, either for-profit or nonprofit, and provide benefits ranging from private insurance through employer-sponsored plans to publicly funded entitlement programs through Medicaid. The payment models for payers to reimburse providers are undergoing monumental changes, and the traditional fee-for-service retrospective system based on volume of care delivered is shifting toward alternative payment models, generically referred to as value-based. Value-based models seek to pay for quality of services delivered as well as actual outcomes, many on a prospective population basis. The move toward value-based reimbursement holds great promise for aligning the financial incentives embedded in a population health approach with the opportunity to allow health-care providers to engage with patient education and care coordination necessary to partner with AYASHCN and their families around transition and get paid for this time effort.

Keywords

Payer Fee-for-service Value-based reimbursement Alternative payment models Benefit management 

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Texas Children’s HospitalHoustonUSA
  2. 2.Academic General Pediatrics, Department of PediatricsBaylor College of MedicineHoustonUSA

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