Defining Successful Transition: Payer Perspective
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.
KeywordsPayer Fee-for-service Value-based reimbursement Alternative payment models Benefit management
- 2.Centers for Medicare and Medicaid Spending (CMS). EPSDT – a guide for states: coverage in the medicaid benefit for children and adolescents. 2014. https://www.medicaid.gov/medicaid/benefits/downloads/epsdt_coverage_guide.pdf.
- 3.Steinway C, Gable JL, Jan S, MINT. Transitioning to adult care: supporting youth with special health care needs. PolicyLab at Children’s Hospital of Philadelphia. 2017. p. 11. http://bit.ly/E2A_TransitionsOfCare.
- 4.Agency for Healthcare Research and Quality (AHRQ), McPheeters M, Davis AM, Taylor JL, Brown RF, Potter SA, Epstein RA. Transition care for children with special health needs. Technical Brief No. 15 (Prepared by the Vanderbilt University Evidence-based Practice Center under Contract No. 290-2012-00009-I). AHRQ Publication No.14-EHC027-EF. Rockville, MD: Agency for Healthcare Research and Quality. June 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
- 5.Centers for Medicare and Medicaid Spending (CMS). Better Care. Smarter Spending. Healthier people: paying providers for value, not volume. 2015. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html.
- 6.Hassink, SK. Letter to Sam Nussbaum, MD. Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. American Academy of Pediatrics. November, 18, 2015.Google Scholar
- 7.American Academy of Pediatrics Committee on Child Health Financing. Essential contractual language for medical necessity in children. Pediatrics. 2013;132(2):396–401. http://pediatrics.aappublications.org/content/pediatrics/132/2/398.full.pdf CrossRefGoogle Scholar
- 9.Healthy People 2020. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. DH-5. https://www.healthypeople.gov/node/4153/data_details
- 10.Healthy People 2020 Objective (DH-5). Midcourse review. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C09-DH.pdf
- 11.Institute for Healthcare Improvement (IHI) The IHI Triple Aim. http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx.