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ADVANCE Perspective: Nurses

Reimbursement 101

Published August 27, 2015 12:12 PM by Guest Blogger

Guest editorial by Stacy Slater, MSN, BS, RN-BC, Revenue Cycle Coordinator, Munson Healthcare, Traverse City, MI

Pay-for-performance, value-based purchasing, the triple aim of healthcare, HCAHPS, volume to value - Nurses need, at the very least, a rudimentary understanding of these terms and how the care they provide directly affects reimbursement and how reimbursement impacts the care they provide to their patients.

What is this: The two main goals of the Patient Protection and Affordable Care Act of 2010 are reforming health insurance (the Marketplace) and reforming delivery and payment systems (pay-for-performance). Pay-for-performance is the reimbursement model that Medicare is using to drive the triple aim (improved value, improved outcomes, and improved patient experience). Value-based purchasing is just one of the elements of pay-for-performance. 

What does it mean and how does it impact nursing: Value-based purchasing (VBP) is a method of payment that involves penalties or incentives. This method allows CMS to "purchase" value when it pays for healthcare versus paying for services based on volume or "fee-for-service."  Currently, all healthcare providers that participate with Medicare are transitioning from volume to value. One of the measures of the VBP program is patient experience. The patient satisfaction scores, measured via the Hospital Consumer Assessment of Healthcare Providers and System (HCAPHS), surveys inpatients post discharge and includes questions that are directly related to nursing care. Questions such as nurse-patient communication, how well pain was controlled, quietness and cleanliness of the patient's room, how well discharge orders were understood, responsiveness of staff, and communication about medications. The quality of care that nurses provide can be measured and can be positively reflected in patient outcomes and payments received by the health system. This collaboration between nursing and finance can lead to improved patient outcomes and improved value.

In her blog, Pamela Austin Thompson, chief executive officer of AONE, eloquently states the need for nursing and finance to be on the same team. To prevent patient care from becoming secondary to reimbursement, we need nursing professionals who understand finance and the financial impact of clinical decisions, and financial professionals who understand how cost-reduction measures impact the delivery of patient care.

This is our time to shine and step out front - nurses and the quality of care that we provide can improve the value of care, improve patient outcomes, improve the patient experience and in essence be the drivers of healthcare reimbursement.


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