NUR 621 Do you think it is important for health care organizations to be paid for quality of performance?

NUR 621 Do you think it is important for health care organizations to be paid for quality of performance?

NUR 621 Do you think it is important for health care organizations to be paid for quality of performance?

According to Sura and Shaw, quality of care is the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes. This is based on evidence based
professional knowledge and is necessary for achieving universal health coverage. Sura and Shaw further
explain that Payers assess quality based on patient outcomes as well as a provider’s ability to contain
costs. Providers earn more healthcare reimbursement when they are able to provide high-quality, low-
cost care as compared with that of their peers The pay-for-performance (P4P) initiatives have been
suggested as a way to improve the quality of patient care and provide incentives to improve
performance from providers.

In 2003, The Centers for Medicare & Medicaid Services endorsed this P4P initiative to strengthen quality
measures, improve patient outcomes and maintain physician accountability. It offered incentives to
hospitals, provider groups, and physicians based on adherence to specific metrics. What the data
showed was that quality composite scores    promoted by CMS with the P4P programs needed
improvement. They focused on initiatives to target high and low performers and ways to influence care.
The goals of the project were straightforward and that was to reward or financially incentivize
healthcare stakeholders to provide high quality care.

I think rewarding rates of improvement is important as it can potentially drive healthcare systems to
produce higher results. It encourages organizations to invest in quality improvement. By creating
financial incentives for providers to participate in P4P, it allows providers to focus on patients’ specific
needs. According to Penner, there were also fewer hospital readmissions within two years following the
implementation of a readmission reduction program, particularly among Medicare patients (Penner,
2016). I think that our healthcare industry is ever evolving but changes are continuously strengthening
our system.

Penner, S. (2016). Economics and financial management for nurses and nurse leaders (3rd ed.). Springer
Publishing Company

Sura, A., & Shah, N. R. (2010). Pay-for-Performance Initiatives: Modest Benefits for Improving Healthcare
Quality. American health & drug benefits, 3(2), 135–142.

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Most industry stakeholders believe that payers and providers need to be on the same page when it
comes to agreeing on a common set of measures, but to date, this has been tough to achieve.

One reason is that a lack of shared financial risk between payers and providers could lead to more
misalignment. For instance, if the company paying the fees is assuming all the financial risk in
each value-based contract, its goals will be different than the provider that is in that
agreement (LEVENTHAL, 2018). I do believe that it is important for health care organizations to be paid
for quality of performance especially if the performance outcome is meeting the set benchmarks
for satisfactory patient outcomes. As well as incentives when the outcomes score above the
expected average for good patient outcomes.
A study showed contemporary evidence from a population-based primary care system in
Hawaii demonstrated that capitated payments were associated with improvements in a Healthcare
Effectiveness Data and Information Set (HEDIS) composite quality measure score, as well as a reduction
in number of visits. Taken together, evidence from a variety of settings and disease entities does not
point to an overall conclusion about the impact of capitated payments on chronic disease quality of
care (Tummalapalli et al., 2022). Several factors may explain these mixed findings. First, the capitation
payment amount should also be considered, which may differ across Medicare, Medicaid, and
commercial managed care settings. Second, practices are subject to different quality metrics and pay-
for-performance initiatives depending on the payor arrangement, which incentivize quality of care
improvements. Thus, the impact of not only capitation vs. FFS reimbursement type, but also quality
metrics and other regulatory requirements, impact quality of care delivery and must be considered in
evaluating new capitation models (Tummalapalli et al., 2022).

Increasingly, funders want to see planning and development strategies for maintaining programs

NUR 621 Do you think it is important for health care organizations to be paid for quality of performance
NUR 621 Do you think it is important for health care organizations to be paid for quality of performance

beyond the proposal’s funding period. Frequently, the funder’s mission is to only provide seed money to
help grant applicants start up the proposed program. Many funders expect applicants to develop plans
and strategies for ongoing program operation and sustainability once the grant funding has expired. The
section on program sustainability should describe ongoing program operation plans and strategies. For
example, the applicant may describe efforts to develop ongoing community partnerships for future
resources, or fund-raising strategies. There may be plans to introduce fees for services, or to obtain
approval for reimbursement by payers such as Medicaid or insurers. If the proposed program is based
within a larger agency such as a nonprofit organization or a health department, plans for increasing
agency support beyond the proposed funding period may be discussed (Penner, 2016).

References

LEVENTHAL, R. (2018). In the New Healthcare, Payers and Providers Look to Redefine
Quality. Healthcare Informatics, 9–11.
Penner, S. J., RN, , MN, , MPA, , DrPH, , & CNL, . (2016). Economics and financial management for nurses
and nurse leaders (3rd ed.). Springer Publishing Company.
Tummalapalli, S. L., Estrella, M. M., Jannat-Khah, D. P., Keyhani, S., & Ibrahim, S. (2022). Capitated versus
fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis. BMC
Health Services Research, 22(1), 1–12. https://doi-org.lopes.idm.oclc.org/10.1186/s12913-021-07313-3

I do agree that we are moving towards paying for quality of care versus quantity of care
and it may be the correct idea and I also agree that it has been poorly executed. Most industry
stakeholders believe that payers and providers need to be on the same page when it comes to agreeing
on a common set of measures, but to date, this has been tough to achieve. One reason is that a lack of
shared financial risk between payers and providers could lead to more misalignment. For instance, if the

company paying the fees is assuming all the financial risk in each value-based contract, its goals will be
different than the provider that is in that agreement (LEVENTHAL, 2018). I do believe that it is important
for health care organizations to be paid for quality of performance especially if the
performance outcome is meeting the set benchmarks for satisfactory patient outcomes. As well as
incentives when the outcomes score above the expected average for good patient outcomes.
A study showed contemporary evidence from a population-based primary care system in
Hawaii demonstrated that capitated payments were associated with improvements in a Healthcare
Effectiveness Data and Information Set (HEDIS) composite quality measure score, as well as a reduction
in number of visits. Taken together, evidence from a variety of settings and disease entities does not
point to an overall conclusion about the impact of capitated payments on chronic disease quality of
care (Tummalapalli et al., 2022). Several factors may explain these mixed findings. First, the capitation
payment amount should also be considered, which may differ across Medicare, Medicaid, and
commercial managed care settings. Second, practices are subject to different quality metrics and pay-
for-performance initiatives depending on the payor arrangement, which incentivize quality of care
improvements. Thus, the impact of not only capitation vs. FFS reimbursement type, but also quality
metrics and other regulatory requirements, impact quality of care delivery and must be considered in
evaluating new capitation models (Tummalapalli et al., 2022).

References

LEVENTHAL, R. (2018). In the New Healthcare, Payers and Providers Look to Redefine
Quality. Healthcare Informatics, 9–11.
Tummalapalli, S. L., Estrella, M. M., Jannat-Khah, D. P., Keyhani, S., & Ibrahim, S. (2022). Capitated versus
fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis. BMC
Health Services Research, 22(1), 1–12. https://doi-org.lopes.idm.oclc.org/10.1186/s12913-021-07313-3