Hospital health systems benefit greatly from pharmacists in terms of quality, safety, and value. The value of the pharmacist is further demonstrated by linking clinical activities with patient and financial outcomes.
Value-based programs encourage paying providers based on the quality, rather than the quantity, of care they provide to patients. These programs reward healthcare providers with incentive payments for the quality of care provided to individuals with Medicare. The goals of these value-based programs include better care, enhanced health, and lower costs.
Payment Based on Value
Value-based programs were first established through the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA). Under this act, value is emphasized over quantity. CMS established five value-based programs with goals to link provider performance of quality measures to provider payment (See Figure).1
The end-stage renal disease (ESRD) program is considered a first-of-its-kind in Medicare: the goal is to promote high-quality services to outpatient dialysis facilities treating patients with ESRD through pay-for-performance or value-based purchasing (VBP) programs. The hospital VBP program rewards acute care hospitals with incentive payments for the quality of care they provide to Medicare patients. The program’s goals include eliminating or reducing adverse events, establishing evidence-based care standards and protocols to improve patient outcomes, improving patient care experiences by enhancing hospital processes, increasing care transparency for consumers, and identifying hospitals that provide high-quality care at a lower cost to Medicare. It’s estimated that the total amount available for value-based incentive payments for 2019 is approximately $1.9 billion.1
Trending: Dispensing Errors Lead Incident Reports
The Patient Protection and Affordable Care Act of 2010, also known as the ACA or Obamacare, includes many payment reforms to promote hospital efforts to address and prevent adverse events after discharge.2
One example is the hospital readmissions reduction program (HRRP) that gives hospitals a strong financial incentive to enhance their communication and care coordination, and collaborate with patients and caregivers on postdischarge planning.2 The HRRP uses the excess readmission ratio to help estimate hospital performance, and it is the ratio of predicted-to-expected readmissions.1 The following conditions and procedures are included in the HRRP: acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty.
The 30-day risk readmission measures include all-cause unplanned readmissions that occur within 30 days of discharge from the initial admission and patients who are readmitted to the same hospital or another acute care hospital for any reason. Unfortunately, about 20% of patients are rehospitalized within 30 days after hospital discharge, with adverse drug events (ADEs) being the most common complication.2
Transitions-of-care (TOC) has been trending throughout the pharmacy profession and is an important process in the prevention of medication errors and ADEs. It is characterized as the movement of a patient from one set of providers or level of care to another and can involve patients moving to a different area of the hospital or being discharged into the community.
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