Jenny
What is the importance of DRGs and RVUs, and fee schedules and payments?
With DRGs the provider is paid per diagnosis or procedure. Not getting paid for how long a patient stays in the hospital cuts down on admissions and lengths of stay. RVUs are based on time and effort and calculated as a fee schedules. The more time and effort a provider puts in the more they get paid (follow up care gets paid less than new patient care, hip replacements get paid more than hip scopes). Fee schedules are set per Medicare as a maximum amount allowable to be paid on a fee-for- service basis.
Select a provider reimbursement type and explain how a provider is paid in your own words with what you just learned. Provide the pros and cons to the selected method of payment.
I pick capitation from a Concierge Medicine stand point. Generally the people that participate in Concierge Medicine are generally more affluent than the average patient. They pay a monthly fee for all their primary and preventative care. Concierge care does not generally cover ER or specialists. The pros are that once the monthly payment is made there is no other fee to see your provider as many times as you want. They tend to have better provider to patient ratios and relationships, the wait to see your provider is considerably shorter and the quality of care is higher. The cons are that the more providers that choose this type of practice the less providers there will be for the lower income population. Also, the concierge medicine generally targets the wealthy. In other situations it could lead to providers cherry picking patients. In an ideal word, the younger and healthier the better. They rarely go to the doctor.
Reference
Heath, S. (2018, January 23). How Concierge Medicine Affects Patient Care, Financial Responsibility. Patient Engagement HIT. https://patientengagementhit.com/news/how-concierge-medicine-effects-patient-care-financial-responsibility
——————————————————————————————————–
Thomas
The DRG system actively works to improve the quality of care by prioritizing early patient diagnosis, management, mobilization of care, and return home. RVUs are important in order to assist the determination of physician payments.They provide a methodical manner to pinpoint the costs associated with the processes included in the Current Procedural Terminology code set. Fee schedules they form the basis for how much a doctor can charge for a procedure and assist the office staff in figuring out coinsurance rates and patient deductibles. Also payment is contingent on delivering good outcomes. It plays a crucial role in upholding stability and order.
Fee For Service: The oldest type of healthcare payment is fee for service. According to this system, physicians and healthcare providers are paid according to the quantity of services or operations they perform. Despite the outcome, this payment model compensates doctors for the volume and amount of services delivered.
Pro and Con of Fee For Service:
Pro: encourages the delivery of care and maximizing patient visits Also relatively flexible and is employed regardless of the size or organizational structure.
Con: offers little or no incentive to deliver efficient care or prevent unnecessary care
Reference:
“Diagnosis-Related Group – an Overview | ScienceDirect Topics.” www.sciencedirect.com/topics/medicine-and-dentistry/diagnosis-related-group. Accessed 20 Oct. 2022.
Gaille, Louise. “17 Fee for Service Pros and Cons – Vittana.org.” 17 Fee for Service Pros and Cons – Vittana.org, 20 Apr. 2019, vittana.org/17-fee-for-service-pros-and-cons.
——————————————————————————————————————————————
Ryan
DRGs are important by processing payments and organizing data while RVUs is a unit that assigns the cost and difficulty of procedures. Capitation is when that the provider gets a set pay per customer/patient each month, no matter how much the patient spends. The downfall of this is that providers who treat very ill people are being paid the same as people who treat healthier people. Technically people who works more or harder will have the same pay as people who don’t do as much, so the provider will want more healthier people to treat. A pro is that the payment system is very simple than compared to the complicated billing and coding.
——————————————————————————————————————
Sam
These four components deal with the method providers are compensated as well as the amount. DRG (Diagnostic Related Groups) comprise of codes that represent different services with a respective price and play a crucial role in properly identifying the correct amount of reimbursement. RVUs (Relative Value Unit) calculate reimbursement amounts based on the CPT (Current Procedural Terminology) code.
Bundled payments reimburse providers with a predefined amount based on the service. For example, if a kidney transplant costs $20,000, then every time a provider performs one, they’ll receive $20,000. This would account for everything involved in the process of the transplant.
This method of payment is very straight forward but could potentially cost the patient way more than necessary. Not every procedure is the same/ requires the same things. Patients that use a couple of the services in the bundle will pay the same amount as a patient that uses all of them. On top of this, providers can be underpaid in some situations, which could tempt them to disregard services within the bundle that the patient might actually need.
