Under the current fee-for-service payment structure, volume is incentivized over value. In order to keep volume levels high enough to maintain operations, providers may be delivering a lesser quality of service. This results in higher readmission rates and an increase in overall spending.
New York State is looking to increase the level of value based payments throughout the State’s Medicaid program. OPWDD is working with stakeholders to develop data-driven measures by which it will reward positive outcomes and encourage programs to work effectively and efficiently to meet goals centered on patient care by focusing on prevention, coordination, or integration.
While in theory, a reimbursement system developed to reward a higher level of care sounds like a viable option, there are several challenges to overcome.
One of the major obstacles is deciding which metrics will be used to assess the effectiveness of a provider. There are few instances where an improvement in a patient’s condition can actually be quantified, especially in an industry where each patient’s need may vary greatly, and treatments are individualized to best suit the needs of each individual. OPWDD will seek input from providers to develop meaningful metrics to determine the effectiveness of providers.
Another obstacle is the stringent regulatory environment for OPWDD providers that creates such a burden that the focus is often taken off of the outcomes of patient care and instead, directed toward following policies and procedures. OPWDD believes the first step is to take an inventory of all the regulations that have been issued and to determine which regulations are duplicative, overly burdensome, and unnecessary. By relieving some of the regulatory burden, providers will be able to focus their attention toward patient care.
Mahnaz Cavalluzzi, CPA