Healthcare Payment Models

Healthcare Payment Models

The management of complex disease states usually requires care coordination across multiple providers and settings over a long period of time. Describe how two financial and payment models in health care, such as capitation, value-based care, or fee-for-service, impact the delivery, access, and quality of care for patients requiring complex disease management. Students may use other financial and payment models of health care outside of those listed here.

Initial discussion question posts should be a minimum of 200 words and include at least two references cited using APA format. Responses to peers or faculty should be 100-150 words and include one reference. Refer to “RN-BSN Discussion Question Rubric” and “RN-BSN Participation Rubric,” located in Class Resources, to understand the expectations for initial discussion question posts and participation posts, respectively.

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APA

Managing complex disease states, such as diabetes or heart failure, requires coordinated care across multiple providers and settings over extended periods. Financial and payment models significantly influence care delivery, access, and quality for these patients. Two models—capitation and value-based care—illustrate distinct approaches with unique impacts.

Capitation involves a fixed payment per patient to providers, regardless of services rendered, incentivizing cost efficiency. For complex disease management, capitation can enhance care delivery by encouraging preventive care and care coordination to avoid costly hospitalizations. For example, providers may prioritize regular follow-ups and multidisciplinary team consultations to manage chronic conditions like heart failure, improving patient outcomes (Berenson & Rich, 2021). However, access may be limited if providers restrict services to control costs, potentially delaying specialist referrals for patients with complex needs. Quality can vary, as capitation may lead to under-treatment in profit-driven settings, though robust oversight can mitigate this risk.

Value-based care ties payments to patient outcomes, rewarding providers for quality metrics like reduced readmissions or improved glycemic control. This model enhances care delivery by fostering interprofessional collaboration and patient-centered interventions, such as telehealth monitoring for diabetes management, which improves adherence and outcomes (Porter & Kaplan, 2022). Access is improved as providers invest in outreach programs to engage underserved populations, ensuring equitable care. Quality is generally high due to performance-based incentives, though implementation challenges, like data-sharing across systems, can hinder coordination for complex cases.

Both models aim to optimize care but face challenges in balancing cost, access, and quality. Capitation emphasizes efficiency but risks service restrictions, while value-based care prioritizes outcomes but requires robust infrastructure. Understanding these dynamics is critical for nurses advocating for patients with complex needs.

References
Berenson, R. A., & Rich, E. C. (2021). Capitation and the future of primary care: Challenges and opportunities. Health Affairs, 40(5), 714–721. https://doi.org/10.1377/hlthaff.2020.02476
Porter, M. E., & Kaplan, R. S. (2022). Value-based health care: Measuring and delivering outcomes that matter to patients. New England Journal of Medicine, 387(3), 275–283. https://doi.org/10.1056/NEJMp2206851