Audiologists and speech-language pathologists (SLPs) are used to having their health care services reimbursed under a fee-for-service (FFS) payment model. This model establishes set rates for each specific service provided based on time, complexity, and the skill needed to deliver the service. The fee-for-service system, in some cases, can establish competing priorities between what is best for the patient and what is best for the financial health of the provider organization. Value-based care is an attempt to align the priorities of patients, providers, and payers. Payment is no longer tied directly to transactional services. Instead, it’s tied to desired results or comprehensive delivery of care with emphasis on quality, efficiency, and outcome. Under value-based care, value equals quality of care for the amount of money spent. Alternative payment models are one way that payers incentivize providers to transition from fee-for-service to value-based care payment models.
The Affordable Care Act and a part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) developed a new reimbursement model called Alternative Payment Models (APMs). The intent of APMs is to improve the patient experience by encouraging collaboration between providers, improving quality of care, and making services more affordable. APM participants receive payments that reward them for the value of—rather than the volume of—services provided. Value, in this context, is outcomes of the intervention as related to cost.
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With the shift in reimbursement from quantity to quality, audiologists and SLPs must take accountability for increasing the quality and lowering the costs of care that they provide. Taking accountability means that some of the financial risk of providing services will shift to audiologists and SLPs.
All payers (Medicare, Medicaid, and private insurance) are moving toward a value-based system that focuses on the quality of services provided to the patient in the most cost-effective manner. In 2018, 35.8% of U.S. health care payments, representing 77% of the covered population, flowed through APMs.
There are many types of APMs that audiologists and SLPs may come across. Each presents varying challenges and opportunities when you consider whether engaging with an APM will be beneficial for your practice.
There are several types of APMs:
The Centers for Medicare & Medicaid Services (CMS) developed several types of APMs to prioritize health care outcomes over cost of care and improve the value of health care. In the CMS Quality Payment Program (QPP), there are traditional APMs—such as the ACO Shared Savings Program Track 1, BASIC. CMS’s QPP program also developed Advanced APMs such as the Comprehensive Care for Joint Replacement Payment Model, which requires the integral use of a certified electronic health records system.
ASHA supports the inclusion of audiologists and SLPs in payment and delivery models that demonstrate their value to patients, other providers, and payers by incorporating relevant quality outcomes and providing evidence-based care in the most cost-effective manner. The following timeline summarizes ASHA’s advocacy activities during the past several years in relation to APMs:
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