American College of Cardiology Payment Reform: Current and Emerging Reimbursement Models

Preface The Payment Reform: Current and Emerging Reimbursement Models white paper is an American College of Cardiology (ACC) member content-driven educational resource meant to provide baseline knowledge of the payment models proposed in the Patient Protection and Affordable Care Act (PPACA) and the innovative payment pilots already being implemented in the private sector. Recognizing that challenges against specific provisions of the PPACA and, in some cases, against the entire landmark law itself, are currently navigating through various judicial and legislative venues, this paper looks to avoid those sensitivities and uncontrollable variables. In so doing, this paper maintains its relevancy, regardless of the outcomes of the legal challenges the PPACA is enduring, by focusing on those areas of payment reform likely to persist, especially in the private sector. To that end, this paper steers clear of forming policy statements or adopting official positions on these innovative payment models. Rather, this paper maintains its true aim of providing an educational component to the ACC's health care reform arsenal by providing clarity to some of the most complex and ambitious payment models likely to affect cardiovascular care. The extent to which the practice of cardiology will affect these models is still unknown. In fact, the role of the cardiovascular community in some of these models is still in question. We hope this paper will lend to the robust discussions that are sure to follow in determining the roles that cardiovascular professionals can play in advancing the payment reform debate. Introduction With the passage of health care reform legislation, physician payment continues to be a focal point in the health care policy debate. Current models in a majority of payment arrangements are based on fee-for-service (FFS) or cost per services rendered, which carries minimal inherent risk for the providers but has the potential to create the incentive that more care is better. 1 Payment models are evolving that will require increased risk for providers as policy makers argue that conversion from FFS to other models, such as capitation flat fees per member per month, may share risk with providers but it reduces inappropriate or unnecessary care. Each of the various payment model proposals in the evolving health care payment landscape will likely include elements of provider risk. Standard FFS and episode-based payments (bundling) involve associated technical risk, and full capitation involves actuarial risk. However, alternative payment systems hold the promise of aligning incentives that …