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When you look at the health care delivery system do you find other ways that the goverment
might change the payment system to avoid fraudelent activity by providers?
Solution
BARRIERS
SOLUTIONS
BARRIER #1:Continued use of fee -for-service payment in payment reforms
SOLUTION: Use episode-of-care payment for acute conditions and global payments for all
patients to eliminate undesirable incentives under fee-for-service and to give providers the
flexibility and accountability to reduce costs and improve quality
BARRIER #2:Expecting providers to be accountable for costs they cannot control.
SOLUTION: Use risk adjustment and risk limits to keep insurance risk with payers but transfer
performance risk to providers.Use risk exclusions to give providers accountability only for the
types of costs they areable to control.Make provisions for contract adjustments to deal with
unforeseen events
BARRIER #3:Physician compensation based on volume, not value
SOLUTION: Change physician compensation systems to match incentives under payment
reform. Modify federal and state fraud and abuse laws to permit gain-sharing between hospitals
and physicians
BARRIER #4:Lack of data for setting payment amounts
SOLUTION: Give providers access to timely analyses of both utilization and costs through
community multi-payer claims databases
BARRIER #5:Lack of patient engagement
SOLUTION: Ask patients to designate their primary care physicians rather than using statistical
attribution rules based on fee-for-service claims to assign them retrospectively. Use value-based
benefit designs to enable and encourage patients to improve health,adhere to treatment plans, and
choose high-value providers and services

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  • 1. When you look at the health care delivery system do you find other ways that the goverment might change the payment system to avoid fraudelent activity by providers? Solution BARRIERS SOLUTIONS BARRIER #1:Continued use of fee -for-service payment in payment reforms SOLUTION: Use episode-of-care payment for acute conditions and global payments for all patients to eliminate undesirable incentives under fee-for-service and to give providers the flexibility and accountability to reduce costs and improve quality BARRIER #2:Expecting providers to be accountable for costs they cannot control. SOLUTION: Use risk adjustment and risk limits to keep insurance risk with payers but transfer performance risk to providers.Use risk exclusions to give providers accountability only for the types of costs they areable to control.Make provisions for contract adjustments to deal with unforeseen events BARRIER #3:Physician compensation based on volume, not value SOLUTION: Change physician compensation systems to match incentives under payment reform. Modify federal and state fraud and abuse laws to permit gain-sharing between hospitals and physicians BARRIER #4:Lack of data for setting payment amounts SOLUTION: Give providers access to timely analyses of both utilization and costs through community multi-payer claims databases BARRIER #5:Lack of patient engagement SOLUTION: Ask patients to designate their primary care physicians rather than using statistical attribution rules based on fee-for-service claims to assign them retrospectively. Use value-based benefit designs to enable and encourage patients to improve health,adhere to treatment plans, and choose high-value providers and services