Value-Based Care: Reimbursement Models from Coursera

COURSE 4 of 7. This course is designed to help you build high-level knowledge of the current medical coding and payment mechanisms of most U.S. healthcare services, referred to as fee-for-service. You will explore why the fee-for-service model has contributed to higher costs in the U.S. healthcare system without clearly improving health outcomes. You will examine the importance of coding to reflect chronic conditions and other diagnoses accurately and how value-based care and payments utilize these measures and data. As you learn about a model to replace fee-for-service, you’ll encounter a range of payment options considered to be value-based that utilize a framework from the Health Care Payment Learning and Action Network (HCP-LAN). To build on those options, you will learn how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. In the summative assignment, you will demonstrate your knowledge by comparing fee-for-service and value-based contracts, using specific examples to explain and justify the importance of documentation and coding, and identifying ways that risk-adjustment and patient satisfaction are incorporated into value-based care contracts.

CME Accreditation

The American Academy of Family Physicians (AAFP) has approved this course for Continuing Medical Education Prescribed Credits. Visit the FAQs for important information regarding 1) Term of approval and 2) Accreditation and Credit Designation statements.

What's inside

Syllabus

From Fee-For-Service to Value-Based Payments

In this course, you will build high-level knowledge of the current medical coding and payment mechanisms of most U.S. healthcare services, referred to as fee-for-service. Then you will explore why the fee-for-service model has contributed to higher costs in the U.S. healthcare system without clearly improving health outcomes. As you examine a model to replace fee-for-service, you’ll encounter a range of payment options considered to be value-based. To build on those options, you will explore how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. This module is an introduction to and exploration of value-based payment models utilizing a framework from the Health Care Payment Learning and Action Network (HCP-LAN). As a preparatory step to that introduction and review, the module starts with a high-level review of current fee-for-service payments, coding for those payments, and the problems resulting in increased healthcare costs and lower-than-expected quality in the U.S. Remember, as you read or hear terms or concepts that are new to you, have your digital (Word doc) or analog (paper) notepad handy to write them down. At any time, you can use your favorite search engine to learn more. Be a self-directed learner!

Quality and Risk Adjustment in Value-Based Payments

In the previous module, you examined the importance of coding to reflect chronic conditions and other diagnoses accurately. You also explored how value-based care and payments utilize these measures and data. As you explore the four categories of the HCP-LAN alternative payment models (APMs)—also known as value-based payment arrangements or value-based contracts – the acronym of the latter is also VBC. As with other acronyms, you will learn to read VBC in context to determine if we are talking about care or payments/contracts. The focus of this module is on two key aspects of value-based payment models: 1) The need for, and methods of, risk-adjustment in value-based contracts, and 2) Quality scores and patient satisfaction measures, which are critical parts of value-based care and contracts. At the end of this module, you will examine how those elements are utilized in value-based contracts. Remember, as you read or hear terms or concepts that are new to you, have your digital (Word doc) or analog (paper) notepad handy to write them down. At any time, you can use your favorite search engine to learn more. Be a self-directed learner!

Course Project: Making This My Own

In this course, you have examined how the fee-for-service model emerged from current medical coding and payment mechanisms and why this model has contributed to higher costs in the U.S. healthcare system. In the videos and discussion postings relating the quest to replace the fee-for-service model, you explored a range of value-based payment options and how risk-adjustment, quality scores, and patient satisfaction measures are critical parts of value-based care and payment contracts. Whether you are currently working in a healthcare provider or payer organization or aspiring to work in either, it is paramount that you be able to synthesize, reframe, and put into practice knowledge gained from this course. Even more important is to recognize that the responsibility for applying this knowledge is shared by providers and payers, as ultimately it is the provider-payer partnership that leads to successful value-based care.

Good to know

Know what's good

, what to watch for

, and possible dealbreakers

Examines core concepts that are pivotal to medical coding and payment mechanisms in healthcare services

Explores the drawbacks of the fee-for-service model and its contribution to the escalation of healthcare costs in the U.S. while inadequately improving health outcomes

Introduces various payment options within the value-based care framework, illuminating their significance and implementation

Cultivates an understanding of the critical role of risk-adjustment, quality scores, and patient satisfaction measures in value-based care and payment contracts, equipping learners to navigate these essential aspects

Emphasizes the shared responsibility between providers and payers in the successful implementation of value-based care

Requires students to actively synthesize and apply knowledge gained throughout the course, fostering critical thinking and practical implementation skills

Reviews summary

Value-based care: reimbursement models

Learners say that this course offers great information on value-based care and reimbursement models. Numerous say it's an excellent course with engaging assignments that helped them understand the how and the why of value-based care.

Course good for professionals

"Very insightful course for professionals needing an insight and levelset into the value based payment model."

Assignments help learning

"I really liked the course and the instruction."

Great material

"best"

"great information "

Course has US-centric focus

"Its an excellent course with a lot of insights on how to develop models of reimbursement. Its very specific to the US however, and examples from other countries would be useful."

Peer review process can be improved

"The peer review is a nightmare, the process of chasing people to review your assigment is time consuming and shamful. "

Activities

Be better prepared before your course. Deepen your understanding during and after it. Supplement your coursework and achieve mastery of the topics covered in Value-Based Care: Reimbursement Models with these activities:

Compile a Glossary of Value-Based Care Terms

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Create a comprehensive glossary of terms related to value-based care to enhance your understanding and facilitate communication with stakeholders

Browse courses on Value-Based Care

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Gather resources such as industry reports, academic papers, and online forums
Extract and compile key terms and their definitions
Organize the glossary in a logical and accessible manner

Review Medical Coding Guidelines

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Review medical coding guidelines, such as Current Procedural Terminology (CPT) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), to refresh your knowledge and ensure accuracy when coding

Browse courses on Medical Coding

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Gather resources such as the CPT manual and ICD-10-CM guidelines
Review chapters relevant to your specialty
Complete practice exercises to test your understanding

Explore Value-Based Payment Models

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Seek out and follow tutorials on value-based payment models to gain a deeper understanding of their implementation and impact on healthcare delivery

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Identify reputable sources for tutorials, such as industry organizations or academic institutions
Choose tutorials that cover topics aligned with your learning goals
Actively engage with the tutorial content, taking notes and asking questions

Five other activities

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Analyze Case Studies on Value-Based Payment Models

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Engage in case study analysis to examine real-world examples of value-based payment models and their impact on healthcare delivery and outcomes

Browse courses on Value-Based Care

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Gather case studies from reputable sources
Review the case studies, identifying key elements and outcomes
Discuss the case studies with peers or mentors

Engage in Discussion Groups on Value-Based Care

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Participate in discussion groups with peers to exchange knowledge, perspectives, and experiences related to value-based care implementation

Browse courses on Value-Based Care

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Identify relevant discussion groups or forums
Actively engage in discussions, sharing insights and asking questions
Reflect on the discussions and apply learnings to your understanding of value-based care

Develop a Contract for a Value-Based Care Arrangement

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Create a sample contract for a value-based care arrangement, considering elements such as risk-adjustment, quality measures, and payment incentives

Browse courses on Value-Based Contracts

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Research different types of value-based contracts
Identify key provisions to include, such as payment methodology, performance metrics, and dispute resolution
Draft the contract, ensuring clarity and legal compliance

Participate in a Value-Based Care Initiative

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Volunteer with organizations implementing value-based care initiatives to gain practical experience and contribute to the advancement of healthcare delivery

Browse courses on Value-Based Care

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Identify organizations or programs focused on value-based care
Inquire about volunteer opportunities and match your skills to the needs of the organization
Actively participate in the initiative, supporting tasks and learning from experienced professionals

Contribute to Open-Source Projects Related to Value-Based Care

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Contribute to open-source projects that advance value-based care, such as data analytics tools or patient engagement platforms

Browse courses on Value-Based Care

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Identify open-source projects related to value-based care
Review the project documentation and identify areas where you can contribute
Submit code changes, bug reports, or documentation improvements

Career center

Learners who complete Value-Based Care: Reimbursement Models will develop knowledge and skills that may be useful to these careers:

Medical Reimbursement Specialist

As a Medical Reimbursement Specialist, you will work with healthcare providers to ensure accurate and timely reimbursement for medical services. Value-Based Care: Reimbursement Models is a relevant course for you to take as it will provide you with a comprehensive understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, including the fee-for-service model and its limitations. You will also learn about the importance of accurate coding to reflect chronic conditions and other diagnoses, which is essential for value-based care and payments.

See salaries and explore the career path for Medical Reimbursement Specialist

Risk Adjustment Specialist

As a Risk Adjustment Specialist, you will work to identify and manage the risks associated with providing healthcare services. Value-Based Care: Reimbursement Models is a valuable course for you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, as well as the role of risk-adjustment in value-based care.

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Healthcare Consultant

As a Healthcare Consultant, you will provide expert advice and guidance to healthcare organizations on a variety of issues, including strategic planning, operational efficiency, and financial management. Value-Based Care: Reimbursement Models can be a valuable asset to you as it will equip you with a thorough understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the challenges and opportunities associated with the transition to value-based care.

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Value-Based Care Manager

As a Value-Based Care Manager, you will work to implement and manage value-based care programs for healthcare organizations. Value-Based Care: Reimbursement Models can be useful to you as it will provide you with a comprehensive understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, as well as the challenges and opportunities associated with the transition to value-based care.

See salaries and explore the career path for Value-Based Care Manager

Health Information Manager

As a Health Information Manager, you will oversee the management and protection of patient health information, ensuring compliance with regulations and standards. Value-Based Care: Reimbursement Models is a valuable course for you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the shift towards value-based care and payments, which is becoming increasingly important in the healthcare industry.

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Quality Improvement Specialist

As a Quality Improvement Specialist, you will work to improve the quality of healthcare services and outcomes. Value-Based Care: Reimbursement Models is a valuable course for you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the role of quality measures and patient satisfaction in value-based care and payments.

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Healthcare Executive

As a Healthcare Executive, you will lead and manage healthcare organizations. Value-Based Care: Reimbursement Models is a valuable course for you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, as well as the challenges and opportunities associated with the transition to value-based care.

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Medical Auditor

As a Medical Auditor, you will review and analyze medical records to ensure accurate coding and billing. Value-Based Care: Reimbursement Models is a valuable course for you as it will provide you with a comprehensive understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the importance of accurate coding to reflect chronic conditions and other diagnoses, which is essential for value-based care and payments.

See salaries and explore the career path for Medical Auditor

Medical Coder

As a Medical Coder, you will assign codes to medical records and health information to ensure accurate billing and reimbursement. Value-Based Care: Reimbursement Models is a helpful course to take as it will enable you to gain a comprehensive understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, including the fee-for-service model and its limitations. You will also learn about the importance of accurate coding to reflect chronic conditions and other diagnoses, which is essential for value-based care and payments.

See salaries and explore the career path for Medical Coder

Healthcare Administrator

As a Healthcare Administrator, you will oversee the management and operation of healthcare organizations. Value-Based Care: Reimbursement Models can be useful to you as it will provide you with a comprehensive understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the challenges and opportunities associated with the transition to value-based care.

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Utilization Review Nurse

As a Utilization Review Nurse, you will review and assess the medical necessity of healthcare services. Value-Based Care: Reimbursement Models is a helpful course for you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system. You will also gain insights into the role of quality measures and patient satisfaction in value-based care and payments.

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Healthcare Data Analyst

As a Healthcare Data Analyst, you will collect, analyze, and interpret healthcare data to identify trends and patterns, and support decision-making. Value-Based Care: Reimbursement Models may be helpful to you as it will provide you with a foundation in medical coding and payment mechanisms, which are essential for understanding and analyzing healthcare data. You will also gain insights into the role of data in value-based care and payments.

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Healthcare Provider

As a Healthcare Provider, you will provide medical care to patients. Value-Based Care: Reimbursement Models can be useful to you as it will provide you with a foundational understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, including the fee-for-service model and its limitations. You will also learn about the importance of accurate coding to reflect chronic conditions and other diagnoses, which is essential for value-based care and payments.

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Healthcare Policy Analyst

As a Healthcare Policy Analyst, you will research and analyze healthcare policies and regulations, and make recommendations for changes to improve the healthcare system. Value-Based Care: Reimbursement Models can be useful to you as it will provide you with a deep understanding of the current medical coding and payment mechanisms used in the U.S. healthcare system, as well as the challenges and opportunities associated with the transition to value-based care.

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Physician Advisor

As a Physician Advisor, you will provide clinical expertise and guidance to health plans and other healthcare organizations. Value-Based Care: Reimbursement Models may be helpful to you as it will provide you with a solid foundation in medical coding and payment mechanisms, which are essential for understanding the financial aspects of healthcare delivery. You will also gain insights into the role of physicians in value-based care and payments.

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