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Payer Incentive Programs

  

Although the shift from volume-based to value-based incentive reimbursement is highly touted in recent healthcare literature, little research is available on the subject. The Patient Protection and Affordable Care Act (PPACA) legislation is rife with quality metric performance language and the Center for Medicare and Medicaid (CMS) is currently offering incentive payments for Electronic Medical Record Meaningful Use and for meeting quality targets. Some commercial payers are launching pilots to introduce value-based Incentive programs similar to CMS. Personal experience with medical group incentive payments in New York State is contained in his article “The Golden Payoff for Effective Care Management” (Pulse, Fall 2011, Navigant Consulting).


Value-based incentive programs usually involve some combination of clinical and preventive metrics. Payers tend to develop the metrics and set targets e.g. 75 to 90% provider compliance with female patients in a certain age range needing bi-annual mammograms.  The following incentive program example was provided by a 50 member medical group in upper state New York: