Pursel Kevin J, Jacobson Martin, Stephenson Kathy
Arise Health Plan, Green Bay, WI 54307-1625, USA.
J Manipulative Physiol Ther. 2012 Jul;35(6):472-6. doi: 10.1016/j.jmpt.2012.07.003. Epub 2012 Aug 24.
The purpose of this study is to describe a reimbursement model that was developed by one Health Maintenance Organization (HMO) to transition from fee-for-service to add a combination of pay for performance and reporting model of reimbursement for chiropractic care.
The previous incentive program used by the HMO provided best-practice education and additional reimbursement incentives for achieving the National Committee for Quality Assurance Back Pain Recognition Program (NCQA-BPRP) recognition status. However, this model had not leveled costs between doctors of chiropractic (DCs). Therefore, the HMO management aimed to develop a reimbursement model to incentivize providers to embrace existing best-practice models and report existing quality metrics. The development goals included the following: it should (1) be as financially predictable as the previous system, (2) cost no more on a per-member basis, (3) meet the coverage needs of its members, and (4) be able to be operationalized. The model should also reward DCs who embraced best practices with compensation, not simply tied to providing more procedures, the new program needed to (1) cause little or no disruption in current billing, (2) be grounded achievable and defined expectations for improvement in quality, and (3) be voluntary, without being unduly punitive, should the DC choose not to participate in the program.
The generated model was named the Comprehensive Chiropractic Quality Reimbursement Methodology (CCQRM; pronounced "Quorum"). In this hybrid model, additional reimbursement, beyond pay-for-procedures will be based on unique payment interpretations reporting selected, existing Physician Quality Reporting System (PQRS) codes, meaningful use of electronic health records, and achieving NCQA-BPRP recognition. This model aims to compensate providers using pay-for-performance, pay-for-quality reporting, pay-for-procedure methods.
The CCQRM reimbursement model was developed to address the current needs of one HMO that aims to transition from fee-for-service to a pay-for-performance and quality reporting for reimbursement for chiropractic care. This model is theoretically based on the combination of a fee-for-service payment, pay for participation (NCQA Back Pain Recognition Program payment), meaningful use of electronic health record payment, and pay for reporting (PQRS-BPMG payment). Evaluation of this model needs to be implemented to determine if it will achieve its intended goals.
本研究旨在描述一种由一家健康维护组织（HMO）开发的报销模式，该模式从按服务收费转变为增加脊椎按摩治疗的绩效付费和报告式报销组合。
该HMO先前使用的激励计划提供了最佳实践教育以及实现国家质量保证委员会背痛认可计划（NCQA - BPRP）认可状态的额外报销激励措施。然而，这种模式并未使脊椎按摩治疗师（DC）之间的成本达到平衡。因此，HMO管理层旨在开发一种报销模式，以激励提供者采用现有的最佳实践模式并报告现有的质量指标。开发目标包括以下几点：它应（1）在财务上与先前系统一样具有可预测性，（2）每位成员的成本不增加，（3）满足其成员的保险需求，（4）能够实施。该模式还应奖励采用最佳实践的DC，给予报酬，而不仅仅与提供更多程序挂钩，新计划需要（1）对当前计费造成很少或没有干扰，（2）基于可实现且明确的质量改进期望，（3）是自愿的，如果DC选择不参与该计划，不应受到过度惩罚。
生成的模式被命名为综合脊椎按摩治疗质量报销方法（CCQRM；发音为“法定人数”）。在这种混合模式中，除了按程序付费外，额外报销将基于对选定的现有医师质量报告系统（PQRS）代码的独特付费解读报告、电子健康记录的有效使用以及获得NCQA - BPRP认可。该模式旨在使用绩效付费、质量报告付费、程序付费方法来补偿提供者。
CCQRM报销模式是为满足一家HMO的当前需求而开发的，该HMO旨在从按服务收费转变为脊椎按摩治疗报销的绩效付费和质量报告模式。该模式理论上基于按服务付费、参与付费（NCQA背痛认可计划付费）、电子健康记录付费的有效使用以及报告付费（PQRS - BPMG付费）的组合。需要对该模式进行评估，以确定它是否能实现其预期目标。
