The Healthcare Guys: Payment Models & Reimbursement

There are several payment models and reimbursement systems used in the healthcare industry.

One common payment model is fee-for-service (FFS), in which healthcare providers are reimbursed for each service or procedure they perform. This model can lead to overuse of services, as providers have financial incentives to perform more procedures.

Another payment model is value-based care (VBC), which aims to improve the quality of care while reducing costs. In VBC, healthcare providers are reimbursed based on the overall health outcomes of their patients, rather than the number of services they provide. This model encourages providers to focus on preventative care and better management of chronic conditions, which can lead to better health outcomes and lower healthcare costs.

Capitation is a reimbursement model that is often used in managed care plans, in which a healthcare provider is paid a fixed amount per patient per period of time, regardless of the number of services provided. This model shifts the financial risk of providing care from the insurer to the provider.

In addition to these, there are also global budgeting, bundled payment, and others.

Reimbursement for healthcare services is typically provided by private insurance companies or government-funded programs, such as Medicare and Medicaid. The specific reimbursement amount for each service or procedure is determined by the payer and may be based on factors such as the cost of the service, the complexity of the procedure, and the facility where the service is provided.