Match each healthcare payment and delivery model with the clinical operational scenario that best describes its mechanism of reimbursement and risk distribution.
- Episode-based bundled paymentA facility receives a single, comprehensive rate covering a patient's preoperative evaluation, joint replacement surgery, and 90 days of related post-acute care.
- Global capitationA primary care consortium receives a fixed per-member per-month fee covering all medical services for a population, assuming full financial liability if total care costs exceed revenues.
- Two-sided risk Accountable Care Organization (ACO)A provider group receives financial bonuses if total spending is below a target benchmark, but must repay a portion of losses to the payer if spending exceeds the benchmark.
- Reference pricingA health plan establishes a maximum contribution limit for a specific elective procedure, requiring patients to pay the entire difference out-of-pocket if they select a higher-cost facility.
Answer
The correct pairings align Episode-based bundled payment with a single rate for a procedure and its 90-day post-acute care; Global capitation with a fixed per-member per-month fee assuming full financial liability; Two-sided risk ACO with shared savings below benchmark and shared losses above benchmark; and Reference pricing with a maximum contribution limit for an elective procedure.
Each payment model shifts financial risk away from traditional fee-for-service in distinct ways. Bundled payments target specific clinical episodes. Global capitation transfers maximum risk to providers via per-member monthly payments. Two-sided ACOs maintain fee-for-service infrastructure but add retrospective reconciliation with both upside potential and downside penalties. Reference pricing targets patient consumer behavior by limiting payer liability for shoppable services.
Step-by-Step Solution
Key Concept
Value-Based Care Reimbursement Models and Financial Risk Distribution