Table 3. New Approaches, Programs, and Models Supported by the ACA.

The new principles for payment
Pay for Performance (P4P)	P4P is the basic principle that undergirds new models of care being supported by the ACA. In these models, providers are rewarded for achieving preestablished quality metrics. The quality metrics for acute care organizations targets the experience of care (HCAHPS), processes of care (such as processes to reduce healthcare-associated infections and improve surgical care), efficiency, and outcomes (i.e., rates of mortality, surgical site infections). In the ambulatory care area, quality performance may be determined by any of the HEDIS measures. The key point for practitioners is total familiarity with how quality is being defined and measured. Knowing this allows for full participation in what must be done to achieve the quality.
Value-Based Purchasing (VBP)	This approach switches the traditional model of healthcare fee structure from fee-for-service where reimbursement is for the number of visits, procedures, and tests to payment based on the value of care delivered—care that is safe, timely, efficient, effective, equitable, and patient-centered. In VBP, insurers such as Medicare set annual value expectations and accompanying incentive payment percentages for each Medicare patient discharge. The purchasers of healthcare are able to make decisions that consider access, price, quality, efficiency, and alignment of incentives and can take their business to organizations/providers with established records for both cost and quality (Aroh, Colella, Douglas, & Eddings, 2015).
Shared Savings Arrangements	Approaches to incentivize providers to offer quality services while reducing costs for a defined patient population by reimbursing a percentage of any net savings realized. Medicare has established shared savings programs in the PCMH and ACO models of care.
New programs and models of delivery and payment
Hospital-Acquired Condition Reduction Program	Under the ACA, Medicare payments for hospitals that rank in the lowest performing quartile for conditions that are hospital-acquired (i.e., infections [central line-associated bloodstream infections and catheter-associated urinary tract infections], postoperative hip fracture rate, postoperative sepsis rate, postoperative pulmonary embolism, or deep vein thrombosis rate) will be reduced by 1%. Upcoming standards will be expanded to include methicillin-resistant Staphylococcus aureus infections (CMS, n.d.).
Hospital Readmissions Reduction Program	Aimed at reducing readmissions within 30 days of discharge (readmission that currently cost Medicare $26 billion per year). To reduce admissions, hospitals must have better coordination of care and support. Hospitals with relatively high rates of readmissions will receive a reduction in Medicare payments. These penalties were first applied in 2013 to patients with congestive heart failure, pneumonia, and acute myocardial infarction. The CMS added elective hip and knee replacements at the end of 2014 (Purvis, Carter, & Morin, 2015).
	In time, 60-, 90-, and 190-day readmissions will be examined.
Accountable Care Organizations (ACOs)	The ACO is a network of health organizations and providers that take collective accountability for the cost and quality of care for a specified population of patients over time. Incentivized by shared savings arrangements, there is a greater emphasis on care coordination and safety across the continuum, avoiding duplication and waste, and promoting use of preventive services to maximize wellness.
	Better coordinated, preventive care is anticipated to save Medicare dollars, and the savings will be shared with the ACO. It is estimated that ACOs will save Medicare up to $940 million in the first 4 years (Sebelius, 2013).
Patient-Centered Medical Homes (PCMHs)	PCMHs is an approach to delivery of higher quality, cost-effective, primary care deemed critically important for people living with chronic health conditions. Medical homes share common elements including comprehensive care addressing most of the physical and mental health needs of clients through a team-based approach to care; patient-centered care providing holistic care that builds capacity for self-management through patient and caregiver engagement that attends to the context of their culture, unique needs, preferences, and values; coordinated care across the continuum of healthcare systems including specialty care, hospitals, home healthcare, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital; accessible care that minimizes wait times and includes expanded hours and after-hours access; and care that emphasizes quality and safety through clinical decision-support tools, evidence-based care, shared decision making, performance measurement, and population health management and incorporation of chronic care models for management of chronic disease (AHRQ, PCMH Resource Center). The CMS has supported demonstration projects to shift its clinics to the medical home model.
Bundled Payment Models	Bundles are single payment models targeting discrete medical or surgical care episodes such as spine surgery or joint replacement. Bundles provide lump sum to providers for a given service episode of care inclusive of preservice time, the procedure itself, and a postservice global period, thereby crossing both inpatient and outpatient services. Can be for a procedure or an episode of care ... providers assume a considerable portion of the economic risk of treatment (McIntyre, 2013). The margin (positive or negative) realized in this process depends on the ability of the different organizations and providers to manage the costs and outcomes across the care continuum.
	The Medicare Comprehensive Care for Joint Replacement model is a bundled care package aimed to support better and more efficient care for those seeking hip and knee replacement surgical procedures. The bundle covers the episode from the time of the surgery through 90 days after hospital discharge.
	Private insurers and businesses are offering bundled payment packages for their participants to receive specialized joint or spine care at approved high-quality, cost-effective facilities. For example, Lowe's and Walmart arrange for no-cost knee and hip replacement surgical procedures for their 1.5 million employees and their dependents if they seek care at one of four approved sites in the United States. These companies will cover the cost of consultations and treatment without deductibles along with travel, lodging, and living expenses for the patient and the caregiver (The Advisory Company, 2013).

Note. ACA = Affordable Care Act; ACO = Accountable Care Organizations; CMS = Centers for Medicare & Medicaid Services; PCMH = Patient-Centered Medical Home.