Using Pay-For-Performance Payment Methodology Framework For Medicaid Reimbursement Rate In State Government

Medicaid Home Community Based Services (HCBS) program reimbursement rate policy plays a critical role in the rate determination and influences the type of care services received by program recipients. This qualitative case study evaluated the impact of the reimbursement rate policy on the quality of care received by Medicaid HCBS program beneficiaries. The practice-focused question for this study was from the Office of Rates and Reimbursements management perspective on how the state can implement an effective alternative reimbursement rate policy to achieve value-based care services that would result in better healthcare outcomes. To achieve the desired result, thematic and narrative analyses were used to analyze collected data, including all literature reviews and archived documents. Semi-structured interview data and all reviewed pieces of the literature showed that the pay-for-performance reimbursement model could impact the health outcomes of program recipients. By implementing the pay-for-performance reimbursement model, the client organization leaders' policy on reimbursement rate may inspire the care providers to implement new innovative care services that will improve the health outcomes of the program recipients. The findings of the study showed that the pay-for-performance reimbursement model is the best alternative value-based payment model for improving the health outcomes of the program beneficiaries. This study will promote positive social change as the less privileged Medicaid HCBS recipients will have access to high-quality care services that will improve their health outcomes.