Ready or Not: Hospital Value-Based Purchasing
Poised to Transform Healthcare Reimbursement
Model and Introduce New Fraud Targets Under the
False Claims Act
By PollyBeth Hawk*
I. AN INTRODUCTION TO VALUE-DRIVEN REFORM
There are a multitude of healthcare reform forces converging on the
United States’ healthcare system, but arguably none as profoundly
transformative as the government’s value-driven healthcare agenda. The
nation’s healthcare stakeholders continue to grapple with reports and
statistics detailing the delivery of inadequate care across provider settings
compounded by spiraling healthcare costs and the looming threat of federal
healthcare program insolvency. 1 One of the government’s primary
responses to this crisis is to alter the longstanding business model governing
reimbursement of healthcare services provided to Medicare beneficiaries.
To be sure, the Department of Health and Human Services (“HHS”) is
spearheading a fundamental transition of the health care payment and
delivery system. Rather than continuing to reward the quantity of care
delivered, the new system will reward the quality, efficiency, and cost-
effectiveness of care. Under the current fee-for-service (“FFS”) model,
Centers for Medicare and Medicaid Services (“CMS”) effectively pays
healthcare providers to perform services without regard to quality and with
no rewards for efficiency. 2 Furthermore, this model fails to effectively
PollyBeth Hawk, LL.M., J.D., C.H. C. is a healthcare attorney practicing with the law firm
of K&L Gates, LLP in Charleston, South Carolina.
