Financing That Rewards Better Health and Well-Being:

Efficiency, effectiveness, equity, and experience implications of integrated payments for health

The National Academy of Medicine Leadership Consortium and the Health and Medicine Division’s Board on Health Care Services of the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop series sponsored by the George Family Foundation, Nemours, the Samueli Foundation, Well Being Trust, and the Whole Health Institute focused on the need to accelerate movement away from traditional fee-for-service payment structures and toward integrated payment approaches that incentivize whole-person and population health and well-being. Below are the key themes discussed by the workshop participants.

“COVID showed us that it’s possible […] that we can find a way to work together and be creative in our financing and really prioritize health.”

Kisha Davis, Aledade

Watch the video: Workshop Series Co-Chair Kisha Davis

“We need to change the way we go about paying for health and health care in this nation.”

Michael McGinnis, National Academy of Medicine

Watch the video: NAM Executive Officer Michael McGinnis

Reimagining Approaches to Care for the Entire Population

  • Integrate services that drive health and well-being. (Abramson, Backus, Birch, Chomilo, Cohen, Conway, Ferris, Fogel, Halfon, Hameed, Ibarra, Kligler, Walker)
  • Extend domains of care to encompass communities. (Abramson, Alley, Brower, Erickson, Gupta, Halfon, Hameed, Ibarra, Pegus)
  • Invest in health care and social supports for infants and children to address health disparities that occur early in life. (Briscoe, Halfon, Walker)
  • Engage in effective life-stage care strategies. (Berwick, Birch, Halfon, Ibarra)
  • Provide high-quality care to older adults and individuals with disabilities. (Lewis)
  • Expand the use of home- and community-based services. (Berwick, Lewis, Halfon)
  • Make full use of telehealth, virtual health, and other technologies. (Alley, Cohen, Lee, Lewis)

“We’re looking at taking a different approach to advancing health equity and addressing structural racism. We’re looking at models that we could pursue to address these issues as part of our mandate to improve quality.”

Elizabeth Fowler, Center for Medicare & Medicaid Innovation

“The role of the health care system is to empower the person: to have the conversation about what’s important to that person, and then to build out that conversation into, 'what kind of skills, or assistance, or tools do you need to move yourself toward what’s important to you?'”

Benjamin Kligler, Veterans Health Administration

Redesigning Health Financing to Incentivize Whole-Person and Population Health and Well-Being

  • Establish health system accountability based on meaningful quality measures. (Alley, Ferris, Mann, Walker)
  • Invest in a workforce that can provide whole-person and population health. (Alley, Backus, Briscoe, Gupta, Ibarra, Lewis, Walker)
  • Leverage state, local, and federal funding opportunities to experiment, authorize, assess, and extend care delivery and financing innovations. (Alley, Backus, Birch, Chomilo, Fowler, Ibarra, Kinzer, Lewis, Mann, Nichols)
  • Set longer time horizons for return on investments in health. (Brower, Halfon, Muhlestein, Walker)
  • Use universal empanelment to provide high-quality primary care. (Berwick, Bitton)
  • Use lessons from the COVID-19 pandemic to recognize gaps and the fragility of fee-for-service financing strategies and transition away from their use. (Cohen, Ferris, Hameed, Lewis, Mann, Nichols)
  • Connect the public- and private-sector producers of better health with the entities interested in investing in better health to direct resources to address the social determinants of health. (Erickson)
  • Shift resources toward vulnerable populations with low incomes to improve population health and lower the costs of health care. (Berwick)
  • Leverage market forces to aid the health system in moving away from fee-for-service financing structures. (Erickson)
  • Implement mandatory payment strategies that do not operate on fee-for-service business models. (Fowler, Muhlestein)
  • Eliminate frictional costs and “gaming the system.” (Brower, Ferris, Fowler)

We have interposed between patients and caregivers—between payers and caregivers—layers of non–value added financial manipulation that just hurt us, and I think we need to stop it. […] Financial interests intermediating between payers and patients and providers do not add value.”

Don Berwick, Institute for Healthcare Improvement

“We need to move beyond 12 month contracting periods—you can’t say that you have successfully managed a population in 12 months. We need longer-term time horizons, and we need to provide incentives to business models that are not built on fee-for-service.”

David Muhlestein, Leavitt Partners

Cross-Cutting Suggestions

  • Ensure that equity is a major driver of transformed health care delivery and financing. (Alley, Berwick, Briscoe, Chomilo, Mann, Pegus, Walker)
  • Study how relationships in complex systems give rise to collective behaviors to learn how to redirect those systems. (Fogel)
  • Create a shared digital infrastructure to enable better communication, coordination, data sharing, and strategic investments. (Birch, Cohen, Ferris, Fowler, Gupta, Kinzer, Lee, Nichols, Walker)
  • Build on collaborative, cross-sector partnerships to advance better health and well-being. (Bitton, Brower, Ferris, Nichols, Pegus, Shurney)
  • Ensure that patients are at the center of payment and care. (Gupta, Hameed, Ibarra)

While it’s important to get the incentives right and pay for the right things, you still need some shared infrastructure to facilitate high value care. Sometimes that’s data exchange and interoperability, and frankly, it is also relationships and conversations.”

Mandy Cohen, North Carolina Department of Health and Human Services

“When thinking about payment for whole person health […] no whole person health without population health; no population health without health equity; no health equity without addressing structural racism; and you can’t address structural racism without involving community.” (paraphrased)

Nathan Chomilo, Minnesota Department of Health

“If we care about these things, if we care about people, value people, we will shift the funding to align with these values. We spend a long time trying to get blood from the stones of an antiquated model. Maybe it’s time we use those stones to build a new foundation of good medicine.”

Fasih Hameed, Petaluma Health Center

“We also need to make sure that we have this opportunity to focus on kids and focus on families—and that is a new way to think about the whole person.”

Kara Odom Walker, Nemours Children’s Health System