Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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8 Achieving and Rewarding High-Value Care
8 Achieving and Rewarding High-Value Care
Pages 227-254
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From page 227... ...
As with most aspects of the health care enterprise, a variety of financial incentives and payment 227
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From page 228... ...
Opportunities exist to eliminate wasteful spending while maintaining or enhancing health care quality and improving overall health outcomes. Several health care organizations and health insurers have been leveraging these opportunities to test new models of paying for care and organizing care delivery.
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. As with many other aspects of the health care enterprise, a variety of financial incentives and payment models are currently in use.
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. Many current payment models can serve as a disincentive for provider organizations seeking to implement high-quality care protocols, given that they may see lower revenues as a result of performing fewer services.
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• The current payment model does not reward quality. One study found, on average, only a 4.3 percent correlation between the qual ity of care delivered and the price of the medical service; indeed, higher prices often were associated with lower quality.
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, value measurement for a particular intervention needs to consider improvements in patient health (length of life, health status) , patient quality of life, the patient's sense of well-being, quality of care (technical and with respect to compassion)
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Another outstanding issue is the need to ensure that performance metrics are linked to patient health outcomes. In some cases, process measures have been found to correlate poorly with clinical outcomes, such as in the case of heart failure (Fonarow et al., 2007)
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. Some of the earliest such efforts include New York State's initiative to report the mortality and complications associated with coronary artery bypass graft surgery and the Health Care Financing Administration's (HCFA's)
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Such benefit structures highlight the need for accurate measurement of care value. Today, however, few consumers use publicly reported information to make decisions about clinicians or health care organizations; a 2008 survey found that only 14 percent of respondents had seen and used comparative quality information about health plans, clinicians, or health care
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. One reason for the low usage of publicly reported information is that many consumers believe care quality does not vary significantly among different health care organizations and different clinicians, which limits their motivation to make use of independent quality assessments.
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Although reporting and transparency have had demonstrated impacts on clinical behavior, limited evidence exists about their overall impact on value. Studies and systematic reviews of the public reporting literature suggest that reporting of performance data stimulates quality improvement activities, especially at hospitals, but the impact on effectiveness, safety, and patient-centeredness remains unknown (Fung et al., 2008; Smith et al., 2012)
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Results of one initiative indicated that cou pling financial incentives with assistance to clinicians in monitoring their practice patterns against those of others decreased spending growth by 2 percent per quarter while improving overall care quality.
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. Since the publication of that report, systematic reviews and studies have continued to find conflicting evidence on which payment models best improve the quality and value of care delivered by individual clinicians and through health care organizations (Government Accountability Office, 2011b; Petersen et al., 2006; Rosenthal, 2008; Scott et al., 2011;
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From page 240... ...
The program provides a global payment to cover all care services for a given patient -- primary care, specialty care, hospital care, prescription drugs, and other services. The global payment, adjusted for age, sex, and health status, is ne gotiated in a 5-year contract.
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Bundled payment For a given condition or clinical episode, the payment is bundled into a single, comprehensive payment that covers all services involved in the patient's care. Global payment A single payment covers all services provided to a patient population during a defined time period.
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Many payers have developed financial incentives specifically focused on patients and consumers, including consumer-directed health plans, employer wellness programs, and value-based insurance design. As an example, value-based insurance design models configure benefit design (such as co-payments, clinician networks, and deductibles)
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Many consumer-focused payment models require that consumers estimate their out-of-pocket costs for their specific situation and under different benefit plans. New tools, such as calculators supplied by large employers and health plans, have been developed to make this task easier.
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Her physicians had described her advanced coronary artery disease as inoperable just before she visited the Special Care Center for the first time. Upon checking in, Vibha met with a health coach, Jayshree, who provided support and could connect with Gujarati-speaking patients like Vibhali while care was specially coordinated among the clinic's doctors, nurses, other clinicians, and health coaches.
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Recommendation 8: Financial Incentives tructure payment to reward continuous learning and improvement in S the provision of best care at lower cost. Payers should structure pay ment models, contracting policies, and benefit designs to reward care that is effective and efficient and continuously learns and improves.
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From page 246... ...
• Health care delivery organizations should reward continuous learning and improvement through the use of internal practice incentives. • Health economists, health service researchers, professional spe cialty societies, and measure development organizations should partner with public and private payers to develop and evaluate metrics, payment models, contracting policies, and benefit designs that reward high-value care that improves health outcomes.
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They build on the successes realized by health care organizations and insurers in developing new models of paying for care and organizing care delivery. While a diversity of payment systems is likely to persist, these successes highlight the opportunity for incentives designed to encourage learning and improvement.
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2003. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial.
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2011. An over view of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes.
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2011a. Early lessons from account able care models in the private sector: Partnerships between health plans and providers.
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Menlo Park, CA: Kaiser Family Fundation. Kaiser Family Foundation.
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2011. The effect of financial incentives on the quality of health care provided by primary care physicians.
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2008b. A test of financial incentives to improve warfarin adherence.
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