Variation in Health Care Spending Target Decision Making, Not Geography (2013) / Chapter Skim
Currently Skimming:
4 Payment and Organizational Reforms to Improve Value
4 Payment and Organizational Reforms to Improve Value
Pages 99-124
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 99... ...
The committee's research and analyses revealed how variation in spending and quality exists in progressively smaller units, down to the hospital, single-specialty group practice, and even individual physician level, suggesting that opportunities exist for improving value at all levels of health care decision making.1 Decision makers differ in their abilities to maximize efficiency and improve value (Audet et al., 2005; Goldberg et al., 2013; Landon et al., 1998; Shih et al., 2008; Sterns, 2007)
|
From page 100... ...
and may be able to improve value through broader initiatives -- for example, through efforts that increase care coordination and target high-risk individuals for disease management programs (Paulus et al., 2008; Shih et al., 2008)
|
From page 101... ...
the importance of clinical and financial integration to building a high-value health care delivery system, and how payment reforms are designed to promote such integration; (2) why, under the tenets of a learning health care system,3 it is important for CMS to evaluate and refine new payment models; and (3)
|
From page 102... ...
. However, financial integration is not a unitary goal; historically, financially integrated health care organizations lacking management, infrastructure, and processes to coordinate care (i.e., clinical integration)
|
From page 103... ...
may help improve disease management and care coordination processes and positively impact health outcomes, especially for patients with multiple chronic conditions (Cebul et al., 2011; Herrin et al., 2012; Kern et al., 2012)
|
From page 104... ...
What Payers Can Do Payers can promote value through payment and organizational reforms that foster the above elements of clinical and financial integration. In fact, many payment reforms included in the ACA and tested in the commercial market (e.g., value-based purchasing [VBP]
|
From page 105... ...
Data that are out-of-date are of relatively little value in communities where there are active efforts to improve the quality and cost of care; indeed, using old data can be counterproductive since it may unfairly imply that problems exist when, in reality, they have already been addressed." What Patients Can Do Finally, patients are also health care decision makers and can be encour aged through alternative cost-sharing arrangements to share in the savings of higher-value care. In this connection, it is important to acknowledge that "clinical services vary in the value they provide to patients, and that not all patients with a specific clinical condition receive the same level of ben efit from a specific intervention" (Fendrick and Chernew, 2006, p.
|
From page 106... ...
RECOMMENDATION 3: To improve value, the Centers for Medi care & Medicaid Services (CMS) should continue to test payment reforms that incentivize the clinical and financial integration of health care delivery systems and thereby encourage their (1)
|
From page 107... ...
. Similarly, the United Kingdom's universal pay-for-performance program for primary care physicians, implemented in 2004, showed improved results on all quality measures in the first year, but several measures subsequently leveled off (Campbell et al., 2009; Doran et al., 2011)
|
From page 108... ...
Patient-Centered Medical Homes The PCMH is a health care delivery model that organizes the care continuum around a practitioner team with the primary care provider at the center, helping patients coordinate care and manage chronic conditions. The PCMH also generally incorporates evidence-based medicine and quality improvement activities (Cassidy, 2010; Jackson et al., 2013)
|
From page 109... ...
, supports the Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration, which pays a monthly care management fee for each eligible Medicare beneficiary receiving primary care services through 1 of 492 FQHCs meeting NCQA requirements for a medical home.
|
From page 110... ...
Finally, the fourth model incorporates all care services, including those of a physician, provided during an acute inpatient stay and readmissions. All of these arrangements include shared savings, and participants have considerable discretion in designing payment allocations (CMS, 2013b)
|
From page 111... ...
. Accountable Care Organizations The ACO is a health care delivery and financing model currently being tested by CMS and commercial insurers.
|
From page 112... ...
, and the Advanced Payment Models ACOs. There are currently 269 health care delivery organizations participating in these programs -- 32 in the Pioneer ACO Model program, 222 in the MSSP, and 15 in Advanced Payment Model ACOs -- reaching more than 4 million Medicare beneficiaries (CMS, 2013h)
|
From page 113... ...
10 Under global payment, an ACO is at financial risk for all of the items and services covered. 11 Under partial capitation payment, an ACO is at financial risk for some, but not all, of the items and services covered (Center for Healthcare Quality and Payment Reform, 2010)
|
From page 114... ...
. · Wisconsin Health Information Organization is a statewide ini The tiative designed to create an all-payer database with which to track health care costs and quality measures, data that can be used to improve the value of care for Wisconsinites with chronic diseases (Wisconsin Health Information Organization, 2013)
|
From page 115... ...
overlay models to different subgroups of dual-eligible beneficiaries." The Future of New Payment Reform Models By creating the Center for Medicare and Medicaid Innovation, the ACA generated a thousand pilot demonstrations of new payment models. It is too early to know which of these models will prove to control health care costs and improve quality.
|
From page 116... ...
, and total Medicare spending.13 RAND's analysis demonstrates that payment reforms targeting health care decision makers can result in large changes (by design) in payments to providers within HRRs, even if those reforms do not substantially affect geographic variation in spending among HRRs.
|
From page 117... ...
. Particularly in the beginning, therefore, Congress might avoid prescribing an immediate wholesale change in payment, instead directing CMS to accelerate the adoption of payment reforms by authorizing differential payment updates for new payment models and traditional Medicare (Davis and Guterman, 2007)
|
From page 118... ...
http://www.healthaffairs.org/healthpolicy briefs/brief.php? brief_id=25 (accessed July 18, 2013)
|
From page 119... ...
2010. Using partial capitation as an alternative to shared savings to support accountable care organizations in Medicare.
|
From page 120... ...
2007. Creating accountable care organizations: The extended hospital medical staff.
|
From page 121... ...
New payment systems reward doctors and hospitals for improving the quality of care, but studies to date show mixed results. http://health affairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_78.pdf (accessed July 18, 2013)
|
From page 122... ...
2012. Anthem Blue Cross and Blue Shield and Orthopedic & Sports Institute of the Fox Valley announce bundled payment.
|
From page 123... ...
2011. Accountable care organizations and health care dis parities.
|
From page 124... ...
2012. Controlling health care spending -- The Massachusetts experiment.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.