Alternative Payment Plans Research Articles

Apple Tree Maternity: A Qualitative Exploration of the Development of a Rural Collaborative Interprofessional Maternity Care Service

Introduction: There is currently a maternity care crisis in Canada, with many of the obstetricians and family physicians reaching retirement age in the next 10 years. Primary midwifery care services may offer solutions. However, due to the many constraints and difficulties faced by midwives practicing in rural settings, there is an emerging interest in exploring interprofessional collaborative models of maternity care as a possible solution to the crisis. This study documents the process and experiences of care providers in establishing and providing collaborative interprofessional maternity care in rural British Columbia. Methods: Semistructured interviews were conducted with key stakeholders (primary care providers and allied health professionals) working at Apple Tree Maternity. Interviewees spoke to both the process of establishing a new collaborative interprofessional model of care and the experience of working and providing care within the model. Findings: Four main themes emerged through the dialogue with the stakeholders: motivation for collaboration; challenges and barriers to collaborative care; attributes and benefits of collaborative care; and core qualities and recommendations for successful interprofessional collaboration. Based on their experience of establishing and working within a new model of collaborative, interprofessional, rural maternity care, the study participants identified core qualities and recommendations for successful interprofessional collaboration in a rural community to be mutual trust and respect; common philosophy of care, mutual commitment, and genuine desire to collaborate; clear and effective communication; ensuring the collaborative model is responsive to the unique needs of specific communities; community support; supportive institutional culture; and alternative payment plans and billing structures. Conclusion and implications for practice: This study revealed a number of attributes to collaboration that mirror those identified by others. In addition, study participants identified particular challenges unique to the rural context. Further research documenting the care provider experiences of interprofessional collaboration in other rural settings is warranted. In addition, there is also a need to explore and document the experiences of collaborative practice, in both rural and urban settings, from the client perspective. It is only when this is achieved that significant policy change suggestions should be made that will facilitate both collaborative practice and an improvement in care to women in rural settings. The need for this research is vital given the maternity care crisis in British Columbia and the need for supporting sustainable rural maternity care models. This article has been peer reviewed.

The Forgotten History of Bankruptcy, 1543–1624

ABSTRACT This article examines the foundations of bankruptcy law in England. Rather than looking at the bankruptcy statutes that were aimed at fraudulent insolvent debtors, it analyses debt settlements of honest insolvent debtors awarded by the court of Chancery between 1543 and 1628. It shows that these agreements were not only aimed at relieving creditors, but also financially rehabilitated debtors if they had become insolvent for reasons beyond their own control. Most debt settlements in the period were awarded following a bill of conformity procedure, in which a minority of creditors could be forced to agree to a settlement. Up to 1621 it was standard practice for debt settlements to include financial rehabilitation. The Chancery ordered delay of payment, part and full discharges of debts or alternative payment plans. Political struggles and fraudulent practices in the early 1620s ended this highly pragmatic practice, which was only to be restored centuries later.

Analysis of Housing Finance Payment Plans on the Axis of Interest and Garar in Line with Islamic Finance Principles

The paper titled "Analysis of Housing Finance Payment Plans in the Context of Interest and Uncertainty (Garar)" represents a study that examines housing finance payment plans within the framework of interest and the concept of uncertainty. Financing methods employed for housing acquisition can generally be categorized into loans obtained from financial institutions and payment plans offered by construction companies. Credit institutions are assessed in terms of interest, while payment plans provided by construction firms are evaluated based on the principle of uncertainty (garar). The significance of this paper lies in its assessment of the compatibility of housing finance payment plans with Islamic finance principles. In Islamic law, interest (riba) and uncertainty (garar) are considered prohibited, and efforts are made to establish a financial system that adheres to fair and permissible practices. This paper contributes to comprehending the Islamic finance perspective by evaluating the alignment of housing finance payment plans with these principles. The payment plans presented to buyers are marketed as being compliant with the criteria of being halal (permissible), caiz, and adhering to Islamic finance standards. In this context, it is believed that this paper will contribute to promoting literacy in Islamic finance. The main objective of this paper is to analyze housing finance payment plans in terms of interest and uncertainty and assess their adherence to Islamic finance principles. This evaluation encompasses determining whether these payment plans are halal or haram (forbidden) and whether they adhere to Islamic finance principles such as justice, transparency, and fairness. The methodology employed involves a detailed examination and analysis of housing finance payment plans. This entails evaluating factors such as interest rates, the level of uncertainty, hidden costs, and other financial details. Additionally, Islamic law and Islamic finance regulations are studied to assess conformity with Islamic finance principles. The analysis is conducted by considering various financing types, including conventional bank loans, savings-based payment plans, and alternative payment plans offered by Real Estate Investment Trusts (REITs) within the framework of Islamic finance criteria. The outcomes of this study demonstrate the extent to which housing finance payment plans align with Islamic finance principles concerning interest and uncertainty. The results identify to what degree payment plans adhere to Islamic finance principles, potential elements of non-compliance (haram), and alternative solutions. Accordingly, alternative models such as murabaha, teverruk, and musharakah-i mutanaqisa, which are employed in participatory banking, are recommended as substitutes for the interest-based debt system utilized by conventional banks. The study emphasizes an approach closer to the real economy through "participatory banking." Moreover, the study highlights that payment plans, particularly models linked to inflation or the dollar, presented by REITs cannot be considered permissible within the scope of uncertainty (garar). Instead, the study suggests opting for fixed payment plans with varying maturity periods, which are more in line with Islamic law.

Focused practice in family medicine

To determine factors associated with having a focused practice among a sample of family medicine graduates in Canada and to assess the characteristics of FPs with focused practices and the range of services provided by these FPs in relation to the full scope of office-based care. Secondary analyses of cross-sectional data from the 2013-2014 Western Family Medicine Resident Follow-Up Survey. Western University in London, Ont. Western University family medicine residency graduates who completed the program between 1985 and 2012. Physician and practice characteristics and the clinical services that survey participants provide. Completion of postgraduate third-year (PGY3) training was associated with having a focused practice. Focused practice FPs were more likely to be remunerated by fee-for-service, alternative payment plans, or alternative funding plans compared with non-focused practice FPs, who were more likely to participate in group payment models. Focused practice FPs appeared to be a heterogeneous group who were distinguished by being either an office-based focused practice FP (OBFFP) or a non-office-based focused practice FP (NOBFFP). Office-based focused practice FPs were less likely than NOBFFPs to have completed PGY3 training and more likely to work under a fee-for-service or group payment model. Further, the OBFFP group offered a greater variety of primary care services than the NOBFFP group, but offered less variety than non-focused practice FPs. Completion of PGY3 training and payment through certain remuneration models were both associated with focused practice. Important differences exist between OBFFPs and NOBFFPs. The overall service provision of focused practice FPs was centred on specialized areas, especially among those practising in non-office-based settings. Novel findings from this study provide insights for family medicine education, work force planning, and policy making in the Canadian health system.

Health check guidelines and billing for family physicians caring for adults with intellectual and developmental disabilities: Incentives to improve care.

To examine the degree to which Canadian consensus guideline recommendations for annual comprehensive preventive care assessments of adults with intellectual and developmental disabilities (IDD) are being taken up by Nova Scotia family physicians since the introduction of incentive billing codes; and to discuss the importance of complete physical examinations for this patient population, extra time needed in clinic encounters, and challenges for practitioners providing care. Analysis of family physicians' billing of codes 03.04C and 03.03E from April 2012 to December 2016. Nova Scotia. Family physicians. Number of billings through fee-for-service and alternative payment plans, and number of providers who used these fee codes. Analysis yielded 3 key results. Use of incentivized billing codes for adult IDD visits and complete examinations in Nova Scotia has steadily increased for patients since the introduction of the modified codes. There is measurable uptake of the IDD adult visit code in total numbers and numbers of providers billing the code. There is poor uptake of the complete examination code. Enhanced billing codes will provide Nova Scotia family physicians with an incentive to employ the newly revised 2018 Canadian consensus guidelines in the care of adults with IDDs. With continued discussion and promotion of annual physical examinations for patients with IDD, more patients and caregivers might make this proactive care item a priority.

Unmet Dental Care Need and Associated Barriers by Race/Ethnicity among US Adults.

Ability to access needed dental care may vary among population subgroups. We assessed 1) the differences in the proportions of adults who reported unmet dental care needs in the past 12 months and the associated barriers (structural, financial, and cognitive) in 2015 to 2016 versus 2003 to 2004 by race/ethnicity and 2) the subgroups that are more likely to report unmet dental care needs. Data of 10,029 respondents aged ≥19 y from the 2003-2004 and 2015-2016 National Health and Nutrition Examination Surveys were used. Chi-square tests assessed the differences in the proportions of adults who reported not getting the needed dental care between the periods. A multiple logistic regression model was run to identify characteristics that were significantly associated with unmet need after adjusting for other factors. Overall, 19.4% of the adults reported an unmet dental care need in 2015 to 2016, as compared with 21% in 2003 to 2004. The overall unmet dental care need decreased only in the Hispanic groups (34% to 28%, P = 0.045) between 2003-2004 and 2015-2016. Between the periods, unmet need decreased among Hispanics aged 19 to 64 y (35% to 28%, P = 0.02), Hispanics with some college education or above (33.5% to 21.0%, P = 0.008), and nonpoor Hispanic adults (29.8% to 20.4%, P = 0.048). No significant differences were observed in the proportions of adults reporting structural (P = 0.09), financial (P = 0.86), or cognitive (P = 0.07) barriers between the periods. When compared with their counterparts, nonelderly adults, women, Hispanics, adults with a high school education, those with less than a high school education, and poor adults were significantly more likely to report unmet dental care needs. Racial and ethnic disparities in accessing and receiving the needed dental care still exist. Financial barriers to dental care are the most commonly cited reasons for not getting the needed dental care. The results of the study will inform policy makers, public health planners, and dental professionals about subgroups that still face difficulty in receiving the dental care they need. Policy makers should develop new policies to mitigate the financial barriers that are still prevalent. Dental professionals can mitigate the public's cognitive and financial barriers by educating the community through outreach programs and by providing services to low-income populations at reduced charges or through alternative payment plans.

The Cost of an Episode of Care in a Total Knee Arthroplasty Patient Is More Than a Total Hip Arthroplasty Patient Within an Alternative Payment Model

BackgroundAlternative payment models were set up to increase the value of care for total joint arthroplasty. Currently, total knee arthroplasty (TKA) and total hip arthroplasty (THA) are reimbursed within the same bundle. We sought to determine whether it was appropriate for these cases to be included within the same bundle. MethodsThe data were collected from consecutive patients in a bundled payment program at a single large academic institution. All payments for 90 days postoperatively were included in the episode of care. Readmission rates, demographics, and length of stay were collected for each episode of care. ResultsThere was a significant difference in cost of episode of care between TKA and THA, with the average TKA episode-of-care cost being higher than the average THA episode-of-care cost ($25803 vs $23805, P < .0001). There was a statistically significant difference between the 2 groups between gender, race, medical complexity, disposition outcome, and length of stay. The TKA group trended toward a lower readmission rate (5.3%) compared to the THA group (6.6%). ConclusionThe cost of an episode of care for patients within the bundled payment model is significantly higher for patients undergoing TKA compared with those undergoing a THA. This should be taken into consideration when determining payment plans for patients in alternative payment plans, along with other aspects of risk that need to be considered in order to allow for hospitals to be successful under the bundled payment model.

National Quality Forum Guidelines for Evaluating the Scientific Acceptability of Risk-adjusted Clinical Outcome Measures: A Report From the National Quality Forum Scientific Methods Panel.

: Quality measurement is at the heart of efforts to achieve high-quality surgical and medical care at a lower cost. Without accurate quality measures, it is not possible to appropriately align incentives with quality. The aim of these National Quality Forum (NQF) guidelines is to provide measure developers and other stakeholders with guidance on the standards used by the NQF to evaluate the scientific acceptability of performance measures. Using a methodologically rigorous and transparent process for evaluating health care quality measures is the best insurance that alternative payment plans will truly reward and promote higher quality care. Performance measures need to be credible in order for physicians and hospitals to willingly partner with payers in efforts to improve population outcomes. Our goal in creating this position paper is to promote the transparency of NQF evaluations, improve the quality of performance measurements, and engage surgeons and all other stakeholders to work together to advance the science of performance measurement.

Accounting for Disparities in the Evaluation of Medicare Alternative Payment Plans

Accounting for Disparities in the Evaluation of Medicare Alternative Payment Plans

Impacts of Alternative Billing Claims on Hypertension Prevalence and Mortality Estimates in Alberta, Canada

ABSTRACT&#x0D; ObjectivesIn Canada, secondary sources of health information such as physician billing claims are used for surveillance of chronic conditions such as hypertension. The value of this data may be affected by different types of physician payment models. Fee-for-service (FFS) physicians submit billing claims in order to be remunerated whereas physicians on salary or capitation also called alternative payment plans (APP) are remunerated regardless of whether claims are submitted. Thus there are concerns nationally that APPs may be associated with decreased frequency of billing submission, thereby eroding data quality and leading to underestimates of disease burdens and outcomes. We assessed the impact of APPs on hypertension prevalence, mortality and cardiovascular (CVD) hospitalization in Alberta.&#x0D; ApproachThe following health administrative databases from Alberta, Canada were used in this study: 1) Alberta Health Care Insurance Plan registry; 2) Hospital Discharge Abstract database (DAD); 3) Physician claims data and; 4) Vital Statistics database. We defined patients with hypertension aged 20 years and older between April 1, 2004 and March 31, 2009 (fiscal years 2004 to 2009) based on previously validated algorithm. Cases were then sorted into FFS and non-FFS billing status. Descriptive statistics for age group, sex, income quintile, rural/urban geographical location, death status and comorbidities were reported between the shadow billing and non-shadow billing groups in regards to prevalence, all-cause mortality and CVD hospitalizations.&#x0D; ResultsA total of 613, 844 adult hypertensive cases were captured during the 5 year study period. The majority of hypertension cases (99.6%, n=610,167) were identified through FFS claims. The effect of non-FFS billing estimates represented a small proportion of hypertension cases (0.40%, n=3677) identified during the study period. Among the FFS claims, overall hypertension prevalence was 22.2% (n=610167) and the effect of non-FFS billing estimates (0.13%, n=3677) on prevalence estimates was relatively minor. All-cause mortality 33.8 (95% CI 33.6-34) and CVD 40.6 (40.4-40.9) were higher for FFS cases than non-FFS cases 19.0 (16.6-21.8) and CVD: 8.0 (6.4-9.8).&#x0D; ConclusionDuring the study time period, the impact of non-FFS (i.e. shadow billings) on physician claims may not have impacted hypertension prevalence estimates greatly. Since Alberta uses shadow billing incentive programs, future research is needed to determine whether incentive programs should be considered in other provinces or nationally in order to preserve the overall quality of physician claims data.

Policies to Optimize Physician Billing Data in Academic Alternative Relationship Payment Plans: Practices and Perspectives

ABSTRACT&#x0D; ObjectivesChanges in physician reimbursement policies may hinder the collection of billing claims in administrative databases. Various provincial academic alternative payment programs (APPs) use incentive- or punitive-based tools to motivate physicians to submit billing claims called shadow billings; however, these incentives are not well documented in the literature. We conducted a nation-wide survey and semi-structured face-to-face interviews in Alberta, Canada to determine existing policies and guidelines for incentivizing and promoting physician billing practices.&#x0D; ApproachMail and online surveys were sent out to academic department head physicians in the following provinces: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, Prince Edward Island and Newfoundland and Labrador. Face-to-face interviews were conducted in the province of Alberta with managers, government stakeholders, and physicians/administrators from academic APPs and Fee-for-Service plans. Face-to-face interviews and responses by mail and email submission were summarized using content analysis grouped by question type.&#x0D; ResultsIn total, there were 46 respondents (15 interviews, 26 mail/online). Content analysis revealed three primary perspectives, grouped at the level of individual physician, academic, and government. Across all of these unique perspectives, three primary themes emerged: 1) governance; 2) accountability; and 3) funding. Within these themes, findings were categorized as either (a) instruments or tools to promote physician billing in AAPPs; (b) enabling factors to support physician billing in AAPPs; and, (c) constraining factors impeding physician billing in AAPPs.&#x0D; ConclusionAccording to the majority of our respondents, financial disincentives (i.e. income at risk, financial clawbacks) appear to be most effective as a mechanism to motivate physicians within an academic APP to submit their billings. However, key barriers to successful implementation and delivery of academic APPs include a lack of alignment between government stakeholders, academic leadership and APP physician members and differences in the organizational and accountability structures of APP plans between academic facilities. It is necessary in moving forward to achieve commonly defined standards and frameworks between the various APP models across provinces and academic institutions.

Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study.

There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary. We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value. Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment. Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.

Payment method as a predictor of daily distress experienced by physicians

Background: Physicians face intrinsic tensions when practicing medicine; therefore, extrinsic factors that could affect distress, such as payment methods, need to be assessed. The study objectives were to: compare levels of distress by payment method, identify factors predicting distress in a two-level regression model, and explore interactions between predictors of distress and payment method. Methods: A cross-sectional study was conducted among physicians in the Saskatoon Health Region, Saskatchewan. Physicians completed a pre-tested questionnaire about their distress. Analysis of variance was used to compare distress levels of physicians paid by fee-for-service (FFS), alternative payment plans (APPs), and blended methods. A mixed linear regression model was built to predict distress with geographical area of practice as the random component. Demographics, workload, complexity of patients, payment method, career satisfaction, and practice profile were the independent variables. The interactions between payment method and predictors of daily distress were evaluated. Results: A total of 382 physicians participated (response rate = 48.1%). Response bias was tested and found to be negligible. In the multivariable analysis, payment method was a predictor of distress which interacted with the proportion of complex cases. Lower levels of distress were found among physicians who had more than 75% of patients with complex conditions and were paid by APPs, compared to those paid by FFS and blended methods. Career satisfaction was found to be an important predictor. Nine percent of the outcome variation was explained by geographic area of practice. Conclusions: Payment method is a predictor of distress when adjusting by confounders, interacting with proportion of complex cases. APPs may promote provision of care for patients with complex conditions. Career satisfaction can be considered a protective indicator of distress. Practice environment influences distress experienced by physicians.

Impact of payment methods on professional equity of physicians

Background: Professional equity, evaluation of own contributions and received rewards compared to contributions and rewards of other physicians has not been assessed according to payment methods. The aim of this study is to compare levels of professional equity among physicians paid by fee-for-service (FFS), alternative payment plans (APPs), and blended schemes. Methods: In 2011, medical practitioners in the Saskatoon Health Region, Saskatchewan, were surveyed using a questionnaire developed for physicians to measure professional equity. Intangible rewards were measured by the dimensions of fulfilment and recognition, and tangible rewards by the dimension of income. The three-dimensional structure of the questionnaire was first corroborated through a confirmatory factor analysis (CFA). Analyses of variances were then performed to account for differences in the levels of professional equity. A linear regression model predicting levels of professional equity was used to test the interaction between specialty and payment method, controlling by number of patients, gender, and age group. Results: In total, 382 (48.1%) physicians participated: 35.6% were family/general practitioners (FPs); 61% were clinical/surgical specialists; and, 3.4% were pathologists. The internal structure of the questionnaire was confirmed by the CFA. Physicians paid by FFS perceived lower professional equity than those paid by APP (p = .005). Practitioners under APPs reported higher levels of income (p = .03) and recognition (p = .001) equity than those with FFS. FPs perceived lower fulfilment (p = .003) and income (p = .008) equity compared to medical-surgical specialists. Furthermore, controlling by number of patients seen per week, higher levels of professional equity are predicted among FPs paid by APPs and blended schemes in comparison to FPs paid by FFS. Conclusions: Higher levels of professional equity were perceived among physicians paid by APPs in comparison to those paid by FFS. Physicians paid by APPs considered that they are receiving fair economic rewards and appropriate recognition. In addition, enhanced levels of professional equity could be predicted among FPs with APPs and blended schemes. APPs could be explored to improve the professional equity of FPs and, indirectly, promote improved primary health care.

Latent gender inequalities in the well-being of physicians according to payment method for practicing medicine: a cross-sectional study

Background: Female physicians face extra challenges in their career development and tend to choose salary or other forms of alternative payment plans (APP). Fee-for-service (FFS) and APP may affect the well-being of female and male physicians differently. Three measures of well-being are: levels of career satisfaction, professional equity, and daily distress. The objectives are to identify differences in the levels of career satisfaction, fulfillment-recognition equity, and daily distress of physicians by gender and payment method, and to assess interactions between these two factors. Methods: A cross-sectional study was conducted in 2011 with physicians practicing in the Saskatoon Health Region, Saskatchewan, Canada. Resident physicians were excluded from the study. Eligible physicians completed a survey, assessing levels of daily distress, fulfillment-recognition equity, and career satisfaction as dependent variables. A multivariate analysis of variance (MANOVA), using the Wilks’ Lambda criterion, was conducted to study differences among the dependent variables by remuneration method and gender. Multiple comparisons were performed as post-hoc tests. Results: Nearly half (382) of the 794 eligible physicians completed the questionnaire; 37.2% were female. Half were remunerated by FFS, a quarter by APP, and the remainder by blended forms. Career satisfaction and fulfillment- recognition equity were positively correlated to each other and daily distress was negatively correlated with both. According to the MANOVA results, the dependent variables were affected by gender but not by payment method, and there was no evidence of an interaction effect between payment method and gender. Women reported lower levels of career satisfaction (p=0.01) and fulfillment-recognition equity (p=0.01), and higher levels of daily distress (p=0.03). Conclusion: Female physicians reported poorer well-being than male physicians. In contrast, no differences in the well-being were found among physicians paid by APP, blended methods, and FFS schemes. Further cross-national studies are recommended to study potential effects of APP on the identified gender inequalities.

A clearer picture of physician income

A new measure of physician income called average gross clinical payment, which provides a more comprehensive picture by taking into account both fee-for-service and alternative payment plans, indicates the average doctor in Canada earned $307 482 in 2010–2011, up 3.1% from the previous year,

Value-based Insurance Design: Barriers to Implementation in Radiology

Expensive and steadily rising health care costs without a concomitant increase in quality have generated a search for solutions to fund health care in the United States. Recent health care reforms and proposals on the agenda have spurred debate about alternative payment plans for health care. Much of the talk centers on imaging, which is a fast-growing and expensive component of health care. Value-based insurance design (VBID), a “clinically sensitive” means of sharing the cost of health care, has been proposed as a means to control the runaway costs of health care management including diagnostic testing. A corollary of pay-for-performance initiatives in which physician incentives are aligned with evidence-based medical practices, VBID seeks to increase patient incentives to comply with evidence-based health care consumption. We previously reviewed the principles of VBID and provided examples of VBID in practice using diabetes management as a model, as well as suggested some areas in diagnostic testing that lend themselves to VBID benefit design. In this article, we summarize the barriers to implementation and outline potential solutions, with particular regard to radiology. Expensive and steadily rising health care costs without a concomitant increase in quality have generated a search for solutions to fund health care in the United States. Recent health care reforms and proposals on the agenda have spurred debate about alternative payment plans for health care. Much of the talk centers on imaging, which is a fast-growing and expensive component of health care. Value-based insurance design (VBID), a “clinically sensitive” means of sharing the cost of health care, has been proposed as a means to control the runaway costs of health care management including diagnostic testing. A corollary of pay-for-performance initiatives in which physician incentives are aligned with evidence-based medical practices, VBID seeks to increase patient incentives to comply with evidence-based health care consumption. We previously reviewed the principles of VBID and provided examples of VBID in practice using diabetes management as a model, as well as suggested some areas in diagnostic testing that lend themselves to VBID benefit design. In this article, we summarize the barriers to implementation and outline potential solutions, with particular regard to radiology.