Despite having the highest health care spending globally, the United States lags in key health outcomes compared to peer nations. Over recent decades, this concerning disconnect between spending and outcomes has spurred substantial national reforms focused on promoting “value” of care over “volume,” prompting the development of numerous value-based payment models. In this analysis, the authors provide an overview of the experience with value-based payment efforts in the United States, particularly within the Medicare program. They outline and evaluate four main value-based care paradigms: public reporting programs, pay-for-performance models, episode-based payment models, and population-based payment models. Across these models, they argue that there has been mixed success in achieving cost reduction and quality improvements. Although some episode-based and population-based models have shown modest savings, the overall efficacy of value-based care reforms remains suboptimal, and many models have yielded unintended consequences that have exacerbated existing health disparities. Considering this evidence alongside the current and emerging threats to value-based payment efforts, we identify several key areas for improvement across these models and discuss a path forward for strengthening value-based payment and delivery system reforms, highlighting key strategies to ensure that future value-based payment models achieve the goals of fostering high-quality, cost-effective, equitable care.

A Contemporary Paradigm for Value-Based Medicine in Vascular Care: Challenges and Opportunities.

Early initial overnight leave after total knee arthroplasty: A novel strategy for optimizing length of stay and resource utilization.

Gender disparities in medicine are well documented, including in emergency medicine. These disparities are influenced by a variety of factors such as payment models, patient expectations, and time spent on different aspects of care, including documentation. While gender-based differences in patient care have been associated with better outcomes for patients treated by women physicians, the underlying reasons remain unclear. This study aims to quantify and compare time spent on patient care tasks, stratified by physician gender, in an academic emergency department (ED). We conducted a prospective observational time-motion study from July to August 2022 in the ambulatory care area of a large tertiary academic ED. Research assistants shadowed physicians during daytime and evening shifts, timing eight predefined clinical tasks for each patient encounter while also collecting data on patient characteristics and provider demographics (gender, years of practice, training stream). Statistical analyses included Wilcoxon rank sum tests and linear regression to examine task durations and gender differences. Our sample size was determined by feasibility. Thirty-seven physicians (32.4% women, 67.6% men) were observed across 65 shifts involving 1204 patient encounters. Women physicians spent significantly more time per patient than men (mean 20.9 vs. 18.1min, + 15.5%, p = 0.015), particularly on initial assessments (7.1 vs. 6.4min, + 10.9%, p = 0.024) and charting (6.7 vs. 5.2min, + 28.8%, p = 0.001). No significant gender differences were found in other tasks. The additional time spent by women was not fully explained by measured tasks, suggesting other unmeasured contributors such as interruptions or workflow inefficiencies. Women emergency physicians spend more time per patient on assessments and documentation than men physicians. These findings raise important considerations for gender equity in clinical performance metrics and documentation burden.

Objective To apply scientific methods to synthesize existing research, aiming to clarify the current status of continuity of care needs and their core influencing factors among older adults with hip fractures, thereby providing a theoretical basis for constructing a patient-needs-based continuity of care program. We posed two explicit research questions: (1) What specific continuity-of-care needs do patients ≥ 65 years old experience after hip fracture? (2) Which individual, caregiver, and system-level factors influence these needs? This review specifically focuses on the Chinese context to provide evidence for developing tailored interventions within China’s healthcare system. Methods The review was conducted following the PRISMA-ScR framework. Literature on the current status of continuity of care needs and influencing factors in older adults with hip fractures was retrieved from the following databases: China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP (CQVIP), SinoMed, PubMed, Web of Science, Embase, and The Cochrane Library. The review particularly aimed to synthesize evidence from China. The search timeframe was restricted from database inception to May 9, 2025. Two researchers independently screened the literature, extracted data, and summarized findings. Results Seventeen studies were ultimately included: nine cross-sectional studies and eight qualitative studies. The results indicated that the demand rate for continuity of care among older adults with hip fractures ranged from 35.83 to 75.60%. The identified needs were categorized into five main types: (1) needs for accessing hospital and community resources, (2) needs for disease-related knowledge, (3) needs for social support, (4) nutritional needs, and (5) psychological needs. Among these, the needs for accessing hospital/community resources and disease-related knowledge were the most prominent. The influencing factors were categorized into two themes: socio-demographic factors and disease-related factors. Socio-demographic factors included age, education level, and marital status; notably, patients aged <70 years exhibited a higher demand for continuity of care compared to older patients. Disease-related factors included physical condition and lack of disease-related knowledge. One study specifically reported the relationship between discharge readiness and patients’ continuity of care needs. Conclusion The findings, primarily based on Chinese studies, indicate a high level of unmet CoC needs among older adults with hip fractures in China. Across 48 studies we found seven core needs—real-time information hand-offs, a named navigator, early mobilization, step-wise pain management, home fall-hazard modification, post-fracture depression screening, and standardized 30- to 180-day outcome tracking—driven by patient factors (cognitive impairment, multimorbidity), caregiver factors (education and financial burden), and system factors (EHR interoperability, integrated payment models). The overall demand for continuity of care among older adults with hip fractures is relatively high, with a portion of these needs remaining unmet. Furthermore, research specifically developing continuity of care programs tailored to identify patient needs is currently lacking. The assessment of continuity of care needs in this population primarily relies on self-developed scales, lacking specific, validated instruments. Future research should focus on the development and application of specific assessment tools to more accurately identify the continuity of care needs of older adults with hip fractures. This will facilitate the construction of needs-based continuity of care programs, ultimately enhancing home-based rehabilitation outcomes and strengthening the effectiveness of continuity of care. This review maps the current evidence and reveals a critical gap: while needs are well-documented, there is a stark lack of studies developing and testing interventions based on these needs, particularly within China. It underscores the imperative for future research to develop specific assessment tools and construct effective, needs-based CoC programs.

In Australia, the general practice sector faces significant challenges, leading to a re-evaluation of its predominantly fee-for-service (FFS) funding models. The aim of this study was to conduct a systematic review of reviews that evaluated the efficacy of funding models in general practice on quality outcomes in multidisciplinary primary and preventive care for people with complex chronic conditions, as well as the contextual factors that have influenced their implementation. Only systematic reviews and meta-analysis were included. Search terms covered funding mechanisms, primary care, and general practice. The review followed PRISMA guidelines for systematic reviews. PubMed, Cochrane, Embase, CINAHL, PsycINFO, PAIS and Web of Science databases were searched in November 2023 for publications from 2010 onwards. Twenty reviews were included. Blended payment models incorporating Pay-for-Performance (P4P) with either Capitation (CAPS) or FFS were associated with small improvements in quality outcomes particularly in multidisciplinary settings. Changes in intermediate health outcomes and process measures for people with complex chronic conditions were most evident in diabetes care but inconclusive for other health outcomes and conditions. Improvements were mainly observed in incentivised activities and in less rigorously designed studies, with ceiling effects and variation reported across healthcare systems. There was no evidence that introducing CAPS as part of blended payments improved quality of care. Although blended payment models show promise, evidence for the effectiveness of models including P4P is highly variable. If adopted, careful evaluation of each incentive's impact on both quality and equity will be essential.

Oncology care is shifting toward value-based care (VBC) payment models that emphasize efficiency, outcomes, and cost control. Patient-centered care, although widely endorsed, remains difficult to operationalize in VBC systems. This article explores the tensions between VBC and patient-centered care across key oncology stakeholders, and highlights how nurses can help bridge the gap by integrating patient values in care delivery. A narrative review of policy developments, oncology-specific VBC frameworks, and stakeholder priorities was conducted. Definitions of value, quality, and cost were compared across stakeholders, and nursing roles were analyzed in relation to current clinical workflow challenges, framework limitations, and payment models. Although VBC frameworks aim to standardize oncology practice and control costs, they often overlook patient-defined goals, lived experiences, and the nuanced trade-offs of cancer treatment. Oncology nurses are equipped to keep care anchored in what matters most to patients by eliciting and translating patient values, integrating them into care plans and workflows, and engaging with payers and policymakers to align quality measures and shape future VBC models.

BackgroundMany factors beyond patient need influence the care that patients receive, including the way physicians are paid, and how services are delivered. In Alberta, outpatient non-invasive cardiac imaging (“cardiac imaging”) is paid for publicly but performed at private, for-profit (investor/physician owned) facilities. We investigated patient, physician, and geographic factors associated with cardiac imaging in patients at low cardiovascular risk seeing specialist physicians in Alberta, Canada.MethodsThis was a population-based retrospective cohort study using administrative health data from Alberta, Canada, where nearly all outpatient cardiac imaging is done at privately for-profit community-based facilities. We used administrative health data to identify a cohort of adult (aged ≥18 years) patients at low cardiovascular risk who were assessed by a cardiologist or internal medicine specialist for a new outpatient visit for a cardiac-related reason between April 1, 2011 and December 30, 2019 in Alberta. The primary outcome was cardiac imaging. Explanatory variables included patient and physician characteristics, including payment model (fee for service (FFS) or salary-based), and geography. We used multilevel, multivariable logistic regression models to measure the association between these factors and cardiac imaging.ResultsWe identified 398,095 patients at low cardiovascular risk, of whom 27.5% received at least one cardiac imaging test. Compared to those seen by FFS cardiologists (and controlling for patient and geographic differences), patients seen by salary-based internal medicine specialists had the lowest odds of receiving cardiac imaging (OR=0.055, P < 0.001, CI 0.036–0.086), followed by those seen by FFS internal medicine specialists (OR=0.010, P < 0.001, CI 0.068–0.14), and salary-based cardiologists (OR=0.27, P < 0.001, CI 0.16–0.45). Findings were robust across multiple sensitivity analyses.ConclusionsPhysician payment models and specialty are strongly associated with non-invasive cardiac imaging among patients at low cardiovascular risk.

Surgery for cervical spondylotic myelopathy (CSM) is becoming increasingly common and costly. Using propensity score matching to rigorously control for demographic, clinical, and surgical confounders, the authors provide the most refined assessment yet of the impact of discharge to subacute rehabilitation (SAR) or home with health services on excess length of stay (LOS) and inpatient expense following surgery for CSM. The prospective Quality Outcomes Database was used to assess patients undergoing surgery for CSM. Propensity score matching was used to balance 12 covariates between patients discharged home and those discharged to SAR, as well as between patients discharged home and those discharged home with health services. The mean LOS, complications, and patient-reported outcomes (at baseline and 3, 12, and 24 months postoperatively) were compared between discharge destinations. Excess LOS was multiplied by the adjusted expense per inpatient day to calculate excess expense. After matching, there were no significant baseline differences between discharge cohorts. Discharge to SAR was associated with a mean excess LOS of 2.7 days and an additional inpatient expense of $8168, while discharge home with health services resulted in a mean excess LOS of 0.9 days and an additional inpatient expense of $2723. Patients discharged to SAR had lower patient satisfaction at 3 months, worse EQ-5D scores at 12 and 24 months, and worse modified Japanese Orthopaedic Association scores at 3 months. Those discharged home with health services had lower patient satisfaction and EQ-5D scores at 12 months postoperatively. These findings underscore the need for proactive, targeted discharge planning to minimize prolonged LOS and reduce healthcare costs, particularly in the context of increasingly common elective CSM surgery and the emergence of alternative payment models. By optimizing discharge processes, payors and hospital administrators can improve resource utilization, enhance patient satisfaction, and reduce financial burdens on healthcare systems.

This study aimed to synthesise Australian evidence on the determinants of private hospital financial viability and the implications for system performance. We conducted a PRISMA-guided systematic review of English-language studies on Australia's mixed public-private system. Databases searched were PubMed, MEDLINE, Embase, Scopus, and EconLit. Eligible publications analysed financial, policy, or operational factors affecting private hospitals. Data were extracted and synthesised using thematic analysis. Twenty-three publications met the inclusion criteria. Five cross-cutting themes emerged. (1) Payment, pricing and fee transparency: fragmented schedules, out-of-pocket exposure, and contracting frictions weaken price signals and can erode margins. (2) Ownership, consolidation, and for-profit pressures: corporate and private-equity dynamics shape capital allocation, service mix, and bargaining power. (3) Insurance incentives and reforms: policy levers modestly influence demand and show limited impact on public waiting times, with mixed consequences for system efficiency. (4) Maternity, allied health, and pandemic disruptions: service lines with thin margins and workforce constraints are exposed to demand shocks and cost growth. (5) Consumer choice, emergency department usage, waiting times, and public-private overlaps: patient flows and portability influence revenue stability but create coordination challenges. The sector remains valuable yet financially fragile. Improving price transparency, reforming payment models and contracting arrangements to better align with value-based principles, and deepening public-private partnerships could strengthen resilience. Targeted data on Aboriginal and Torres Strait Islander peoples health and clearer outcome-price linkages are priorities for practice and policy.

Objective: U.S. healthcare spending is rising, driven in large part by spending on cardiovascular disease. In response, the Centers for Medicare&amp;Medicaid Services (CMS) is implementing payment models to incentivize more efficient care. The Transforming Episode Accountability Model (TEAM) is a mandatory bundled payment model launching in 2026. Hospitals will be accountable for spending on episodes of care, spanning admission to 30 days after discharge, for 5 surgeries, including coronary artery bypass grafts (CABGs). If they meet spending targets, they will receive a financial bonus from CMS; if not, they must pay a penalty. Little is known about the hospitals mandated to participate in TEAM. Understanding how participants differ from nonparticipants is important as CMS scales insights from TEAM to the broader cardiovascular payment landscape. Design: We identified TEAM participation from CMS and hospital characteristics from the American Hospital Association survey, Area Health Resources File, and Medicare enrollment and claims data. t -tests compared characteristics. Findings: We identified 716 hospitals in TEAM. Compared to nonparticipants, participants were larger (263 vs 214 beds), more often urban (100.0% vs 90.6%), and part of the safety net (14.4% vs 8.3%). Participants served a higher share of patients dually enrolled in Medicare and Medicaid. 30-day episode spending ranged from $29,778 for lower extremity joint replacements to $50,092 for CABGs, but for all bundles, spending was higher among participants than nonparticipants. The contribution of post-acute care (PAC) spending to episode spending varied from $5,705 (11.4% of 30-day spending) for CABG to $21,556 (50.1% of 30-day spending) for hip/femur fracture bundles. Conclusions: Hospitals mandated to participate in TEAM were larger, more urban, cared for a higher share of marginalized patients, and were more often part of the safety net. This raises concerns that such hospitals, which have fared poorly in prior payment models, could bear disproportionate penalties under TEAM. In addition, our results suggest that spending reductions might be heterogeneous across bundles. Bundled payment participants generally reduce overall episode spending by reducing PAC spending. Greater spending reductions might thus be expected in procedures for which we found PAC to represent a greater portion of episode spending, such as the hip/femur fracture bundle, as opposed to the CABG bundle.

Background: Value-based care (VBC) models aim to improve health care quality and affordability through aligned incentives across payors and providers. Although widely promoted, limited real-world evidence exists on how varying levels of risk influence cardiovascular quality outcomes. Understanding these dynamics is critical to informing strategies aligned with the American Heart Association’s position to advance high-value, whole person-centered, affordable care. Research Question: Do cardiovascular-related clinical quality outcomes differ between VBC and non-VBC models, and across risk sharing levels (2-sided, 1-sided, pay-for-performance [P4P], and non-VBC) in a Medicare Advantage (MA) population? Methods: Retrospective analysis of 2023 CMS Star Ratings data compared clinical quality scores (%, mean ± standard deviation) across MA members with ≥6 mo of enrollment for cardiovascular-related measures: medication adherence for hypertension (MAH), medication adherence for cholesterol (MAC), statin therapy for patients with cardiovascular disease (SPC), and controlling blood pressure (CBP). Propensity score matching and weighting balanced sociodemographic and clinical characteristics between payment models and across risk levels. Generalized linear models with Bonferroni correction tested group differences; post-hoc Tukey tests assessed pairwise comparisons. Results: Between-group standardized mean differences were ≤10.8%, indicating acceptable balance. Among 3,228,872 members (72.4±9.2yr, 56.5% female), VBC consistently outperformed non-VBC (MAH 1.8±0.1, MAC 1.8±0.1%, SPC 3.0±0.2%, and CBP 17.3±0.1%; all P &lt;.001). Higher levels of risk were associated with improved performance (all P &lt;.001). For SPC, 2-sided risk outperformed 1-sided risk (0.6±0.1%); P4P outperformed non-VBC (1.0±0.1%; both P &lt;.001). For MAH, MAC, and CBP, performance improved incrementally with increasing risk sharing (i.e., 2-sided&gt;1-sided&gt;P4P&gt;FFS; range: 0.4±0.1 to 9.3.4±0.1%; all P &lt;.001). Conclusion: This large, real-world study of ~3.2 million MA members found VBC models were associated with superior cardiovascular quality outcomes, with performance improving as financial risk increased. Observed differences in adherence, secondary prevention, and blood pressure control reflect clinically meaningful outcomes with direct relevance to population health. These findings support shared-risk arrangements as a practical lever for advancing high-quality, value-based cardiovascular care at scale.

Background: Accountable Care Organizations (ACOs) assume financial risk for total cost of care under value-based payment models and require scalable interventions to reduce high-cost utilization. Remote patient monitoring (RPM) has demonstrated potential to decrease emergency department (ED) visits and hospitalizations in single-disease cohorts, but real-world economic evaluations within fully risk-bearing ACOs remain limited. Hypothesis: We hypothesize that ACO patients enrolled in an RPM program will experience significantly lower per-member-per-month (PMPM) healthcare expenditures, reduced utilization of high-cost services (including ED visits, inpatient admissions, and readmissions) compared to ACO patients not participating in RPM. Methods: We conducted a retrospective cohort analysis of Medicare Fee-for-Service beneficiaries attributed to the Mount Sinai ACO between January and October 2024. Patients with ≥2 structured RPM encounters in Epic (n = 255) were compared to non-RPM controls (n = 4,245) over a 12-month follow-up from each patient’s index date. Outcomes included mean annual claims expense per patient, PMPM costs, and utilization-driven cost components (ED visits, admissions, readmissions, length of stay). Results: RPM participants incurred a mean annual claims expense of $3,223.90 versus $4,333.93 for non-RPM patients, yielding $1,110 (26%) savings per patient-year (p&lt;0.001). On a PMPM basis, costs were $268.66 (RPM) versus $361.16 (non-RPM), for a $92.50 monthly savings (p&lt;0.001). Utilization analyses (per 1,000 patients annually) showed ED visits decreased by 13.3% (452.5 to 392.2), inpatient admissions decreased by 44.7% (198.6 to 109.8), readmissions decreased by 36.0% (24.5 to 15.7), and average length of stay decreased by 11.0% (5.25 to 4.67 days). Preventable ED visits rose by 27.6% (67.4 to 86.0). Conclusions: RPM enrollment was associated with significant reductions in annual and PMPM healthcare expenditures, driven primarily by fewer hospitalizations, and ED visits. These findings support RPM as a scalable, evidence-based strategy to enhance patient engagement and curb avoidable costs under value-based care.

Wage determination constitutes a fundamental aspect of labor relations, as it concerns the workers’ basic rights to fair compensation for services rendered. Nevertheless, wage systems frequently give rise to disputes, particularly regarding payment delays, unclear nominal values, and inconsistencies with the principle of justice. Such issues are evident in the wage practices of rice-drying laborers in the studied village, where employment agreements are made orally and wage payments depend on the sale of the dried rice. This phenomenon merits scholarly examination from the perspective of Islamic economic law, especially through the concept of ujrah, which emphasizes justice, contractual clarity, and timeliness in wage payment. This study employs a qualitative method with a juridical-empirical approach. Primary data were collected through in-depth interviews with rice mill owners, paddy owners, and rice-drying workers, complemented by direct field observations. Secondary data were derived from relevant literature on Islamic economic law and fiqh al-mu‘āmalah. The data were analyzed through reduction, presentation, and conclusion-drawing processes based on the principles of wage determination in Islamic law—justice, clarity of contract, mutual consent, and punctual payment. The findings reveal that the rice-drying wage system follows a piece-rate payment model, in which the wage amount is determined by the quantity of rice successfully dried. Payments are generally made after the rice is sold, which occasionally results in delayed disbursement. To mitigate such issues, rice mill owners provide cash advances (kasbon) for workers in urgent need of funds. From the standpoint of Islamic economic law, this practice largely aligns with the principles of contractual transparency and mutual consent, although improvements are needed in ensuring timely wage payment to prevent potential harm to workers.

Variation in Post-Acute Care Transitions for Medicare Beneficiaries With Stroke.

Bridging the gap between expanded pharmacy services and payment models: A jurisdictional scan.

Revising the Sustainability Plan for the National Diabetes Prevention Program.

In 2025, intensive care and emergency medicine in Germany face profound structural and political transformation. The new Hospital Care Improvement Act (KHVVG) introduces a three-pillar financing model consisting of standby budgets, nursing reimbursement, and residual DRGs, aiming to reduce economic incentives and strengthen quality, safety, and specialization. At the same time, workforce shortages in medicine and nursing, as well as the integration of new roles such as Advanced Practice Nurses and Physician Assistants, pose major challenges. Structural reforms, regionalization, and the establishment of specialized centers are designed to ensure efficient resource allocation. Digitalization, telemedicine, and artificial intelligence offer opportunities for process optimization, cost management, and improved care quality, but require standardized frameworks and effective change management. In addition, sustainability initiatives, outpatient shifts, and quality-oriented payment models are gaining relevance. Overall, these developments mark a paradigm shift intended to secure high-quality, safe, and sustainable care for critically ill and emergency patients.

Engaging community pharmacies and schools of pharmacy.

Transplantation in Mandatory Kidney Payment Models: Understanding the Potential Influence of the ESRD Treatment Choices Model on the Increasing Organ Transplant Access Model