Value-based Payment Programs Research Articles

Academic Medical Centers and High-Need, High-Cost Patients: A Call to Action.

Health care delivery systems, including academic medical centers (AMCs), are increasingly focused on improving care for vulnerable, high-need, high-cost patients, in part because value-based payment models offer the promise of financial returns, or the avoidance of losses, for doing so. AMCs and other providers that have participated in Medicare and Medicaid demonstrations and value-based payment programs have important insights to offer about the features of successful and promising programs for high-need, high-cost patients. As more AMCs embrace value-based payment, they may have greater flexibility to provide services that address the medical and nonmedical needs of clinically complex patients and thereby reduce avoidable health care utilization. AMCs have many opportunities to create high-performing health systems, establish operational evidence for how to transform delivery systems, and train the next generation of providers to better address the care of high-need, high-cost individuals.

Practice Rurality of Family Physicians Enrolled in a Practice Transformation Network.

The Transforming Clinical Practice Initiative prioritized the delivery of free practice transformation assistance by Practice Transformation Networks (PTNs) to small and rural practices that may otherwise lack the resources needed to succeed in Medicare's value-based payment (VBP) programs. We assessed the enrollment of rural practices in PTNs using 2016 TCPI enrollment data and American Board of Family Medicine recertification examination registration data from 2013 to 2016. PTNs enrolled a higher proportion of rural family medicine practices than are represented across the general workforce (P < .0001). We await more comprehensive data releases to fully understand enrollment to this important initiative.

Assessing Performance and Quality After Non-ST Segment Elevation Acute Coronary Syndromes.

This review summarizes and discusses the evidence base supporting current performance and quality measures used in assessing institutions in their care of patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS). Professional societies in the USA and Europe have developed performance and quality measures for NSTE-ACS. These measures are reviewed and updated periodically to reflect the most important evidence from the literature. In the USA, the ACC/AHA Task Force on Performance Measures published the updated 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. In Europe, the ESC Acute Cardiac Care Association published the 2017 Quality Indicators for acute myocardial infarction. These documents build on guidelines previously developed and published by the two organizations. They include detailed reviews of current and past studies establishing that adherence with guidelines improves clinical outcomes. Both measure sets provide quantitative methodologies to assess program performance. Institutional programs that focus on these validated measures can increase guideline adherence, streamline and standardize care processes, and reduce morbidity and mortality. Performance and quality measures have become a critical part of healthcare today, allowing patients, providers, administrators, and payors to assess patient care objectively. They are also becoming an important component of value-based payment programs. To be fair, and useful, for internal institutional assessment, in comparing different institutions, and for value-based payments, only validated performance measures such as these should be employed.

Patient Perceptions of Home Health Care Services After Total Joint Replacement

Value-based payment programs have incentivized the reduction of many post-acute care services, including home health care. Patient perceptions of home health care services are currently unknown. The objectives of this study were to determine the value that patients place on home health care after joint replacement surgery and to assess their impression of Medicare reimbursement for these services. Patients with traditional Medicare insurance who underwent primary total hip or knee arthroplasty between January 2016 and July 2017 were given a questionnaire in which they were asked to quantify their satisfaction with home health care, estimate Medicare reimbursement for these services, and give their impression of actual reimbursement. One hundred sixtythree patients completed the questionnaire. Patients were generally satisfied with the services received, giving an overall mean ranking of 9.3 (range, 1-10). Respondent estimates of the cost of home health care services ranged from $0 to $300,000 (average, $8067). Ninety-three percent of patients would choose home health care again if they were to undergo another joint replacement. Patients in this study placed significant value on home health care services after total hip and knee replacement surgery. Further consideration of patient satisfaction may be warranted prior to eliminating home health care services following total joint arthroplasty. [Orthopedics. 2018; 41(5):e713-e717.].

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Dually Enrolled Beneficiaries Have Higher Episode Costs On The Medicare Spending Per Beneficiary Measure.

Cost measures are a growing part of Medicare's value-based payment programs. Medicare Spending per Beneficiary (MSPB) is the cost measure included in Medicare's Hospital Value-Based Purchasing (VBP) Program. Beneficiaries who are dually enrolled in Medicare and Medicaid are known to have higher spending on care, but it is unknown whether spending on the MSPB measure varies based on dual enrollment and whether this has implications for the performance of safety-net hospitals. We found that after adjustment for comorbidities, dually enrolled beneficiaries had 4.3percent higher spending, which was primarily driven by higher costs in the postacute setting associated with use of institutional postacute care. Hospitals in the highest quintile of the disproportionate share hospital index had poorer performance on the MSPB measure, and were more likely to be penalized under VBP. After adjustment for dual status, differences in MSPB performance between safety-net and non-safety-net hospitals were no longer significant. This suggests that differences in performance between the two types of hospitals were driven at least in part by differences in their patient populations. However, overall VBP payment impacts were largely unchanged after the MSPB measure was adjusted for dual-enrollment status.

Linking Quality and Spending to Measure Value for People with Serious Illness.

Healthcare payment is rapidly evolving to reward value by measuring and paying for quality and spending performance. Rewarding value for the care of seriously ill patients presents unique challenges. To evaluate the state of current efforts to measure and reward value for the care of seriously ill patients. We performed a PubMed search of articles related to (1) measures of spending for people with serious illness and (2) linking spending and quality measures and rewarding performance for the care of people with serious illness. We limited our search to U.S.-based studies published in English between January 1, 1960, and March 31, 2017. We supplemented this search by identifying public programs and other known initiatives that linked quality and spending for the seriously ill and extracted key program elements. Our search related to linking spending and quality measures and rewarding performance for the care of people with serious illness yielded 277 articles. We identified three current public programs that currently link measures of quality and spending-or are likely to within the next few years-the Oncology Care Model; the Comprehensive End-Stage Renal Disease Model; and Home Health Value-Based Purchasing. Models that link quality and spending consist of four core components: (1) measuring quality, (2) measuring spending, (3) the payment adjustment model, and (4) the linking/incentive model. We found that current efforts to reward value for seriously ill patients are targeted for specific patient populations, do not broadly encourage the use of palliative care, and have not closely aligned quality and spending measures related to palliative care. We develop recommendations for policymakers and stakeholders about how measures of spending and quality can be balanced in value-based payment programs.

Care Transformation Strategies and Approaches of Accountable Care Organizations.

Although accountable care organizations (ACOs) proliferate, little is known about the activities and strategies ACOs are pursuing to meet goals of reducing costs and improving quality. We use semistructured interviews with executives at 16 ACOs to understand ACO approaches. We identified two overarching ACO approaches to changing clinical care: a practice-based transformation approach, working to overhaul care processes and teams from the inside out; and an overlay approach, where ACO activities were centralized and delivered external to physician practices. We additionally identified four methods ACOs were using to achieve their aims: using patient support roles; targeted clinics, events, programs, and interventions; clinical process standardization; and tracking and identifying patients on which to focus resources. We expect that ACOs using either of the major approaches can succeed under current ACO programs, but that as value-based payment programs mature, ACOs will need to undertake practice-based approaches to be successful in the long term.

Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons.

In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

The relative contribution of provider and ED-level factors to variation among the top 15 reasons for ED admission

Study objectiveWe examine adult emergency department (ED) admission rates for the top 15 most frequently admitted conditions, and assess the relative contribution in admission rate variation attributable to the provider and hospital. MethodsThis was a retrospective, cross-sectional study of ED encounters (≥18years) from 19 EDs and 603 providers (January 2012–December 2013), linked to the Area Health Resources File for county-level information on healthcare resources. “Hospital admission” was the outcome, a composite of inpatient, observation, or intra-hospital transfer. We studied the 15 most commonly admitted conditions, and calculated condition-specific risk-standardized hospital admission rates (RSARs) using multi-level hierarchical generalized linear models. We then decomposed the relative contribution of provider-level and hospital-level variation for each condition. ResultsThe top 15 conditions made up 34% of encounters and 49% of admissions. After adjustment, the eight conditions with the highest hospital-level variation were: 1) injuries, 2) extremity fracture (except hip fracture), 3) skin infection, 4) lower respiratory disease, 5) asthma/chronic obstructive pulmonary disease (A&C), 6) abdominal pain, 7) fluid/electrolyte disorders, and 8) chest pain. Hospital-level intra-class correlation coefficients (ICC) ranged from 0.042 for A&C to 0.167 for extremity fractures. Provider-level ICCs ranged from 0.026 for abdominal pain to 0.104 for chest pain. Several patient, hospital, and community factors were associated with admission rates, but these varied across conditions. ConclusionFor different conditions, there were different contributions to variation at the hospital- and provider-level. These findings deserve consideration when designing interventions to optimize admission decisions and in value-based payment programs.

Medicare Access and CHIP Reauthorization Act: What do Geriatrics Healthcare Professionals Need to Know About the Quality Payment Program?

Commencing in 2017, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 will change how Medicare pays health professionals. By enacting MACRA, Congress brought an end to the (un)sustainable growth rate formula while also setting forth a vision for how to transform the U.S. healthcare system so that clinicians deliver higher-quality care with smarter spending by the Centers for Medicare and Medicaid Services (CMS). In October 2016, CMS released the first of what stakeholders anticipate will be a number of (annual) rules related to implementation of MACRA. CMS received extensive input from stakeholders including the American Geriatrics Society. Under the Quality Payment Program, CMS streamlined multiple Medicare value-based payment programs into a new Merit-based Incentive Payment System (MIPS). CMS also outlined how it will provide incentives for participation in Advanced Alternative Payment Models (called APMs). Although Medicare payments to geriatrics health professionals will not be based on the new MIPS formula until 2019, those payments will be based upon performance during a 90-day period in 2017. This article defines geriatrics health professionals as clinicians who care for a predominantly older adult population and who are eligible to bill under the Medicare Physician Fee Schedule. Given the current paucity of eligible APMs, this article will focus on MIPS while providing a brief overview of APMs.

Hospital Associated Venous Thromboembolism in Oklahoma County

Introduction: Venous thromboembolism (VTE) is a leading cause of death and disability of the adverse outcomes associated with a hospital stay among low, middle, and high income countries evaluated by the WHO Patient Safety Program.Objective: Compare characteristics and risk factors for hospital associated and non-hospital associated cases of VTE in Oklahoma County from April 1, 2012 to March 31, 2014.Methods: In collaboration with the Centers for Disease Control and Prevention (CDC), a population-based surveillance system for VTE was established in Oklahoma County, OK between April 1, 2012-March 31, 2014 to estimate the incidences of first-time and recurrent VTE events. The Commissioner of Health made VTE a reportable condition and delegated surveillance-related responsibilities to the University of Oklahoma, College of Public Health. Active surveillance involved reviewing imaging studies (e.g., chest computed tomography and compression ultrasounds of the extremities) from all inpatient and outpatient facilities in the county and collecting demographic, treatment and risk factor data on all VTE case-patients. Hospital associated VTE is defined as a VTE diagnosis made either during the hospital stay or within 90 days of hospital admission, regardless of the reason for hospitalization. Odds ratios and 95% confidence intervals (CI) were calculated. Those age 80+ years were used as the referent age group. Comparisons between hospital associated and non-hospital associated VTE cases were made by using two-sided χ2tests.Results: We identified 2,737 patients with imaging-confirmed VTE. Of these, 1,223 (44.7%) cases were identified as hospital associated and 1,514 (55.3%) cases as non-hospital associated VTE. Of the hospital associated VTE cases, 863 (70.6%) had VTE diagnosed while hospitalized and 360 (29.4%) were diagnosed VTE as outpatients after hospital discharge; of these 360 cases, 239 (66.4%) were re-admitted to the hospital and 121 (33.6%) were managed as outpatients. Of the non-hospital associated VTE cases, 776 (51.3%) were admitted to the hospital after diagnosis and 738 (48.7%) were treated as outpatients. The median length of stay for hospital-associated cases was 8 days (range 1-206 days). The distribution of PE (p = 0.17) and DVT (p = 0.07) were similar in hospital associated cases and non-hospital associated cases. The distributions of race (p = 0.34) and sex (p = 0.17) were similar for patients with and without hospital associated VTE; however, hospital associated cases of VTE tended to be older than non-hospital associated cases (p<0.01; 18-39 years OR = 1.7, 95% CI 1.2-2.2, 40-49 years OR = 1.8, 95% CI 1.3-2.4, 50-59 years OR = 1.3, 95% CI 1.0-1.7, 60-69 years OR = 1.1, 95% CI 0.84-1.4, 70-79 years OR = 1.2, 95% CI 0.91-1.5). Venous catheterization in the last 6 months (OR= 4.4, 95% CI 3.4-5.7), surgery (OR = 3.4, 95% CI 2.8-4.0) and trauma (OR = 3.0, 95% CI 2.3-3.9) in the last 12 months, and histories of: congestive heart failure (OR = 2.6, 95% CI 2.0-3.3), stroke (OR = 2.6, 95% CI 1.9-3.6), myocardial infarction (OR = 2.2, 95% CI 1.6-3.1), superficial vein thrombosis (OR = 1.8, 95% CI 1.3-2.5), and cancer (OR = 1.5, 95% CI 1.3-1.8) were risk factors for hospital associated cases of VTE. Hospital associated VTE cases had 3.5 times the odds of death (95% CI 2.4-5.0) than non-hospital associated cases.Discussion: A significant proportion (45%) of the total VTE burden continues to be hospital associated. A substantial proportion of hospital associated cases are diagnosed after discharge and result in re-admission, with the potential for significant financial penalties under Medicare value-based payment programs. Hospital associated cases of VTE were older, had more risk factors, and were more likely to die than non-hospital associated cases. DisclosuresRaskob:Bayer Healthcare: Consultancy; BMS: Consultancy; Daiichi Sankyo: Consultancy; Janssen Pharmaceuticals: Consultancy; Pfizer: Consultancy; ISIS Pharmaceuticals: Consultancy.

Disadvantaged Patients in Value-Based Payment Programs

Disadvantaged Patients in Value-Based Payment Programs

Society Leaders Guide the Way Through Public Policy Maze

Society Leaders Guide the Way Through Public Policy Maze

MACRA Marks New Start for Medicare Payment of Physicians

MACRA Marks New Start for Medicare Payment of Physicians

Value-Based Payment Will Change Practice, Reimbursement

Value-Based Payment Will Change Practice, Reimbursement

Is Value-Driven Health Care an Unfunded Mandate for Radiologists?

The goals of the 2010 Patient Protection and Affordable Care Act (ACA) can be summed up by the Triple Aim, as defined by the Institute for Healthcare Improvement: Improve population health, optimize the patient experience, and reduce the costs of care. Despite recent reimbursement reductions, radiologists have increasing opportunities to participate in value-based payment programs and should leverage those opportunities.

Protect Yourself From Overexposure

Protect Yourself From Overexposure

Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience

Health plans and Medicare are using cost profiles to identify which physicians account for more health care spending than others. By identifying the costliest physicians, health plans and Medicare hope to craft policy interventions to reduce total health care spending. To identify which physician types, if any, might be costlier than others, we analyzed cost profiles created from health plan claims for physicians in Massachusetts. We found that physicians with fewer than ten years of experience had 13.2 percent higher overall costs than physicians with forty or more years of experience. We found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and the size of the group in which the physician practices. Although winners and losers are inevitable in any cost-profiling effort, physicians with less experience are more likely to be negatively affected by policies that use cost profiles, unless they change their practice patterns. For example, these physicians could be excluded from high-value networks or receive lower payments under Medicare's planned value-based payment program. We cannot fully explain the mechanism by which more-experienced physicians have lower costs, but our results suggest that the more costly practice style of newly trained physicians may be a driver of rising health care costs overall.