Value-Based Purchasing Program Research Articles

Accountable Care Organizations Versus Accountable Care: Is There a Difference?

The notion of accountable health care is not new, although the measures of accountability have changed in the 13 years since I wrote the definition above. In addition to measuring quality, virtually all current notions of accountability incorporate cost components as well. Today, the real value of the care delivered is based on quality measured against an evidence base and that also incorporates patient safety and accounts for the patient experience of care, with contained costs. The Health Reform legislation is replete with references to value, quality, transparency, patient experience of care, efficiency, and effectiveness. Many of the mandatory Medicare initiatives for hospitals and physicians—as well as the many demonstrations and pilot programs that the law has spawned—were intended to address these new performance demands. In particular, hospitals are facing a new value-based purchasing mandate that will reduce Medicare payments overall but will reward specific hospitals that score well. Hospitals will be denied payment for hospital-acquired conditions and avoidable re-admissions. Physicians will also be subject to a value-based purchasing program applied to the Medicare Physician Fee Schedule. These are mandatory programs. 2 Against that background, it is fairly astonishing that what began as the concept of measuring hospital quality performance by aggregating data from the “extended medical staff” 3 morphed into the Medicare shared savings program available to accountable care organizations (ACOs) in the legislation. Even more astonishing has been the fervor with which the consultancy community has pushed the idea on health systems and physicians that they must become ACOs to survive. The relatively brief legislative provision, which has very little by way of detail, is not even a pilot or demonstration program. It is merely a voluntary opportunity. Further, now that the proposed regulations have been published, many of the organizations that spent large amounts of time and money preparing to become ACOs are questioning the viability of the proposition. Whether there will be any savings shared will be measured by the expenditures for beneficiaries assigned to the ACOs, which must accept and distribute payments from Parts A and B. This approach has no precedent, but the closest analogue is the Medicare Group Practice Demonstration. In that demonstration, after a similar 3-year obligation, only half the participants saw any bonus at all. 4 That very few of the more than 5700 hospitals and 780,000 physicians in America will be able to function as Medicare ACOs in the Health Reform legislation is becoming clear. The Centers for Medicare & Medicaid Services (CMS) projects that only 75 to 150 organizations in the country will be able to be ACOs. The capital requirements are high and the information technology necessary to manage financial risk is often lacking. The organizational infrastructures to govern such organizations do not exist in most quarters; and, above all, the change in clinical process design necessary to be able to eventually benefit financially from the Medicare model requires far greater sophistication than most health care systems currently demonstrate. Even the American Medical Group Association, whose

The Physiatrist's Advantage: Making the Patient Experience Count

If it is true that objects in the mirror may be larger than they appear, perhaps the Federal Register publication on January 13, 2011, by the Centers for Medicare and Medicaid Services (CMS) of their proposed rule for Hospital Value-Based Purchasing should be taken seriously by rehabilitation physicians and hospitals, even though they are exempt from the Rule for the time being. The Rule is gaining ground, and we are almost certain to be next, which might even be a good thing, but it definitely deserves some attention. Public funds pay for 47.3% of health care in this country [1], so for years CMS has been talking about making sure it is getting its money’s worth. Commercial insurers write the checks for another 33.5% of health care [1], so they (and the large employers who cover ost of the costs themselves) are also highly interested in getting the most for their money. n policy circles, this concept is called value-based purchasing (VBP). Idealists attribute great powers to the concept of VBP. They believe it can root out edical error and raise practice standards while simultaneously promoting administrative mprovements and eliminating waste. Cynics think it is all about saving a buck, with little oncern for patient and physician individuality and preferences. Either way, VBP rests on he concept that it is possible to identify certain preferred behaviors or outcomes and adjust he health care payment system to increase the likelihood of their occurrence. Over recent ears, CMS has required community and academic hospitals to report their results on a umber of performance measures. But the Patient Protection and Affordable Care Act of 010 requires the Secretary of Health and Human Services to go beyond requiring a report nd actually establish a program to pay short-term acute care hospitals based on their erformance scores beginning in October 2012. So now CMS has the task of deciding which areas of performance it will reward and that s what the new Proposed Rule does. But do not think that high performance earns new onus money for a hospital. The VBP program can claim to be “budget neutral” because it unds itself with money withheld from the otherwise expected level of Medicare prospective ayment system payments. So VBP pits hospitals against each other to compete for money hat Congress had previously planned to pay for care anyway. Although inadequate ayments for health care services would obviously have serious ramifications, it is hard for ny purchaser to resist using the power of the economic transaction to influence the quality f the product. The new Proposed Rule would establish 17 specific clinical performance measures (eg, lood culture performed before administration of first antibiotic for pneumonia). In ggregate, these would account for 70% of a hospital’s score. The Proposed Rule also roposes that grades from the Hospital Consumer Assessment of Healthcare Providers and ystems survey of the patient experience with care would be calculated to account for the ther 30% of a hospital’s total score. Whether you label it customer service, patient atisfaction, or patient experience, the concept is that how the encounter “feels” to the atient is a matter of considerable importance. Those who pay for the care, including edicare, are not convinced that the services that they are currently buying hit the mark ith respect to meeting patients’ expectations, so they are proposing to establish specific nancial accountability. The Patient Protection and Affordable Care Act passed in 2010 (also known as Health eform) also sets the stage for the secretary to act by 2013 to create performance measures hat would apply to inpatient rehabilitation hospitals. Whatever political challenges this egislation faces based on the partisan divide between the House and the Senate, it is unlikely

Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act

The Affordable Care Act signed into law by President Obama, with its value-based purchasing program, is designed to link payment to quality processes and outcomes. Treatment of critically ill patients represents nearly 1% of the gross domestic product and 25% of a typical hospital budget. Data suggest that high-intensity staffing patterns in the intensive care unit (ICU) are associated with cost savings and improved outcomes. We evaluate the literature investigating the cost-effectiveness and clinical outcomes of high-intensity ICU physician staffing as recommended by The Leapfrog Group (a consortium of companies that purchase health care for their employees) and identify ways to overcome barriers to nationwide implementation of these standards. Hospitals that have implemented the Leapfrog initiative have demonstrated reductions in mortality and length of stay and increased cost savings. High-intensity staffing models appear to be an immediate cost-effective way for hospitals to meet the challenges of health care reform.

Improving Evaluations of Value‐Based Purchasing Programs

Although value-based purchasing (VBP) holds promise for encouraging quality improvement and addressing rising costs, currently there is limited evidence about how best to structure and implement VBP programs. In this commentary, we highlight several issues for improving evaluations of VBP programs. Implementation research can be enhanced through early and continuous assessment and greater variation in program designs. Impact research can be improved by creating better outcome measures, increasing the availability of linked patient-level data, and advancing synthesis research. We offer several recommendations for improving the foundation to conduct evaluations of VBP programs to better inform policy and practice.

Pay for performance: will dentistry follow?

Background"Pay for performance" is an incentive system that has been gaining acceptance in medicine and is currently being considered for implementation in dentistry. However, it remains unclear whether pay for performance can effect significant and lasting changes in provider behavior and quality of care. Provider acceptance will likely increase if pay for performance programs reward true quality. Therefore, we adopted a quality-oriented approach in reviewing those factors which could influence whether it will be embraced by the dental profession.DiscussionThe factors contributing to the adoption of value-based purchasing were categorized according to the Donabedian quality of care framework. We identified the dental insurance market, the dental profession position, the organization of dental practice, and the dental patient involvement as structural factors influencing the way dental care is practiced and paid for. After considering variations in dental care and the early stage of development for evidence-based dentistry, the scarcity of outcome indicators, lack of clinical markers, inconsistent use of diagnostic codes and scarcity of electronic dental records, we concluded that, for pay for performance programs to be successfully implemented in dentistry, the dental profession and health services researchers should: 1) expand the knowledge base; 2) increase considerably evidence-based clinical guidelines; and 3) create evidence-based performance measures tied to existing clinical practice guidelines.SummaryIn this paper, we explored factors that would influence the adoption of value-based purchasing programs in dentistry. Although none of these factors were essential deterrents for the implementation of pay for performance programs in medicine, the aggregate seems to indicate that significant changes are needed before this type of program could be considered a realistic option in dentistry.

A First Take on LTC in Health Care Reform

A First Take on LTC in Health Care Reform

Provider-Initiated Pay-for-Performance in a Clinically Integrated Hospital Network

Long Island Health Network developed a provider-initiated pay-for-performance (PI-PFP) program beginning in 2004 and operated by 10 clinically integrated hospitals. The PI-PFP administrative processes, length of stay, patient satisfaction, and Hospital Quality Alliance measures are elaborated. PI-PFP has evolved over time and supports best practice sharing. We document how the risk amount is determined and then allocated to the Network and the individual hospitals based on performance, and we quantify the success of the program in achieving the goal of improved performance. A PI-PFP can prepare physicians and management for pay-for-performance or value-based purchasing programs operated by payers. Being self-administered, such a program can go beyond payer-run programs to focus attention on issues that are considered important by the hospitals and medical staffs, and that may not be feasible to measure or to include in a mandatory payer-run program.

Quality Measurement and Public Reporting in Total Joint Arthroplasty

Concerns over rising health care costs and variations in practice patterns have stimulated the development of value-based purchasing programs that seek to incentivize higher quality and lower cost health care. The purpose of this study was to evaluate differences in practice patterns in total joint arthroplasty (TJA) and to determine whether adherence to payer-defined guidelines are associated with improved patient outcomes and lower costs of care. Claims data were reviewed for all total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures completed for a 2-year period in a national commercially insured population. Differences in practice patterns among providers were compared using summary measures normalized for patient severity of illness. Correlations between adherence to guidelines and patient outcomes and costs were evaluated. Adherence to guidelines, patient outcomes, and costs of care varied significantly for both THA and TKA. Adherence to payer-defined guidelines had little or no correlation with either patient outcomes or costs of care. These findings underscore the need to define evidence-based performance measures for use in TJA public reporting programs.

Escalating Health Care Costs Threaten Nation's Future

Escalating Health Care Costs Threaten Nation's Future

Advocates Condemn Cuts In Federal Health Spending

Advocates Condemn Cuts In Federal Health Spending