The Theory of Value-Based Payment Incentives and Their Application to Health Care

The Value of Managing Acute Pancreatitis With Standardized Order Sets to Achieve "Perfect Care"

OBJECTIVES

We aimed to define perfect care index (PCI) metrics and to evaluate whether implementation of standardized order sets would improve outcomes without increasing hospital-based charges in patients with acute pancreatitis (AP).

METHODS

This is a retrospective, pre-post, observational study measuring clinical quality, processes of care, and hospital-based charges at a single tertiary care center. The first data set included AP patients from August 2011 to December 2014 (n = 219) before the implementation of a standardized order set (Methodist Acute Pancreatitis Protocol [MAPP]) and AP patients after MAPP implementation from January 2015 to September 2018 (n = 417). The second data set included AP patients (n = 150 in each group) from January 2013 to September 2014 (pre-MAPP) and January 2018 to September 2019 (post-MAPP) to evaluate perfect care between the 2 cohorts after controlling for systemic inflammatory response syndrome at baseline. Length of stay, PCI, and hospital-based charges were measured.

RESULTS

The post-MAPP cohort had a significantly shorter length of stay (median, 3 days vs 4 days; P = 0.01). In the second data set, PCI significantly increased after implementation of MAPP order sets (5.3%-35.3%, P < 0.0001).

CONCLUSIONS

The MAPP order sets increased the value of care by improving clinical outcomes without increasing hospital-based charges.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series

BACKGROUND

Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization.

METHODS

From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale.

RESULTS

Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations.

CONCLUSIONS

The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Improving quality and performance in substance use treatment programs: What is being done and why is it so hard?

SUMMARY

As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12).

FINDINGS

Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control.

APPLICATIONS

Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.

A Dissemination Strategy to Identify Communities Ready to Implement a Pediatric Weight Management Intervention in Medically Underserved Areas

Purpose and Objectives

We developed a competitive application process to test the feasibility of a fund and contract dissemination strategy to identify and engage communities that demonstrated the necessary resources and motivation to adopt, implement, and sustain a pediatric weight management intervention, Building Healthy Families, in rural and micropolitan (<50,000 residents) communities in Nebraska.

Intervention Approach

From April through December 2019, a community advisory board with representation from rural and micropolitan clinical, public health, education, and recreational organizations collaboratively developed a request for applications, as a fund and contract dissemination strategy, to encourage community adoption of Building Healthy Families.

Evaluation Methods

Quantitative assessments included determining the distribution of requests for applications, evaluating organizational readiness to change assessment (ORCA) ratings (on a scale of 1 to 5, from strongly disagree to strongly agree that the organization is ready to change), and reviewing community advisory board member ratings of applications. We gathered qualitative data from community narratives provided in response to the request for applications and community advisory board reviews of the applications.

Results

The request for applications was distributed to all 93 counties in Nebraska. Of the 8 communities that submitted a letter of intent, 7 submitted a community narrative. Across the 8 communities, 31 ORCAs were completed by the organizational decision makers (n = 15) and staff members (n = 16) who would be responsible for screening, recruiting, or implementing the intervention. Overall mean ORCA scores varied by ratings of evidence (4.1–4.6), context (4.2–4.9), and facilitation (4.3–4.8), indicating a high degree of readiness. Community advisory board ratings of applications ranged from 2.3 to 3.4 of 4 points. Qualitative data indicated that lower community narrative scores were primarily caused by weak implementation and sustainability plans.

Implications for Public Health

Findings provide guidance for translating pediatric weight management programs in medically underserved geographic areas by maximizing the probability of successful adoption and implementation through a fund and contract dissemination strategy.

Assessment of Common Comorbidity Phenotypes Among Older Adults With Knee Osteoarthritis to Inform Integrated Care Models

Objective

To establish the frequency of concordant, discordant, and clinically dominant comorbidities among Medicare beneficiaries with knee osteoarthritis (KOA) and to identify common concordant condition subgroups.

Participants and Methods

We used a 5% representative sample of Medicare claims data to identify beneficiaries who received a diagnosis of KOA between January 1, 2012, and September 30, 2015, and matched control group without an osteoarthritis (OA) diagnosis. Frequency of 34 comorbid conditions was categorized as concordant, discordant, or clinically dominant among those with KOA and a matched sample without OA. Comorbid condition phenotypes were characterized by concordant conditions and derived using latent class analysis among those with KOA.

Results

The study sample included 203,361 beneficiaries with KOA and 203,361 non-OA controls. The largest difference in frequency between the two cohorts was for co-occurring musculoskeletal conditions (23.7% absolute difference), chronic pain syndromes (6.5%), and rheumatic diseases (4.5%), all with a higher frequency among those with knee OA. Phenotypes were identified as low comorbidity (53% of cohort with classification), hypothyroid/osteoporosis (27%), vascular disease (10%), and high medical and psychological comorbidity (10%).

Conclusions

Approximately 47% of Medicare beneficiaries with KOA in this sample had a phenotype characterized by one or more concordant conditions, suggesting that existing clinical pathways that rely on single or dominant providers might be insufficient for a large proportion of older adults with KOA. These findings could guide development of integrated KOA-comorbidity care pathways that are responsive to emerging priorities for personalized, value-based health care.

Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review

An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.

Association Between a National Insurer's Pay-for-Performance Program for Oncology and Changes in Prescribing of Evidence-Based Cancer Drugs and Spending

PURPOSE

Cancer drug prescribing by medical oncologists accounts for the greatest variation in practice and the largest portion of spending on cancer care. We evaluated the association between a national commercial insurer's ongoing pay-for-performance (P4P) program for oncology and changes in the prescribing of evidence-based cancer drugs and spending.

METHODS

We conducted an observational difference-in-differences study using administrative claims data covering 6.7% of US adults. We leveraged the geographically staggered, time-varying rollout of the P4P program to simulate a stepped-wedge study design. We included patients age 18 years or older with breast, colon, or lung cancer who were prescribed cancer drug regimens by 1,867 participating oncologists between 2013 and 2017. The exposure was a time-varying dichotomous variable equal to 1 for patients who were prescribed a cancer drug regimen after the P4P program was offered. The primary outcome was whether a patient's drug regimen was a program-endorsed, evidence-based regimen. We also evaluated spending over a 6-month episode period.

RESULTS

The P4P program was associated with an increase in evidence-based regimen prescribing from 57.1% of patients in the preintervention period to 62.2% in the intervention period, for a difference of +5.1 percentage point (95% CI, 3.0 percentage points to 7.2 percentage points; P < .001). The P4P program was also associated with a differential $3,339 (95% CI, $1,121 to $5,557; P = .003) increase in cancer drug spending and a differential $253 (95% CI, $100 to $406; P = .001) increase in patient out-of-pocket spending, but no significant changes in total health care spending ($2,772; 95% CI, -$181 to $5,725; P = .07) over the 6-month episode period.

CONCLUSION

P4P programs may be effective in increasing evidence-based cancer drug prescribing, but may not yield cost savings.

The Perception and Impact of Relative Value Units (RVUs) and Quality-of-Care Compensation in Neurosurgery: A Literature Review

The debate surrounding the integration of value in healthcare delivery and reimbursement reform has centered around integrating quality metrics into the current fee-for-service relative value units (RVU) payment model. Although a great amount of literature has been published on the creation and utilization of the RVU, there remains a dearth of information on how clinicians from various specialties view RVU and the quality-of-care metric in the compensation formula. The aim of this review is to analyze and consolidate existing theories on the RVU payment model in neurosurgery. Google and PubMed were searched for English-language literature describing opinions on the RVU in neurosurgery. Commentary was noted to be primary opinions if it was mentioned at least twice in the eight articles included in this review. Overall, seven primary opinions on the RVU were identified across the analyzed articles. Integration of quality into the RVU is viewed favorably by neurosurgeons with a few caveats and opportunities for further improvement.

Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

Incentive-based pay-for-performance (P4P) models have been introduced during the last 2 decades as a mechanism to improve the delivery of evidence-based care that ensures clinical quality and improves health outcomes. There is mixed evidence that P4P has a positive effect on health outcomes and researchers cite lack of engagement from health care professionals as a limiting factor. This qualitative metasynthesis of existing qualitative research was conducted to integrate health care professionals’ perceptions of P4P in clinical practice. Four themes emerged during the research process: positive perceptions of the value of performance measurement and associated financial incentives; negative perceptions of the performance measurement and associated financial incentives; perceptions of how P4P programs influence the quality/appropriateness of care; and perceptions of the influence of P4P program on professional roles and workplace dynamics. Identifying factors that influence health care professionals’ perceptions about this type of value-based payment model will guide future research.

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

BACKGROUND

Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important.

OBJECTIVES

The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups.

METHODS

In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections.

RESULTS

We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included.

CONCLUSIONS

Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

Redefining value: a discourse analysis on value-based health care

Background

Today’s remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. This is evident within academic publications, and mirrored in fragmented and diversified implementation efforts, both within and across countries.

Method

This article builds on discourse analysis in order to map the ambiguity surrounding VBHC. We conducted a document analysis of publicly accessible, official publications (n = 22) by actors and organizations that monitor and influence the quality of care in the Netherlands. Additionally, between March and July 2019, we conducted a series of semi-structured interviews (n = 23) with national stakeholders.

Results

Our research revealed four discourses, each with their own perception regarding the main purpose of VBHC. Firstly, we identified a Patient Empowerment discourse in which VBHC is a framework for strengthening the position of patients regarding their medical decisions. Secondly, in the Governance discourse, VBHC is a toolkit to incentivize providers. Thirdly, within the Professionalism discourse, VBHC is a methodology for healthcare delivery. Fourthly, in the Critique discourse, VBHC is rebuked as a dogma of manufacturability. We also show, however, that these diverging lines of reasoning find common ground: they perceive shared decision-making to be a key component of VBHC. Strikingly, this common perception contrasts with the pioneering literature on VBHC.

Conclusions

The four discourses will profoundly shape the diverse manners in which VBHC moves from an abstract concept to the practical provision and administration of health care. Moreover, our study reveals that VBHC’s conceptual ambiguity largely arises from differing and often deeply rooted presuppositions, which underlie these discourses, and which frame different perceptions on value in health care. The meaning of VBHC – including its perceived implications for action – thus depends greatly on the frame of reference an actor or organization brings to bear as they aim for more value for patients. Recognizing this is a vital concern when studying, implementing and evaluating VBHC.

A pain relieving reimbursement program? Effects of a value-based reimbursement program on patient reported outcome measures

Background

Value-based reimbursement programs have become increasingly common. However, little is known about the effect of such programs on patient reported outcomes. Thus, the aim of this study was to analyze the effect of introducing a value-based reimbursement program on patient reported outcome measures and to explore whether a selection bias towards less complicated patients occurred.

Methods

This is a retrospective observational study with a before and after design based on the introduction of a value-based reimbursement program in Region Stockholm, Sweden. We analyzed patient level data from inpatient and outpatient care of patients undergoing lumbar spine surgery during 2006–2015. Patient reported outcome measures used was Global Assessment, EQ-5D-3L and Oswestry Disability Index. The case-mix of surgically treated patients was analyzed using medical and socioeconomic factors.

Results

The value-based reimbursement program did not have any effect on targeted or non-targeted patient reported outcome measures. Moreover, the share of surgically treated patients with risk factors such as having comorbidities and being born outside of Europe increased after the introduction. Hence, the value-based reimbursement program did not encourage discrimination against sicker patients. However, the income was higher among patients surgically treated after the introduction of the value-based reimbursement. This indicates that a value-based reimbursement program may contribute to increased inequalities in access to healthcare.

Conclusions

The value-based reimbursement program did not have any effect on patient reported outcome measures. Our study contributes to the understanding of the effects of a value-based reimbursement program on patient reported outcome measures and to what extent cherry-picking arises.

Potential value of electronic health records in capturing data on geriatric frailty for population health

OBJECTIVES

Despite the availability of many frailty measures to identify older adults at risk, frailty instruments are not routinely used for risk assessment in population health management. Here, we assessed the potential value of electronic health records (EHRs) and administrative claims in providing the necessary data for variables used across various frailty instruments.

SETTING AND PARTICIPANTS

The review focused on studies conducted worldwide. Participants included older people aged 50 and older.

DESIGN

We identified frailty instruments published between 2011 and 2018. Frailty variables used in each of the frailty instruments were extracted, grouped, and categorized across health determinants and various clinical factors.

MEASURES

The availability of the extracted frailty variables across various data sources (e.g., EHRs, administrative claims, and surveys) was evaluated by experts.

RESULTS

We identified 135 frailty instruments, which contained 593 unique variables. Clinical determinants of health were the best represented variables across frailty instruments (n = 516; 87 %), unlike social and health services factors (n = 33; ∼5% and n = 32; ∼5%). Most frailty instruments require at least one variable that is not routinely available in EHRs or claims (n = 113; ∼83 %). Only 22 frailty instruments have the potential to completely rely on EHR (structured or free-text data) and/or claims data, and possibly be operationalized on a population-level.

CONCLUSIONS AND IMPLICATIONS

Frailty instruments continue to be highly survey-based. More research is therefore needed to develop EHR-based frailty instruments for population health management. This will permit organizations and societies to stratify risk and better allocate resources among different older adult populations.

RE-AIM Evaluation Plan for Washington State Innovation Models Project

The State of Washington received a State Innovation Models (SIM) $65 million award from the federal Centers for Medicare & Medicaid Services to improve population health and quality of care and reduce the growth of health care costs in the entire state, which has over 7 million residents. SIM is a "complex intervention" that implements several interacting components in a complex, decentralized health system to achieve goals, which poses challenges for evaluation. Our purpose is to present the state-level evaluation methods for Washington's SIM, a 3-year intervention (2016-2018). We apply the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) evaluation framework to structure our evaluation. We create a conceptual model and a plan to use multiple and mixed methods to study SIM performance in the RE-AIM components from a statewide, population-based perspective.

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer's Perspective

Policy Points Because bundled payments are relatively new and require a different type of collaboration among payers, providers, and other actors, their design and implementation process is complex. By sorting the 53 key elements that contribute to this complexity into specific pre- and postcontractual phases as well as the actors involved in the health system, this framework provides a comprehensive overview of this complexity from a payer's perspective. Strategically, the design and implementation of bundled payments should not be approached by payers as merely the introduction of a new contracting model, but as part of a broader transformation into a more sustainable, value-based health care system.

CONTEXT

Traditional fee-for-service (FFS) payment models in health care stimulate volume-driven care rather than value-driven care. To address this issue, increasing numbers of payers are adopting contracts based on bundled payments. Because their design and implementation are complex, understanding the elements that contribute to this complexity from a payer's perspective might facilitate their adoption. Consequently, the objective of our study was to identify and structure the key elements in the design and implementation of bundled payment contracts.

METHODS

Two of us independently and systematically examined the literature to identify all the elements considered relevant to our objective. We then developed a framework in which these elements were arranged according to the specific phases of a care procurement process and actors' interactions at various levels of the health system.

FINDINGS

The final study sample consisted of 147 articles in which we identified the 53 elements included in the framework. These elements were found in all phases of the pre- and postcontractual procurement process and involved actors at different levels of the health care system. Examples of elements that were cited frequently and are typical of bundled payment procurement, as opposed to FFS procurement, are (1) specification of care services, patients' characteristics, and corresponding costs, (2) small and heterogeneous patient populations, (3) allocation of payment and savings/losses among providers, (4) identification of patients in the bundle, (5) alignment of the existing care delivery model with the new payment model, and (6) limited effects on quality and costs in the first pilots and demonstrations.

CONCLUSIONS

Compared with traditional FFS payment models, bundled payment contracts tend to introduce an alternative set of (financial) incentives, touch on almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. Accordingly, payers should not strategically approach their design and implementation as merely the adoption of a new contracting model, but rather as part of a broader transformation toward a more sustainable value-based health care system, based less on short-term transactional negotiations and more on long-term collaborative relationships between payers and providers.

An Electronic Strategy for Eliminating Unnecessary Duplicate Genetic Testing

OBJECTIVES

To determine the impact of an electronic intervention designed to block duplicate constitutional genetic tests.

METHODS

We constructed, implemented, and studied an electronic intervention that stopped duplicate genetic tests. The activation frequency, types of tests affected, and cost savings achieved with this intervention were determined. The frequency and justification of override requests were also studied.

RESULTS

This intervention stopped 710 unnecessary duplicate genetic tests over a 3-year period and saved $98,596. The tests with the highest numbers of alerts were those used for screening presurgical or transplant patients and were commonly part of an order set or test panel. Most override requests were justified because of the lack of exclusion codes in the initial programming.

CONCLUSIONS

Electronic interventions that stop duplicate genetic testing, if properly constructed, can reduce waste, save health care dollars, and facilitate patient care by directing the provider to a test that has already been performed.

Hospital Value-Based Purchasing and Trauma-Certified Hospital Performance

INTRODUCTION

Hospital Value-Based Purchasing (HVBP) is an initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide. A hospital's trauma certification has the potential to influence HVBP scores as attaining the certification provides indication of the service quality offered by the hospital. As such, this study focuses on hospitals' level of trauma certification attainment through the American College of Surgeons and whether this certification is associated with greater HVBP.

METHODS

A retrospective review of the 2015 HVBP database, 2015 Area Health Resources Files (AHRF) database, and the 2015 American Hospital Association (AHA) database is utilized, and propensity score matching was employed to determine the association between level of trauma certification and scores on HVBP dimensions.

RESULTS

Results reveal trauma certification is associated with lower HVBP domain scores when compared to hospitals without trauma certification. In addition, hospitals with a greater degree of trauma specialization were associated with lower total performance score and efficiency domain scores.

CONCLUSIONS

Although payers attempt to connect hospital reimbursements with quality and outcomes, unintended consequences may occur. In response to these results, HVBP risk adjustment and scoring methods should receive further scrutiny.

Is it feasible to pay specialty substance use disorder treatment programs based on patient outcomes?

BACKGROUND

Some US payers are starting to vary payment to providers depending on patient outcomes, but this approach is rarely used in substance use disorder (SUD) treatment.

PURPOSE

We examine the feasibility of applying a pay-for-outcomes approach to SUD treatment.

METHODS

We reviewed several relevant literatures: (1) economic theory papers that describe the conditions under which pay-for-outcomes is feasible in principle; (2) description of the key outcomes expected from SUD treatment, and the measures of these outcomes that are available in administrative data systems; and (3) reports on actual experiences of paying SUD treatment providers based on patient outcomes.

RESULTS

The economics literature notes that when patient outcomes are strongly influenced by factors beyond provider control and when risk adjustment performs poorly, pay-for-outcomes will increase provider financial risk. This is relevant to SUD treatment. The literature on SUD outcome measurement shows disagreement on whether to include broader outcomes beyond abstinence from substance use. Good measures are available for some of these broader constructs, but the need for risk adjustment still brings many challenges. Results from two past payment experiments in SUD treatment reinforce some of the concerns raised in the more conceptual literature.

CONCLUSION

There are special challenges in applying pay-for-outcomes to SUD treatment, not all of which could be overcome by developing better measures. For SUD treatment it may be necessary to define outcomes more broadly than for general medical care, and to continue conditioning a sizeable portion of payment on process measures.

Relationship of pay-for-performance and provider pay

BACKGROUND

Policymakers and health care leaders search for a payment model to balance the interests of providers, patients, and payers. This has shifted reimbursement from a fee-for-service (FFS) to pay-for-performance (P4P) model. The FFS model of reimbursement may lead to provider overuse. The P4P model incentivizes quality, not quantity, of care. However, the payer's reimbursement shift to P4P has not affected compensation of individual providers.

OBJECTIVES

To explore the effects of payment compensation models on provider behavior and employment.

DATA SOURCES

CINAHL, Cochrane, and EBSCO databases were searched. To ensure accuracy, a PRISMA flow diagram was used. A thematic analysis was performed using 52 articles.

CONCLUSIONS

Four themes emerged: health care as an economic anomaly, the ability to incentivize value, ethics, and provider-employer-payer alignment. Basic economic principles are distorted in health care because of payment layers and competing goals. Although payment structure affects health care provider (HCP) performance, the correlation is not understood. There is a lack of knowledge on several key areas: 1) HCP behavioral research, 2) how employment may be influencing existing HCP attitudes and actions, 3) how nurse practitioners (NPs) differ from physicians, and 4) P4P outcome data. There is also a lack of literature involving NP's and reimbursement.

IMPLICATIONS FOR PRACTICE

Nurse practitioners must be included in compensation model research. Payment reform should address all individual HCP compensation. Reforms will be limited if focus remains on payer-organization reform and ignores HCP compensation. As HCPs, it is imperative to understand how payers reimburse services to establish guiding principles for equitable and ethical compensation negotiations.

Barriers to payment reform: Experiences from nine Dutch population health management sites

Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms.

Ontwikkelingen in zorginkoop: van inkoop van verrichtingen naar inkoop van zorgbundels

Zorgverzekeraars en zorgaanbieders maken meestal contractafspraken op basis van een vergoeding per verrichting. Dat stimuleert echter volume van zorg in plaats van uitkomsten. Daarom passen zorgverzekeraars en zorgaanbieders steeds vaker ‘bundelinkoop’ als bekostiging toe. Dan wordt een bedrag per patiënt afgesproken. We beschrijven wat bundelinkoop is en introduceren de contractelementen. De impact van zorgbundels is dat ze door een andere verdeling van (financiële) verantwoordelijkheden uitkomsten centraal stellen, schotten doorbreken en innovatie stimuleren. Opschalen van deze methode van zorginkoop vraagt om standaardisatie van de contractelementen en uniformiteit van de bundeldefinitie per aandoening anders nemen de administratieve lasten voor zorgaanbieders toe.

Predictive modeling in spine surgery

As the cost of healthcare in the United States increases at an unsustainable rate, health-policy leaders are looking towards innovative ways to maximize value in delivery of care. Incorporating technology, such as artificial intelligence/machine-learning, to assist physicians in decision-making and predicting outcomes, on a real-time basis, is a major topic of discussion. While machine learning is gradually pulling traction in the medical community, it still remains a nascent field in the realm of spine surgery. The current review aims to gather current literature discussing the validity and applicability of machine-learning models in spine surgery.

Variables associated with pediatric emergency department visits for uncontrolled pain in postoperative adenotonsillectomy patients

OBJECTIVE

Returns to the emergency department (ED) for pain or dehydration after adenotonsillectomy (T&A) are frequent. Attempts to associate the specific pain regimens with these visits have been unrevealing, suggesting a need to assess for other potential factors associated with readmission.

METHODS

A review of a 2:1 cohort matched by age, gender and payer status compared post-T&A patients who did not return ED for pain or dehydration within 21 days to those who returned. Factors investigated included patient demographics, comorbidities, medication regimen and the presence of postoperative telephone encounters. Patients returning to the ED were further assessed for rates of medication adherence.

RESULTS

7493 patients underwent T&A during the period. Of these, 144 (1.9%) returned for pain/dehydration. Comparison to 285 matched patients revealed an association between ED returns and Hispanic ethnicity (p < 0.001), Spanish language (p = 0.0002), and comorbid Down syndrome and ADHD (p = 0.011 in both). The incidence of parent telephone calls to the office was associated with ED returns (58.7 in the ED cohort, 28.4% in non-ED cohort, p < 0.0001). On multivariable analysis, Hispanic ethnicity and phone calls were associated with ED returns (p < 0.0001 and p < 0.0001, respectively). Only 64.0% of patients returning to the ED were adherent with postoperative pain regimens.

CONCLUSIONS

While demographic factors may be associated with rate of ED returns for pain and dehydration, post-operative phone calls were most highly associated with returns. The majority of patients returning to the ED were non-adherent with recommended pain regimens, suggesting an opportunity to investigate medication adherence in all post-tonsillectomy patients.

Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges

BACKGROUND

Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery.

OBJECTIVE

To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN).

METHODS

Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department.

RESULTS

Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively.

CONCLUSION

From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.

Why Money Alone Can’t (Always) “Nudge” Physicians

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Value-Based Care in Hematopoietic Cell Transplantation and Cellular Therapy: Challenges and Opportunities

PURPOSE OF REVIEW

Improved tolerability and outcomes after hematopoietic cell transplantation (HCT), along with the availability of alternative donors, have expanded its use. With this growth, and the development of additional cellular therapies, we also aim to increase effectiveness, efficiency, and the quality of the care provided. Fundamentally, the goal of value-based care is to have better health outcomes with streamlined processes, improved patient experience, and lower costs for both the patients and the health care system. HCT and cellular therapy treatments are multiphase treatments which allow for interventions at each juncture.

RECENT FINDINGS

We present a summary of the current literature with focus on program structure and overall system capacity, coordination of therapy across providers, standardization across institutions, diversity and disparities in care, patient quality of life, and cost implications. Each of these topics provides challenges and opportunities to improve value-based care for HCT and cellular therapy patients.

Comparing the Hospital-Acquired Condition Reduction Program and the Accreditation of Cancer Program: A Cross-sectional Study

Under the Hospital-Acquired Condition Reduction Program (HACRP), introduced by the Affordable Care Act, the Centers for Medicare and Medicaid must reduce reimbursement by 1% for hospitals that rank among the lowest performing quartile in regard to hospital-acquired conditions (HACs). This study seeks to determine whether Accredited Cancer Program (ACP) hospitals (as defined by the American College of Surgeons) score differently on the HACRP metrics than nonaccredited cancer program hospitals. This study uses data from the 2014 American Hospital Association Annual Survey database, the 2014 Area Health Resource File, the 2014 Medicare Final Rule Standardizing File, and the FY2017 HACRP database (Medicare Hospital Compare Database). The association between ACPs, HACs, and market characteristics is assessed through multinomial logistic regression analysis. Odds ratios and 95% confidence intervals are reported. Accredited cancer hospitals have a greater risk of scoring in the Worse outcome category of HAC scores, vs Middle or Better outcomes, compared with nonaccredited cancer hospitals. Despite this, they do not have greater odds of incurring a payment reduction under the HACRP measurement system. While ACP hospitals can likely improve scores, questions concerning the consistency of the message between ACP hospital quality and HACRP quality need further evaluation to determine potential gaps or issues in the structure or measurement. ACP hospitals should seek to improve scores on domain 2 measures. Although ACP hospitals do likely see more complex patients, additional efforts to reduce surgical site infections and related HACs should be evaluated and incorporated into required quality improvement efforts. From a policy perspective, policy makers should carefully evaluate the measures utilized in the HACPR.

Incentives in a public addiction treatment system: Effects on waiting time and selection

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.

General Pediatricians and Value-Based Payments

BACKGROUND AND OBJECTIVE

In an effort to transform the health care system, payers and physicians are experimenting with new payment models, mostly in an effort to move from a volume-based system to one based on value. We conducted a national survey to evaluate pediatricians' experience with and views about new value-based models of payment.

METHODS

An American Academy of Pediatrics 2016 member survey was used to assess provider and practice characteristics, provider experience with value-based payments (VBPs) (through accountable care organizations [ACOs] or pay for quality performance), and provider views about new payment models. We used descriptive statistics and multivariable logistic regression models to examine relationships between experience and views.

RESULTS

The survey response rate was 48.7% (n = 786 of 1614). Of practicing general pediatricians, 52% reported experience with VBP, 32% believed payment for quality metrics have a "positive impact" on pediatricians' ability to provide quality care for patients, and 12% believed ACOs have a positive impact. Adjusting for covariates, respondents experienced with payments for quality metrics (adjusted odds ratio: 2.01; 95% confidence interval 1.26-3.19) and ACOs (odds ratio: 6.68; 95% confidence interval 3.55-13.20) were more likely to report a positive impact.

CONCLUSIONS

Although experience and views vary, just more than half of surveyed pediatricians report receiving some form of VBP. Pediatricians reporting this experience are more likely to feel that these payment models have a positive impact on patient care when compared with pediatricians without this experience.

Value-based provider payment: towards a theoretically preferred design

Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by 'value', however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at: (1) identifying value dimensions that are ideally stimulated by VBP and (2) constructing a framework of a theoretically preferred VBP design. Based on a synthesis of both theoretical and empirical studies on payment incentives, we conclude that VBP should consist of two components: a relatively large base payment that implicitly stimulates value and a relatively small payment that explicitly rewards measurable aspects of value (pay-for-performance). Being the largest component, the base payment design is essential, but often neglected when it comes to VBP reform. We explain that this base payment ideally (1) is paid to a multidisciplinary provider group (2) for a cohesive set of care activities for a predefined population, (3) is fixed, (4) is adjusted for the population's risk profile and (5) includes risk-mitigating measures. Finally, some important trade-offs in the practical operationalisation of VBP are discussed.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patients With Major Depressive Disorder Experience Increased Perception of Pain and Opioid Consumption Following Total Joint Arthroplasty

BACKGROUND

Pain in the immediate postoperative period following total joint arthroplasty is influenced by various patient factors, including major depressive disorder (MDD). Therefore, this study aimed to compare the patient perception of pain and opioid consumption between patients with and without MDD who received either a total knee arthroplasty (TKA) or total hip arthroplasty (THA). Specifically, we compared (1) pain intensity, (2) lengths of stay, (3) opioid consumption, and (4) patient perception of pain control.

METHODS

We reviewed our institutional Press Ganey database to identify patients with a diagnosis of MDD who received a THA (n = 48) and TKA (n = 68) between 2012 and 2016. An independent samples t-test and chi-square analyses were conducted to assess continuous and categorical variables, respectively. Analysis of covariance assessed the effects of depression on postoperative pain intensity. Mixed-design analysis of variance assessed the difference in opioid consumption between groups.

RESULTS

Patients with MDD who received THA or TKA demonstrated a higher mean pain intensity score when compared to those without MDD; however, this was not statistically different (235.6 vs 207.7; P = .264 and 214.8 vs 185.1; P = .055, respectively). Patients with MDD who received THA or TKA consumed more opioids when compared to those without MDD (P = .048 and P = .038, respectively).

CONCLUSION

Patients with MDD undergoing total joint arthroplasty consume more opioids compared to their matched cohort during the immediate postoperative period. Identifying patient-specific factors, such as MDD, could help arthroplasty surgeons modulate patients' course of recovery. These findings warrant more cooperation between arthroplasty surgeons and primary care providers to optimize outcome.

ACOs Holding Commercial Contracts Are Larger And More Efficient Than Noncommercial ACOs

Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variation in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.

Financial Incentives and Physician Practice Participation in Medicare's Value-Based Reforms

OBJECTIVES

To evaluate whether greater experience and success with performance incentives among physician practices are related to increased participation in Medicare's voluntary value-based payment reforms.

DATA SOURCES/STUDY SETTING

Publicly available data from Medicare's Physician Compare (n = 1,278; January 2012 to November 2013) and nationally representative physician practice data from the National Survey of Physician Organizations 3 (NSPO3; n = 907,538; 2013).

STUDY DESIGN

We used regression analysis to examine practice-level relationships between prior exposure to performance incentives and participation in key Medicare value-based payment reforms: accountable care organization (ACO) programs, the Physician Quality Reporting System ("Physician Compare"), and the Meaningful Use of Health Information Technology program ("Meaningful Use"). Prior experience and success with financial incentives were measured as (1) the percentage of practices' revenue from financial incentives for quality or efficiency; and (2) practices' exposure to public reporting of quality measures.

DATA COLLECTION/EXTRACTION METHODS

We linked physician participation data from Medicare's Physician Compare to the NSPO3 survey.

PRINCIPAL FINDINGS

There was wide variation in practices' exposure to performance incentives, with 64 percent exposed to financial incentives, 45 percent exposed to public reporting, and 2.2 percent of practice revenue coming from financial incentives. For each percentage-point increase in financial incentives, there was a 0.9 percentage-point increase in the probability of participating in ACOs (standard error [SE], 0.1, p < .001) and a 0.8 percentage-point increase in the probability of participating in Meaningful Use (SE, 0.1, p < .001), controlling for practice characteristics. Financial incentives were not associated with participation in Physician Compare. Among ACO participants, a 1 percentage-point increase in incentives was associated with a 0.7 percentage-point increase in the probability of being "very well" prepared to utilize cost and quality data (SE, 0.1, p < .001).

CONCLUSIONS

Physicians organizations' prior experience and success with performance incentives were related to participation in Medicare ACO arrangements and participation in the meaningful use criteria but not to participation in Physician Compare. We conclude that Medicare must complement financial incentives with additional efforts to address the needs of practices with less experience with such incentives to promote value-based payment on a broader scale.

Policy-Oriented Research on Improved Physician Incentives for Higher Value Health Care

Policy makers (both public and private) are seeking ways to improve the value delivered within our health care system, that is, using fewer resources to provide the same benefit to patients, or using equivalent resources to provide more benefit. One strategy is to alter the predominant fee‐for‐service (FFS) economic incentives in the current system. To inform such policy changes, this paper identifies areas in which little is known about the effects of specific incentives (FFS, salary, etc.) on the two components of value: resource use and quality. Specific suggestions are offered regarding research that would be informative for policy makers, focusing on fundamental “building block” studies rather than overall evaluations of complex interventions, such as accountable care organizations. This research would better identify critical aspects of the FFS model and salary‐based payments that are particularly problematic, as well as situations in which FFS or salary may be less problematic. The research would also explore when alternatives, such as episode‐based payment might be feasible, or simply be hypothetical solutions. The availability of electronic health record‐based data in various delivery systems would allow many of these studies to be accomplished in 3–5 years with budgets manageable by public and private funding sources.

How Financial and Reputational Incentives Can Be Used to Improve Medical Care

OBJECTIVES

Narrative review of the impact of pay-for-performance (P4P) and public reporting (PR) on health care outcomes, including spillover effects and impact on disparities.

PRINCIPAL FINDINGS

The impact of P4P and PR is dependent on the underlying payment system (fee-for-service, salary, capitation) into which these schemes are introduced. Both have the potential to improve care, but they can also have substantial unintended consequences. Evidence from the behavioral economics literature suggests that individual physicians will vary in how they respond to incentives. We also discuss issues to be considered when including patient-reported outcome measures (PROMs) or patient-reported experience measures into P4P and PR schemes.

CONCLUSION

We provide guidance to payers and policy makers on the design of P4P and PR programs so as to maximize their benefits and minimize their unintended consequences. These include involving clinicians in the design of the program, taking into account the payment system into which new incentives are introduced, designing the structure of reward programs to maximize the likelihood of intended outcomes and minimize the likelihood of unintended consequences, designing schemes that minimize the risk of increasing disparities, providing stability of incentives over some years, and including outcomes that are relevant to patients' priorities. In addition, because of the limitations of PR and P4P as effective interventions in their own right, it is important that they are combined with other policies and interventions intended to improve quality to maximize their likely impact.