Value-Based Payment Models In The Commercial Insurance Sector: A Systematic Review

Inciting maintenance: Tiered institutional work during value-based payment reform in oncology

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned.

Revising the Logic Model Behind Health Care's Social Care Investments

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

Augmenting a Transitional Care Model With Artificial Intelligence Decreased Readmissions

OBJECTIVES

Evaluate if augmenting a transitions of care delivery model with insights from artificial intelligence (AI) that applied clinical and exogenous social determinants of health data would reduce rehospitalization in older adults.

DESIGN

Retrospective case-control study.

SETTING AND PARTICIPANTS

Adult patients discharged from integrated health system between November 1, 2019, and February 31, 2020, and enrolled in a rehospitalization reduction transitional care management program.

INTERVENTION

An AI algorithm utilizing multiple data sources including clinical, socioeconomic, and behavioral data was developed to predict patients at highest risk for readmitting within 30 days and provide care navigators five care recommendations to prevent rehospitalization.

METHODS

Adjusted incidence of rehospitalization was estimated with Poisson regression and compared between transitional care management enrollees that used AI insights and matched enrollees for whom AI insights were not used.

RESULTS

Analyses included 6371 hospital encounters between November 2019 and February 2020 across 12 hospitals. Of the encounters 29.3% were identified by AI as being medium-high risk for re-hospitalizing within 30 days, for which AI provided transitional care recommendations to the transitional care management team. The navigation team completed 40.2% of AI recommendations for these high-risk older adults. These patients had overall 21.0% less adjusted incidence of 30-day rehospitalization compared with matched control encounters, or 69 fewer rehospitalizations per 1000 encounters (95% CI 0.65‒0.95).

CONCLUSIONS AND IMPLICATIONS

Coordinating a patient's care continuum is critical for safe and effective transition of care. This study found that augmenting an existing transition of care navigation program with patient insights from AI reduced rehospitalization more than without AI insights. Augmenting transitional care with insights from AI could be a cost-effective intervention to improve transitional care outcomes and reduce unnecessary rehospitalization. Future studies should examine cost-effectiveness of augmenting transitional care models of care with AI when hospitals and post-acute providers partner with AI companies.

Association Between a Bundled Payment Program for Lower Extremity Joint Replacement and Patient Outcomes Among Medicare Advantage Beneficiaries

Importance

Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality.

Objective

To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery.

Design, Setting, and Participants

Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022.

Exposures

Physician practice participation in the bundled payment program.

Main Outcomes and Measures

The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions).

Results

The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]).

Conclusions and Relevance

In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

Value-Based Purchasing Design And Effect: A Systematic Review And Analysis

During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.

The Next Generation of Payment Reforms for Population Health - An Actionable Agenda for 2035 Informed by Past Gains and Ongoing Lessons

Policy Points The predominantly fee-for-service reimbursement architecture of the US health care system contributes to waste and excess spending. While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population-based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity. To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value-based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross-sector entities to invest in the upstream drivers of health.

Development of a value-based care and population health internship for student pharmacists

INTRODUCTION

Pharmacists assist in achieving desired outcomes and reducing costs of care within newer value-based payment models. The purpose of this article is to describe a summer internship for first- and second-year student pharmacists to gain exposure to value-based care.

METHODS

University Health Network is a clinically integrated health network and accountable care organization in East Tennessee. Two student interns completed consecutive seven-week programs alongside clinical pharmacist specialists in the primary care settings of the network. Program requirements included direct patient care for chronic disease state management, topic discussions, formal writing assignments and presentations, and a quality improvement project. Student perception of internship activities was measured using a Likert type survey and free response questionnaire.

RESULTS

Student interns responded positively to program requirements with feelings of enhanced preparedness for advanced pharmacy practice experiences and post-graduate residency positions. Additionally, interns perceived themselves as more competitive for post-graduate positions having completed the internship.

CONCLUSIONS

As the US continues to move toward value-based payment models, student pharmacists must be well prepared to contribute to quality and population health initiatives. Student pharmacists benefit from an internship in a clinically integrated health network by gaining an improved understanding of the future of United States healthcare, an expanded clinical skillset, experience in demonstrating a pharmacist's value to the healthcare team, and the ability to overcome barriers to pharmacy services. A pharmacy internship within a clinically integrated health network may help prepare students to successfully contribute to value-based models of healthcare.

Value-Based Payment and Behavioral Health

This Viewpoint discusses behavioral health and its transition to value-based payment models.