Dataset Information

A Scoping Review of Alternative Payment Models in Maternity Care: Insights in Key Design Elements and Effects on Health and Spending.

ABSTRACT:

Introduction

Although effects of alternative payment models on health outcomes and health spending are unclear, they are increasingly implemented in maternity care. We aimed to provide an overview of alternative payment models implemented in maternity care, describing their key design elements among which the type of APM, the care providers that participate in the model, populations and care services that are included and the applied risk mitigation strategies. Next to that, we made an inventory of the empirical evidence on the effects of APMs on maternal and neonatal health outcomes and spending on maternity care.

Methods

We searched PubMed, Embase and Scopus databases for articles published from January 2007 through October 2020. Search key words included 'alternative payment model', 'value based payment model', 'obstetric', 'maternity'. English or Dutch language articles were included if they described or empirically evaluated initiatives implementing alternative payment models in maternity care in high-income countries. Additional relevant documents were identified through reference tracking. We systematically analyzed the initiatives found and examined the evidence regarding health outcomes and health spending. The process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to ensure validity and reliability.

Results

We identified 17 initiatives that implemented alternative payment models in maternity care. Thirteen in the United States, two in the United Kingdom, one in New Zealand and one in the Netherlands. Within these initiatives three types of alternative payment models were implemented; pay-for-performance (n = 2), shared savings models (n = 7) and bundled payment models (n = 8). Alternative payment models that shifted more financial accountability towards providers seemed to include more strategies that mitigated those risks. Risk mitigation strategies were applied to the included population, included services or at the level of total expenditures. Of these seventeen initiatives, we found four empirical effect studies published in peer-reviewed journals. Three of them were of moderate quality and one weak. Two studies described an association of the alternative payment model with an improvement of specific health outcomes and two studies described a reduction in medical spending.

Conclusions

This study shows that key design elements of alternative payment models including risk mitigation strategies vary highly. Risk mitigation strategies seem to be relevant tools to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. Empirical evidence on the effects of APMs on health outcomes and spending is still limited. A clear definition of key design elements and a further, in-depth, understanding of key design elements and how they operate into different health settings is required to shape payment reform that aligns with its goals.

SUBMITTER: de Vries EF

PROVIDER: S-EPMC8086739 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ImportanceConsolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation.ObjectiveTo examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices.Design, setting, and participantsA cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019.ExposuresSelf-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors.Main outcomes and measuresParticipation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts.ResultsA total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation.Conclusions and relevanceGreater APM participation appears to be supported by integration and system ownership.

Project description:BackgroundAlternative payment models (APMs) in healthcare are emerging that reward quality of care over quantity of services. Most bundled payment programs that are described in published studies are related to episodes for a surgical inpatient hospital stay. With outpatient services, monthly capitated payments are an alternative to bundled payments for specialty services.ObjectiveTo assess the association of a capitated contractual arrangement between a primary care physician group and an oncology clinic group with the quality of care received.MethodsWe evaluated the effect of an oncology group's transition from a fee-for-service (FFS) arrangement to a partial-capitated-payment model with a primary care group. We compared outcomes for patients who received treatment after implementation of the new arrangement (ie, postcontract capitated group) with outcomes of patients receiving treatment before the change (ie, precontract capitated group). In addition, we conducted a parallel analysis of patients from a population that was not affected by the contract to assess temporal effects (ie, postcontract FFS group vs precontract FFS group). All patients were enrolled in Medicare Advantage plans of a single health plan (ie, Humana), and outcomes were measured using claims data provided by that company. Patients in the 2 precontract groups received treatment between July 1, 2010, and June 30, 2011; patients in the 2 postcontract groups received treatment between January 1, 2013, and December 31, 2013. Age- and sex-adjusted all-cause hospitalization, complications from cancer treatment, and ambulance transfers during 6 months of follow-up were evaluated.ResultsIn the population subject to the partial-capitated-payment model, the postcontract group (N = 305) was younger than the precontract group (N = 165). In a subset of patients in the 2 capitated groups who had Deyo-Charlson Comorbidity Index (CCI) RxRisk scores, the postcontract capitated group had significantly higher CCI scores. Adjusted odds ratios for the postcontract capitated group versus the precontract capitated group showed no difference in the likelihood that any of the outcomes would occur. However, the mean number of chemotherapy-related complications and ambulance transports were greater postcontract. In the parallel analysis of the population not affected by the new payment arrangement, no differences were found between the pre- and postcontract groups. This suggests that temporal changes potentially affecting patients in the capitated and FFS populations would not have influenced postcontract outcomes.ConclusionsAfter the implementation of partial-capitated payments for medical oncology services in the oncology practice, the likelihood of a patient experiencing at least 1 event of a specific adverse outcome did not change; however, the average number of some adverse events did increase, which may in part be explained by a higher level of underlying morbidity in the postcontract group. The overall findings of this study suggest that quality of care was not compromised in this APM.

Project description:BackgroundPopulation-based global payment gives health care providers a spending target for the care of a defined group of patients. We examined changes in spending, utilization, and quality through 8 years of the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts, a population-based payment model that includes financial rewards and penalties (two-sided risk).MethodsUsing a difference-in-differences method to analyze data from 2006 through 2016, we compared spending among enrollees whose physician organizations entered the AQC starting in 2009 with spending among privately insured enrollees in control states. We examined quantities of sentinel services using an analogous approach. We then compared process and outcome quality measures with averages in New England and the United States.ResultsDuring the 8-year post-intervention period from 2009 to 2016, the increase in the average annual medical spending on claims for the enrollees in organizations that entered the AQC in 2009 was $461 lower per enrollee than spending in the control states (P<0.001), an 11.7% relative savings on claims. Savings on claims were driven in the early years by lower prices and in the later years by lower utilization of services, including use of laboratory testing, certain imaging tests, and emergency department visits. Most quality measures of processes and outcomes improved more in the AQC cohorts than they did in New England and the nation in unadjusted analyses. Savings were generally larger among subpopulations that were enrolled longer. Enrollees of organizations that entered the AQC in 2010, 2011, and 2012 had medical claims savings of 11.9%, 6.9%, and 2.3%, respectively, by 2016. The savings for the 2012 cohort were statistically less precise than those for the other cohorts. In the later years of the initial AQC cohorts and across the years of the later-entry cohorts, the savings on claims exceeded incentive payments, which included quality bonuses and providers' share of the savings below spending targets.ConclusionsDuring the first 8 years after its introduction, the BCBS population-based payment model was associated with slower growth in medical spending on claims, resulting in savings that over time began to exceed incentive payments. Unadjusted measures of quality under this model were higher than or similar to average regional and national quality measures. (Funded by the National Institutes of Health.).

Project description: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.ContextTraditional 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.MethodsTwo 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.FindingsThe 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.ConclusionsCompared 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.