Detecting bad actors in value-based payment models.
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ABSTRACT: Supplementary information
The online version contains supplementary material available at 10.1007/s10742-021-00253-9.
SUBMITTER: Lissenden B
PROVIDER: S-EPMC8237252 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:IntroductionValue-based healthcare has potential for cost control and quality improvement. To assess this, we review the evidence on the impact of value-based payment (VBP) models in the context of networks of care (NOC) and transmural care.MethodsWe used the PRISMA guidelines for this systematic literature review. We searched eight databases in July 2021. Subsequently, we conducted title and abstract and full-text screenings, and extracted information in an extraction matrix. Based on this, we assessed the evidence on the effects of VBP models on clinical outcomes, patient-reported outcomes/experiences, organization-related outcomes/experiences, and costs. Additionally, we reviewed the facilitating and inhibiting factors per VBP model.FindingsAmong articles studying shared savings and pay-for-performance models, most outline positive effects on both clinical and cost outcomes, such as preventable hospitalizations and total expenditures, respectively. Most studies show no change in patient satisfaction and access to care when adopting VBP models. Providers' opinions towards the models are frequently negative. Transparency and communication among involved stakeholders are found to be key facilitating factors, transversal to all models. Additionally, a lack of trust is an inhibitor found in all VBP models, together with inadequate targets and insufficient incentives. In bundled payment and pay-for-performance models, complexity in the structure of the program and lack of experience in implementing required mechanisms are key inhibitors.ConclusionsThe overall positive effect on clinical and cost outcomes validates the success of VBP models. The mostly negative effects on organization-reported outcomes/experiences are corroborated by findings regarding providers' lack of awareness, trust, and engagement with the model. This may be justified by their exclusion from the design of the models, decreasing their sense of ownership and, therefore, motivation. Incentives, targets, benchmarks, and quality measures, if adequately designed, seem to be important facilitators, and if lacking or inadequate, they are key inhibitors. These are prominent facilitators and inhibitors for P4P and shared savings models but not as prominent for bundled payments. The complexity of the scheme and lack of experience are prominent inhibitors in all VBP models, since all require changes in several areas, such as behavioral, process, and infrastructure.
| S-EPMC10119264 | biostudies-literature
Project description:Background:When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average. Objective:To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients. Design:Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics. Setting:Fee-for-service Medicare. Patients:Random 20% sample of beneficiaries. Measurements:Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality. Results:No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores. Limitation:Observational design and administrative data. Conclusion:The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities. Primary Funding Source:The Laura and John Arnold Foundation and National Institute on Aging.
| S-EPMC5820192 | biostudies-literature
Project description:BackgroundUncertainty about the benefits new cancer medicines will deliver in clinical practice risks delaying patient access to new treatment options in countries such as England, where the cost effectiveness of new medicines affects reimbursement decisions. Outcome-based payment (OBP) schemes, whereby the price paid for the drug is linked to patients' real-world treatment outcome(s) has been put forward as a mechanism to accelerate access. Although OBP schemes have generally focused on clinical outcomes to determine reimbursement, the degree to which these represent the outcomes that are important to patients is unclear.ObjectiveTo advance the application of OBP we ask, what outcomes do patients with cancer value (most) that might form a practical basis for OBP?MethodsA review of the literature on outcomes in cancer produced a long list of candidates. These were evaluated in a focus group with patients with cancer and were then, in a second focus group, distilled to a shortlist of ten outcomes using a card sort method. The ten outcomes were included in an online survey of patients with cancer and carers, who were asked to rank the importance of each outcome.ResultsThe focus groups identified a range of both clinical and functional outcomes that are important to patients. Analyses of the 164 survey responses suggested that the four most important outcomes to patients and carers are survival; progression, relapse or recurrence; post-treatment side effects; and return to normal activities of daily life.ConclusionCommissioners of cancer services wishing to instigate an OBP scheme should prioritise collecting data on these outcomes as they are important to patients. Of these, only mortality data are routinely collected within the national health service (NHS). Progression and some morbidity data exist but are not currently linked, creating a challenge for OBP.
| S-EPMC7478942 | biostudies-literature
Project description:ObjectiveTo examine the impact of a scaled implementation of workforce training intervention on value-based payment measures in a large home-based Medicaid managed long-term care plan population in New York.Data sourcesManaged long-term care clients' health assessments from the Uniform Assessment System of New York merged with paid claims, home health aide operational visit data, and workforce training rosters between 2018 and early-2020.Study designA quasi-experimental design was used. Exposure and control groups were constructed using the proportion of service hours delivered by trained aides between clients' baseline and follow-up/outcome assessments. Multivariate logistic generalized linear and additive models were estimated to examine associations between exposure to trained aides and value-based payment measures.Data collection/extraction methodsThe analytic sample consisted of 19,212 pairs of assessments from 13,320 long-term care clients continuously enrolled in the plan between baseline and follow-up/outcome assessments. Matched assessment pairs were 6-10 months apart.Principal findingsOver 27% of the study population (n = 3656 clients) received services from one or more of 8683 trained aides. Statistically significant associations were observed for four of seven value-based payment measures; however, the presence and magnitudes of positive training effects differed by client service needs. With covariate adjustment, workforce training had the largest estimated positive impacts on rates of flu vaccination among average-need clients (1.60%, standard error [SE] = 0.01), not experiencing uncontrolled pain among above-average-need clients (0.69%, SE = 0.001), stable/improved pain intensity among heavy-need clients (1.25%, SE = 0.01), and stable/improved shortness of breath among light-need clients (0.88%, SE = 0.003).ConclusionAlthough we found mixed associations between scaled workforce training implementation and value-based payment metrics, we noted workforce training could benefit high-need long-term care recipients. Health indicators more sensitive to the daily support provided by direct care workers should be integrated into value-based health care models.
| S-EPMC8928035 | biostudies-literature
Project description: Not available
| S-EPMC8931557 | biostudies-literature
Project description:To assess the role of value-based payment (VBP) in improving fidelity and patient outcomes in community implementation of an evidence-based mental health intervention, the Collaborative Care Model (CCM).Retrospective study based on a natural experiment.We used the clinical tracking data of 1806 adult patients enrolled in a large implementation of the CCM in community health clinics in Washington state. VBP was initiated in year 2 of the program, creating a natural experiment. We compared implementation fidelity (measured by 3 process-of-care elements of the CCM) between patient-months exposed to VBP and patient-months not exposed to VBP. A series of regressions were estimated to check robustness of findings. We estimated a Cox proportional hazard model to assess the effect of VBP on time to achieving clinically significant improvement in depression (measured based on changes in depression symptom scores over time).Estimated marginal effects of VBP on fidelity ranged from 9% to 30% of the level of fidelity had there been no exposure to VBP (P <.05 for every fidelity measure). Improvement in fidelity in response to VBP was greater among providers with a larger patient panel and among providers with a lower level of fidelity at baseline. Exposure to VBP was associated with an adjusted hazard ratio of 1.45 (95% confidence interval, 1.04-2.03) for achieving clinically significant improvement in depression.VBP improved fidelity to key elements of the CCM, both directly incentivized and not explicitly incentivized by the VBP, and improved patient depression outcomes.
| S-EPMC5559616 | biostudies-literature
Project description:OBJECTIVE:To assess the impact of alternative methods of aggregating individual quality measures on Accountable Care Organization (ACO) overall scores. DATA SOURCE:2014 quality scores for Medicare ACOs. STUDY DESIGN:We compare ACO overall scores derived using CMS' aggregation approach to those derived using alternative approaches to grouping and weighting measures. PRINCIPAL FINDINGS:Alternative grouping and weighting methods based on statistical criteria produced overall quality scores similar to those produced using CMS' approach (? = 0.80 to 0.95). Scores derived from giving specific domains greater weight were less similar (? = 0.51 to 0.93). CONCLUSIONS:How measures are grouped into domains and how these domains are weighted to generate overall scores can have important implications for ACO's shared savings payments.
| S-EPMC6232509 | biostudies-literature
Project description:OBJECTIVES:To (1) compare the 2015 hospital grades reported on Medicare's Hospital Compare website for heart failure (HF) and acute myocardial infarction (AMI) readmissions with the HF- and AMI-specific scores for excess readmissions used to assess Medicare readmission penalties and (2) assess how often hospitals were penalized for excess readmissions in only 1 or 2 conditions, given that hospitals received a penalty impacting all Medicare payments based on an overall readmission score calculated from 5 conditions (HF, AMI, pneumonia, chronic obstructive pulmonary disease, and total hip/knee arthroplasty). STUDY DESIGN:Retrospective secondary data analysis. METHODS:Descriptive analyses of hospital-specific, condition-specific grades and excess readmission scores and hospital-level penalties downloaded from Hospital Compare. RESULTS:Of the 2956 hospitals that had publicly reported HF grades on Hospital Compare, 91.9% (2717) were graded as "no different" than the national rate for HF readmissions, which included 48.6% that were scored as having excessive HF admissions, and 87% received an overall readmission penalty. Of 120 (4.1%) hospitals graded as "better" than the national rate for HF, none were scored as having excessive HF readmissions and 50% were penalized. AMI data yielded similar results. Among 2591 hospitals penalized for overall readmissions, 26.6% had only 1 condition with excess readmissions and 27.5% had 2 conditions. CONCLUSIONS:Many hospitals with an HF and AMI readmission grade of "no different" than the national rate on Hospital Compare received penalties for excessive readmissions under the Hospital Readmissions Reduction Program. The value signal to consumers and hospitals communicated by grades and penalties is therefore weakened because the methods applied to the same hospital data produce conflicting messages of "average grades" yet "bad enough for penalty."
| S-EPMC7526620 | biostudies-literature
Project description:IntroductionOutcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.MethodsWe first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.ResultsWe included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.DiscussionAlthough strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
| S-EPMC6438941 | biostudies-literature
Project description:BackgroundImplementation of payment reform for breast reconstruction following mastectomy demands a comprehensive understanding of costs related to the complex process of reconstruction. Bundled payments for services to women with breast cancer may profoundly impact reimbursement and access to breast reconstruction. The authors' objectives were to determine the contribution of cancer therapies, comorbidities, revisions, and complications to costs following immediate reconstruction and the optimal duration of episodes to incentivize cost containment for bundled payment models.MethodsThe cohort was composed of women who underwent immediate breast reconstruction between 2009 and 2016 from the MarketScan Commercial Claims and Encounters database. Continuous enrollment for 3 months before and 24 months after reconstruction was required. Total costs were calculated within predefined episodes (30 days, 90 days, 1 year, and 2 years). Multivariable models assessed predictors of costs.ResultsAmong 15,377 women in the analytic cohort, 11,592 (75 percent) underwent tissue expander, 1279 (8 percent) underwent direct-to-implant, and 2506 (16 percent) underwent autologous reconstruction. Adjuvant therapies increased costs at 1 year [tissue expander, $39,978 (p < 0.001); direct-to-implant, $34,365 (p < 0.001); and autologous, $29,226 (p < 0.001)]. At 1 year, most patients had undergone tissue expander exchange (76 percent) and revisions (81 percent), and a majority of complications had occurred (87 percent). Comorbidities, revisions, and complications increased costs for all episode scenarios.ConclusionsEpisode-based bundling should consider separate bundles for medical and surgical care with adjustment for procedure type, cancer therapies, and comorbidities to limit the adverse impact on access to reconstruction. The authors' findings suggest that a 1-year time horizon may optimally capture reconstruction events and complications.
| S-EPMC8503817 | biostudies-literature