Association of Electronic Health Record Use Above Meaningful Use Thresholds With Hospital Quality and Safety Outcomes.

Importance: By 2018, Medicare spent more than $30 billion to incentivize the adoption of electronic health records (EHRs), based partially on the belief that EHRs would improve health care quality and safety. In a time when most hospitals are well past minimum meaningful use (MU) requirements, examining whether EHR implementation beyond the minimum threshold is associated with increased quality and safety may guide the future focus of EHR development and incentive structures. Objective: To determine whether EHR implementation above MU performance thresholds is associated with changes in hospital patient satisfaction, efficiency, and safety. Design, Setting, and Participants: This quantile regression analysis of cross-sectional data used publicly available data sets from 2362 acute care hospitals in the United States participating in both the MU and Hospital Value-Based Purchasing (HVBP) programs from January 1 to December 31, 2016. Data were analyzed from August 1, 2019, to May 22, 2020. Exposures: Seven MU program performance measures, including medication and laboratory orders placed through the EHR, online health information availability and access rates, medication reconciliation through the EHR, patient-specific educational resources, and electronic health information exchange. Main Outcomes and Measures: The HVBP outcomes included patient satisfaction survey dimensions, Medicare spending per beneficiary, and 5 types of hospital-acquired infections. Results: Among the 2362 participating hospitals, mixed associations were found between MU measures and HVBP outcomes, all varying by outcome quantile and in some cases by interaction with EHR vendor. Computerized provider order entry (CPOE) for laboratory orders was associated with decreased ratings of every patient satisfaction outcome at middle quantiles (communication with nurses: ß = -0.33 [P = .04]; communication with physicians: ß = -0.50 [P < .001]; responsiveness of hospital staff: ß = -0.57 [P = .03]; care transition performance: ß = -0.66 [P < .001]; communication about medicines: ß = -0.52 [P = .002]; cleanliness and quietness: ß = -0.58 [P = .007]; discharge information: ß = -0.48 [P < .001]; and overall rating: ß = -0.95 [P < .001]). However, at middle quantiles, CPOE for medication orders was associated with increased ratings for communication with physicians (τ = 0.5; ß = 0.54; P = .009), care transition (τ = 0.5; ß = 1.24; P < .001), discharge information (τ = 0.5; ß = 0.41; P = .01), and overall hospital ratings (τ = 0.5; ß = 0.97; P = .02). At high quantiles, electronic health information exchange was associated with improved ratings of communication with nurses (τ = 0.9; ß = 0.23; P = .03). Medication reconciliation had positive associations with increased communication with nursing at low quantiles (τ = 0.1; ß = 0.60; P < .001), increased discharge information at middle quantiles (τ = 0.5; ß = 0.28; P = .03), and responsiveness of hospital staff at middle (τ = 0.5; ß = 0.77; P = .001) and high (τ = 0.9; ß = 0.84; P = .001) quantiles. Patients accessing their health information online was not associated with any outcomes. Increased use of patient-specific educational resources identified through the EHR was associated with increased ratings of communication with physicians at high quantiles (τ = 0.9; ß = 0.20; P = .02) and with decreased spending at low-spending hospitals (τ = 0.1; ß = -0.40; P = .008). Conclusions and Relevance: Increasing EHR implementation, as measured by MU criteria, was not straightforwardly associated with increased HVBP measures of patient satisfaction, spending, and safety in this study. These results call for a critical evaluation of the criteria by which EHR implementation is measured and increased attention to how different EHR products may lead to differential outcomes.

Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.

Utilization management strategies, including prior authorization, are commonly used to facilitate safe and guideline-adherent provision of new, individualized, and potentially costly cardiovascular therapies. However, as currently deployed, these approaches encumber multiple stakeholders. Patients are discouraged by barriers to appropriate access; clinicians are frustrated by the time, money, and resources required for prior authorizations, the frequent rejections, and the perception of being excluded from the decision-making process; and payers are weary of the intensive effort to design and administer increasingly complex prior authorization systems to balance value and appropriate use of these treatments. These issues highlight an opportunity to collectively reimagine utilization management as a transparent and collaborative system. This would benefit the entire healthcare ecosystem, especially in light of the shift to value-based payment. This article describes the efforts and vision of the multistakeholder Prior Authorization Learning Collaborative of the Value in Healthcare Initiative, a partnership between the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. We outline how healthcare organizations can take greater utilization management responsibility under value-based contracting, especially under different state policies and local contexts. Even with reduced payer-mandated prior authorization in these arrangements, payers and healthcare organizations will have a continued shared need for utilization management. We present options for streamlining these programs, such as gold carding and electronic and automated prior authorization processes. Throughout the article, we weave in examples from cardiovascular care when possible. Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.

Value-based insurance design in Louisiana: Blue Cross Blue Shield's Zero Dollar Co-pay program.

OBJECTIVES: To determine whether a program that eliminated pharmacy co-pays, the Blue Cross Blue Shield of Louisiana (BCBSLA) Zero Dollar Co-pay (ZDC) program, decreased health care spending. Previous studies have found that value-based insurance designs like the ZDC program have little or no impact on total health care spending. ZDC included an expansive set of medications related to 4 chronic diseases rather than a limited set of medications for 1 or 2 chronic diseases. Additionally, ZDC focused on the most at-risk patients. STUDY DESIGN: ZDC began in 2014 and enrolled patients over time based on (1) when a patient answered a call from a nurse care manager and (2) when a patient or their employer changed the benefit structure to meet the program criteria. During 2015 and 2016, 265 patients with at least 1 chronic condition (asthma, diabetes, hypertension, mental illness) enrolled in ZDC. METHODS: Observational study using within-patient variation and variation in patient enrollment month to identify the impact of the ZDC program on health spending measures. We used 100% BCBSLA claims data from January 2015 to June 2018. Monthly level event studies were used to test for differential spending patterns prior to ZDC enrollment. RESULTS: We found that total spending decreased by $205.9 (P = .049) per member per month, or approximately 18%. We saw a decrease in medical spending ($195.0; P = .023) but did not detect a change in pharmacy spending ($7.59; P = .752). We found no evidence of changes in spending patterns prior to ZDC enrollment. CONCLUSIONS: The ZDC program provides evidence that value-based insurance designs that incorporate a comprehensive set of medications and focus on populations with chronic disease can reduce spending.

Effect of a Virtual Pharmacy Review Program: A Population Health Case Study.

INTRODUCTION: The growing emphasis on value-based health care has created a need for innovative population health management strategies. Pharmacists are underused resources for implementation of meaningful population health models that ensure appropriate medication use through optimization of electronic medical record (EMR) technology and pharmacist knowledge. The objective of our program was to improve the health outcomes of a patient population with diabetes while also reducing costs. PROGRAM DESCRIPTION: A virtual pharmacy review (ViPRx) program was used to remotely provide previsit comprehensive medication reviews for patients in the defined population. The pharmacist used the EMR to review medications and relevant histories and to intervene when needed to ensure appropriate medication use. Pharmacist recommendations and supporting statements were delivered to the provider's EMR in-box 1-2 days before a scheduled visit. The information technology resources and virtual model allow the pharmacist to manage patient care and collaborate with providers electronically across multiple clinic locations. OBSERVATIONS: The pharmacist managed a panel of over 700 patients in this virtual model. The program has yielded improvements in key diabetes metrics. Most notable is a 6% increase in the percentage of patients with a hemoglobin A1c (HbA1c) value of 9% or less and a 7% improvement in the controlled low-density lipoprotein (LDL) measure. Monitoring parameters (nephropathy screening, HbA1c, and LDL) increased by 8%-12% from baseline. Additional positive outcomes include improved medication adherence in the defined population as seen by a 1.5% improvement in medication possession ratio for diabetes medications. Reductions in per member per month (PMPM) prescription costs are estimated at $11 per month through discontinuation of unnecessary and duplicate medications. IMPLICATIONS: The results of this case study on the effect of a virtual pharmacy review program demonstrate an opportunity for pharmacists to engage in a population health management model that improves patient outcomes and may reduce the rate at which PMPM prescription drug costs increase. DISCLOSURES: No outside funding supported this work. The authors have no conflicts of interest to disclose. This work was presented at the 2017 Vizient Connections Summit; April 6, 2017; Las Vegas, NV, and the 2018 Cerner Health Conference; October 10, 2018; Kansas City, MO.

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures.

OBJECTIVES: Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN: A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING: Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS: Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS: Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS: Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00). CONCLUSION: Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

Regulatory, Policy, and Operational Considerations for Outcomes-Based Risk-Sharing Agreements in the U.S. Market: Opportunities for Reform.

BACKGROUND: Although interest in outcomes-based risk-sharing agreements (OBRSAs) and other value-based contracts (VBCs) continues to grow, the number of VBCs in the United States is still limited. A better understanding of the evolving and fluid context of policies, regulations, and operational factors affecting their uptake in the United States is needed in order to lower or obviate barriers and advance OBRSAs. OBJECTIVES: To (a) identify and recognize priorities among policies, regulations, and other factors that are most likely to influence the feasibility, design, and execution of OBRSAs and (b) suggest opportunities for reform and other modifications that may advance OBRSAs in the United States. METHODS: Across 18 months during 2017-2018, we reviewed health policy literature, examined stakeholder group communications, and conducted semistructured interviews with representatives of 12 diverse stakeholder organizations. Across these, and incorporating real-time contextual changes, we identified priorities for enabling and improving OBRSAs. RESULTS: Regulatory and policy priorities most often cited by manufacturers were Medicaid best price rule, Medicare Part B average sales pricing, FDA restrictions on communications, and the Anti-Kickback Statute. While recognizing these, health plans were more concerned about operational barriers, particularly associated with data collection and analysis, selection of outcomes that are feasible to assess, bandwidth for managing OBRSAs, and implementation costs relative to return on investment. Most recognized limitations on access to personal health information, target population turnover, and insufficient information sharing of OBRSA experiences. Noteworthy were asymmetries of administrative burden and cost management: individual manufacturers may pursue OBRSAs for 1 or a few products per year, while health plans are approached by multiple manufacturers about OBRSAs for their respective products; manufacturers focus on drugs, while health plans must manage broader costs of care. CONCLUSIONS: While all stakeholders express interest in OBRSAs, health plans tend to consider them as a narrower priority than manufacturers. Solving operational barriers, in addition to addressing policy and regulatory barriers, is essential for aligning efforts to advance OBRSAs. Doing so depends on collaboration to improve decisions about when and how to pursue OBRSAs, with attention to data management, modeling and piloting OBRSAs, and information sharing. These findings pertain to companies operating in the United States and some likely extend to certain value-based arrangements in other countries. DISCLOSURES: This analysis was funded by Merck Sharp & Dohme (MSD), a subsidiary of Merck, as a component of the Learning Laboratory for Advancing Value-Based Healthcare, which is a multiyear collaboration of MSD and Optum, a health services, technology, and data company. The manuscript underwent an internal review by the sponsor. The Lewin Group (Lewin) is a subsidiary of OptumServe. OptumServe is wholly owned by UnitedHealth Group (UHG). Neither OptumServe nor UHG or its subsidiaries review the work products of Lewin. Lewin operates with editorial independence and provides its clients with health care and human services policy research and consulting services. Goodman and Villarivera are employees of Lewin; Gregor is an employee of Optum; and van Bavel is an employee of MSD. Goodman and Villarivera report fees from UHG, unrelated to this study. A poster presentation based on this manuscript was accepted and presented at the ISPOR Europe 2018 Conference in Barcelona, Spain, on November 13, 2018.

Understanding public health insurance in India: A design perspective.

It is broadly accepted that health policy is crucially affected by contextual conditions. Yet, little is known about how the context limits the effectiveness of public health insurance (PHI) programs and the extent to which these limitations could be overcome. The objective of the paper is to address these issues on the basis of the examination of 17 PHI schemes introduced by federal and state governments in India since independence. Faced with the challenge of simultaneously expanding insurance coverage while containing costs, governments have overwhelmingly favored the latter. At the same time, governments have lacked the capacity to monitor performance, which has led providers to compromise quality in return for low payment rates. While there have been modest improvements in recent years, reform efforts have been hindered by contextual conditions that constrain the use of measures to control profiteering by for-profit agencies. The paper argues that system-wide data on the quality of providers (system-level operational capacity) and the ability of public agencies to monitor quality and link it with payment (organizational-level operational capacity) critically determined the program effectiveness. We demonstrate the interaction between contextual variables, program design elements, and policy capacity linking to performance, arguing for a broader approach to understand PHI performance. We extend the present frameworks on PHI effectiveness that have narrowly focused on the design of health financing functions without factoring unfavorable context and limited policy capacity in developing countries. The paper contributes to improving PHI performance operating in unfavorable contextual conditions in India and elsewhere.

Insurers' perspectives on MA value-based insurance design model.

OBJECTIVES: Value-based insurance design (VBID) lowers cost sharing for high-value healthcare services that are clinically beneficial to patients with certain conditions. In 2017, the Center for Medicare and Medicaid Innovation began a voluntary VBID model test in Medicare Advantage (MA). This article describes insurers' perspectives on the MA VBID model, explores perceived barriers to joining this model, and describes ways to address participation barriers. STUDY DESIGN: A descriptive, qualitative study. METHODS: In spring/summer 2017, we conducted semistructured interviews with 24 representatives of 10 nonparticipating MA insurers to learn why they did not join the model test. We interviewed 73 representatives of 8 VBID-participating insurers about their participation decisions and implementation experiences. All interview data were analyzed thematically. RESULTS: Fewer than 30% of eligible insurers participated in the first 2 years of the model test. The main barriers to entry were a perceived lack of information on VBID in MA, an expectation of low return on investment, concerns over administrative and information technology (IT) hurdles, and model design parameters. Most VBID participants encountered administrative and IT hurdles but overcame them. CMS made changes to the model parameters to increase the uptake. CONCLUSIONS: The model uptake was low, and implementation challenges and concerns over VBID effectiveness in the Medicare population were important factors in participation decisions. To increase uptake, CMS could consider providing in-kind implementation assistance to model participants. Nonparticipants may want to incorporate lessons learned from current participants, and insurers should engage their IT departments/vendors early on.

Evaluation of value-based insurance design for primary care.

OBJECTIVES: To evaluate the impact of value-based insurance design (VBID), which removed patient cost sharing for primary care visits, on healthcare spending in a large, geographically diverse employer. STUDY DESIGN: Quasi-experimental, difference-in-differences (DID) design, administrative claims-based study. METHODS: Healthcare spending during the preintervention period (2008 and 2009) was compared with the postintervention period (2011 through 2014) to measure the impact of removing primary care cost sharing. The study population included Anthem commercially insured enrollees with continuous medical eligibility from 2008 to 2014 who were younger than 65 years. The VBID cohort included health plan enrollees from a national large employer that implemented the benefit change. The comparison cohort included other Anthem enrollees who did not have a similar benefit change and were propensity score-matched to the VBID cohort. Utilization of various types of healthcare services was also examined. RESULTS: The VBID cohort experienced a $12.0 per member per month relative reduction in overall spending compared with the comparison cohort (P = .02). The trend was driven by reductions in expenditures for emergency department (ED) visits ($1.3 relative reduction; DID, -10.0%; P = .03) and other outpatient services ($7.6 relative reduction; DID, -5.8%; P = .02), which aligned with reduced utilization of ED visits (DID, -4.5%; P = .07) and other outpatient services (DID, -4.1%; P = .004). For physician office visits, the VBID cohort did not experience a significant relative increase compared with the comparison cohort (DID, 0.9%; P = .25). CONCLUSIONS: The attempt to increase primary care access by reducing cost sharing did not produce a negative outcome in terms of total spending for healthcare.

AMCP Partnership Forum: Integrated Delivery Networks' Role in Pharmaceutical Value-Based Agreements.

Health care payment models that reward value over volume have the potential to improve patient care and control rising costs. These payment models are increasingly being implemented by a range of care delivery providers in the United States. Integrated delivery networks (IDNs)-systems of providers and sites (e.g., group practices and hospitals) that care for and provide health care services and health insurance plans to patients in a specific region or market-present special opportunities and challenges for value-based care and represent an important sector for the advancement of value-based models. Successful implementation of value-based agreements in IDNs requires a range of complex capabilities, including advanced data analytics, population health management solutions, comprehensive care management, and successful patient engagement. To address these and other operational issues, the Academy of Managed Care Pharmacy convened a stakeholder forum on November 13-14, 2018, in Baltimore, MD. Forum attendees addressed topics including (a) the current delivery of value-based care in IDNs; (b) opportunities and barriers to implementing pharmaceutical value-based agreements; (c) recommendations for IDNs to reach the full potential of value-based agreements; and (d) opportunities for collaborations among managed care organizations, accountable care organizations, and IDNs to improve health care outcomes. Thought leaders with a wide range of backgrounds attended the forum, including those representing patients, payers, providers, government, and biopharmaceutical companies. The forum was sponsored by Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Genentech, Lilly, MedImpact, Merck, National Pharmaceutical Council, Novo Nordisk, Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda. This proceedings document presents common themes and comments from individual participants at the forum, which are not necessarily endorsed by all attendees, nor should they be construed to reflect group consensus. DISCLOSURES: This AMCP Partnership Forum and the development of this proceedings document were supported by Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Genentech, Lilly, MedImpact, Merck, National Pharmaceutical Council, Novo Nordisk, Pharmaceutical Research and Manufacturers of America, Takeda, and Xcenda.

Consumers' Perceptions And Choices Related To Three Value-Based Insurance Design Approaches.

The burden of rising health care costs is being shifted to consumers, and 30 percent of health care costs are attributed to wasteful spending on low- or no-value services. Value-based insurance design (VBID) is intended to encourage the use of high-value services or discourage the use of low-value services by aligning cost with quality. During the summer and fall of 2016, this mixed-methods study used focus groups and a quantitative analysis of survey data to explore consumer decision making in Northern California. When presented with three common VBID approaches, the focus groups favored value-based benefit design the most (41 percent), followed by reference pricing (28 percent) and narrow networks (21 percent). When presented with VBID scenarios, participants were skeptical of the value-based trade-offs and reported seeking information they wanted instead of relying on information that health plans provide. Engaging consumers to successfully reduce waste through VBID will require clarifying trade-offs to support consumers' processes for arriving at high-value decisions as well as reaching out to consumers through trusted sources and networks.

Are value-based incentives driving behavior change to improve value?

OBJECTIVES: To understand physician organization (PO) responses to financial incentives for quality and total cost of care among POs that were exposed to a statewide multipayer value-based payment (VBP) program, and to identify challenges that POs face in advancing the goals of VBP. STUDY DESIGN: Semistructured qualitative interviews and survey. METHODS: We drew a stratified random sample of 40 multispecialty California POs (25% of the POs that were eligible for incentives). In-person interviews were conducted with physician leaders and a survey was administered on actions being taken to reduce costs and redesign care and to discuss the challenges to improving value. We performed a thematic analysis of interview transcripts to identify common actions taken and challenges to reducing costs. RESULTS: VBP helps to promote care delivery transformation among POs, although efforts varied across organizations. Investments are occurring primarily in strategies to control hospital costs and redesign primary care, particularly for chronically ill patients; specialty care redesign is largely absent. Physician payment incentives for value remain small relative to total compensation, with continued emphasis on productivity. Challenges cited include the lack of a single enterprisewide electronic health records platform for information exchange, limited ability to influence specialists who were not exclusive to the organization, lack of payer cost and utilization data to manage costs, inability to recoup care redesign investments given the small size of VBP incentives, and lack of physician cost awareness. CONCLUSIONS: Transformation could be advanced by strengthening financial incentives for value; engaging specialists in care redesign and delivering value; enhancing partnerships among POs, hospitals, and payers to align quality and cost actions; strengthening information exchange across providers; and applying other strategies to influence physician behavior.

Evolving Changes in the Delivery of Health Services: A Place for Urological Homecare?

The ongoing pressure to improve quality while reducing costs is leading to increased uptake of various urological homecare models. Urological homecare can involve reductions in hospital usage and costs, traveling time for the patient, and hospital deaths and can improve patient experience and satisfaction.

Atención en salud basada en el valor: retos y oportunidades / Value-based health care: challenges and opportunities / Assistência médica baseada em valor: desafios e oportunidades

La atención en Salud Basada en el Valor es un modelo de atención re-ciente, innovador, dirigido a garantizar mejores resultados en salud para la población atendida, paralelo a un uso óptimo de los recursos. Para su implementación, dicho modelo propone una serie de principios, los cua-les son analizados dentro del presente documento. Para esto, se tiene en cuenta no sólo sus características fundamentales, sino también, su facti-bilidad, posibles barreras y oportunidades. Los principios revisados son: unidades integradas de atención, medición de resultados en salud y cos-tos, plataformas tecnológicas, modelos de pago centrados en la atención, sistemas integrados de atención y expansión geográfica. Adicionalmente, se incluyen la atención centrado en el paciente y el trabajo en equipo co-mo componentes fundamentales de este modelo también

Value-based Health Care is a recent, innovative delivering healthcare model which has emerged as a cost-effective alter-native to provide superior health outcomes for patients while decreasing inefficiencies in the system. For its successful im-plementation this model provides a set of principles which are revised in the present article, providing insights on their feasibility, challenges and opportunities. The principles revised here are: Integrated Practice Units, Health Outcomes and Cost Measurement, Value-based Payments, enabling health systems platforms, and efficient allocation of resources. Along with the-se, a person-centered approach and stakeholders' participation and engagement have been also revised as key components of the model.

A assistência médica baseada em valor é um modelo de assis-tência inovador que visa garantir melhores resultados de saúde para a população atendida e o uso ideal dos recursos. Para sua implementação, propõe-se uma série de princípios anali-sados neste documento, uma análise na qual são levadas em consideração as características fundamentais, viabilidade, pos-síveis barreiras e oportunidades que esse modelo pode gerar. Os princípios revisados são: unidades de atendimento integra-das, mensuração de resultados de saúde e custo, plataformas tecnológicas, modelos de pagamento focados na geração de valor, sistemas / redes de atendimento integrados e expansão geográfica. Além disso, o atendimento centrado no paciente e o trabalho em equipe são incluídos como componentes funda-mentais deste modelo.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State.

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.

Shifting to Value-Based Principles in Sickness Insurance: Challenges in Changing Roles and Culture.

Purpose Management principles in insurance agencies influence how benefits are administered, and how return to work processes for clients are managed and supported. This study analyses a change in managerial principles within the Swedish Sickness Insurance Agency, and how this has influenced the role of insurance officials in relation to discretion and accountability, and their relationship to clients. Methods The study is based on a qualitative approach comprising 57 interviews with officials and managers in four insurance offices. Results The reforms have led to a change in how public and professional accountability is defined, where the focus is shifted from routines and performance measurements toward professional discretion and the quality of encounters. However, the results show how these changes are interpreted differently across different layers of the organization, where New Public Management principles prevail in how line managers give feedback on and reward the work of officials. Conclusions The study illustrates how the introduction of new principles to promote officials' discretion does not easily bypass longstanding management strategies, in this case managing accountability through top-down performance measures. The study points out the importance for public organizations to reconcile new organizational principles with the current organizational culture and how this is manifested through managerial styles, which may be resistant to change. Promoting client-oriented and value-driven approaches in client work hence needs to acknowledge the importance of organizational culture, and to secure that changes are reflected in organizational procedures and routines.