Patient-Centered Payment for Care of Chronic Conditions.

Current payment systems make it difficult for both specialists and primary care practices to provide all of the services needed by patients with chronic conditions. "Value-based payment" programs have failed to solve these problems. In a patient-centered payment system, there should be 4 separate payments designed specifically to support each of the phases of chronic condition care: (1) Diagnosis Payment, (2) Care Planning Payment, (3) Initial Condition Management Payment, and (4) Monthly Condition Management Payments. Physicians should be accountable for delivering evidence-based services to patients in each phase of care, and payment amounts should be higher for more complex patients.

Impact of Travel Time on Health Care Costs and Resource Use by Phase of Care for Older Patients With Cancer.

PURPOSE: Many community cancer clinics closed between 2008 and 2016, with additional closings potentially expected. Limited data exist on the impact of travel time on health care costs and resource use. METHODS: This retrospective cohort study (2012 to 2015) evaluated travel time to cancer care site for Medicare beneficiaries age 65 years or older in the southeastern United States. The primary outcome was Medicare spending by phase of care (ie, initial, survivorship, end of life). Secondary outcomes included patient cost responsibility and resource use measured by hospitalization rates, intensive care unit admissions, and chemotherapy-related hospitalization rates. Hierarchical linear models with patients clustered within cancer care site (CCS) were used to determine the effects of travel time on average monthly phase-specific Medicare spending and patient cost responsibility. RESULTS: Median travel time was 32 (interquartile range, 18-59) minutes for the 23,382 included Medicare beneficiaries, with 24% of patients traveling longer than 1 hour to their CCS. During the initial phase of care, Medicare spending was 14% higher and patient cost responsibility was 10% higher for patients traveling longer than 1 hour than those traveling 30 minutes or less. Hospitalization rates were 4% to 13% higher for patients traveling longer than 1 hour versus 30 minutes or less in the initial (61 v 54), survivorship (27 v 26), and end-of-life (310 v 286) phases of care (all P < .05). Most patients traveling longer than 1 hour were hospitalized at a local hospital rather than at their CCS, whereas the converse was true for patients traveling 30 minutes or less. CONCLUSION: As health care locations close, patients living farther from treatment sites may experience more limited access to care, and health care spending could increase for patients and Medicare.

Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing.

The Blueprint for Advancing High-Value Maternity Care Through Physiologic Childbearing charts an efficient pathway to a maternity care system that reliably enables all women and newborns to experience healthy physiologic processes around the time of birth, to the extent possible given their health needs and informed preferences. The authors are members of a multistakeholder, multidisciplinary National Advisory Council that collaborated to develop this document. This approach preventively addresses troubling trends in maternal and newborn outcomes and persistent racial and other disparities by mobilizing innate capacities for healthy childbearing processes and limiting use of consequential interventions. It provides more appropriate care to healthier, lower-risk women and newborns who often receive more specialized care, though such care may not be needed and may cause unintended harm. It also offers opportunities to improve the care, experience and outcomes of women with health challenges by fostering healthy perinatal physiologic processes whenever safely possible.

How alternative payment models in emergency medicine can benefit physicians, payers, and patients.

While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.

Making Value-Based Payment Work for Academic Health Centers.

Under fee-for-service payment systems, physicians and hospitals can be financially harmed by delivering higher-quality, more efficient care. The author describes how current "value-based purchasing" initiatives fail to address the underlying problems in fee-for-service payment and can be particularly problematic for academic health centers (AHCs). Bundled payments, warranties, and condition-based payments can correct the problems with fee-for-service payments and enable physicians and hospitals to redesign care delivery without causing financial problems for themselves. However, the author explains several specific actions that are needed to ensure that payment reforms can be a "win-win-win" for patients, purchasers, and AHCs: (1) disconnecting funding for teaching and research from payment for service delivery, (2) providing predictable payment for essential hospital services, (3) improving the quality and efficiency of care at AHCs, and (4) supporting collaborative relationships between AHCs and community providers by allowing each to focus on their unique strengths and by paying AHC specialists to assist community providers in diagnosis and treatment. With appropriate payment reforms and a commitment by AHCs to redesign care delivery, medical education, and research, AHCs could provide the leadership needed to improve care for patients, lower costs for health care purchasers, and maintain the financial viability of both AHCs and community providers.

From volume to value: better ways to pay for health care.

Payment systems for health care today are based on rewarding volume, not value for the money spent. Two proposed methods of payment, "episode-of-care payment" and "comprehensive care payment" (condition-adjusted capitation), could facilitate higher quality and lower cost by avoiding the problems of both fee-for-service payment and traditional capitation. The most appropriate payment systems for different types of patient conditions and some methods of addressing design and implementation issues are discussed. Although the new payment systems are desirable, many providers are not organized to accept or use them, so transitional approaches such as "virtual bundling," described in this paper, will be needed.