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In countries where GPs fulfill a central role in the health care system, like in the Netherlands, the lack of value-based incentives in GP payment systems may have negative consequences for value delivered in other parts of the health care spectrum. We evaluate an experiment in which GPs were allowed to share in savings in total health care expenditures, conditionally on achieving quality targets. At least in theory, these so-called 'shared savings contracts' incentivize GPs to become critical gatekeepers, coordinate the provision of care and substitute for specialist services when appropriate. This study evaluates a Dutch shared savings program targeted at GPs. This study employs a difference-in-differences design using a regional control group of non-participating GPs. We find that program participation led to savings in health care expenditures (-2%), while patient satisfaction was unaffected and while the results for other quality indicators were ambiguous. Additional analyses show that savings have been predominantly realized by lowering the volume of specialist care, and that almost every participating GP displayed cost-saving behavior. This finding suggests that shared savings contracts, even when added as a mere complemented to existing volume-based payment models, already elicit substantive effort to increase the value of health care provided.(c) 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).In countries where GPs fulfill a central role in the health care system, like in the Netherlands, the lack of value-based incentives in GP payment systems may have negative consequences for value delivered in other parts of the health care spectrum. We evaluate an experiment in which GPs were allowed to share in savings in total health care expenditures, conditionally on achieving quality targets. At least in theory, these so-called ?shared savings contracts? incentivize GPs to become critical gatekeepers, coordinate the provision of care and substitute for specialist services when appropriate. This study evaluates a Dutch shared savings program targeted at GPs. This study employs a difference-in-differences design using a regional control group of non-participating GPs. We find that program participation led to savings in health care expenditures (-2%), while patient satisfaction was unaffected and while the results for other quality indicators were ambiguous. Additional analyses show that savings have been predominantly realized by lowering the volume of specialist care, and that almost every participating GP displayed cost-saving behavior. This finding suggests that shared savings contracts, even when added as a mere complemented to existing volume-based payment models, already elicit substantive effort to increase the value of health care provided. ? 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license

Bundled payment models may lead to selection of healthier total joint arthroplasty (TJA) candidates resulting in comorbid patients being taken care of in fewer hospitals. We aimed to (1) evaluate hospital-specific TJA comorbidity burden ("casemix") over time and (2) associations with resource utilization.This retrospective cohort study used 2011 and 2016 New York State data (n = 36,078 hip/knee arthroplasties). Comorbidity burden was estimated by the Charlson-Deyo Index; main outcomes were hospitalization cost and nonhome discharge. Hospitals were categorized into those with a decreased, stable (with a 5% buffer), or increased percentage of comorbidity-free patients (Charlson-Deyo = 0) between 2011 and 2016. Mixed-effects models measured the association between Charlson-Deyo Index category and outcomes, by hospital casemix categorization. Odds ratios and 95% confidence intervals (CIs) are reported.Overall, 29 (n = 8810), 37 (n = 16,297), and 46 (n = 10,971) hospitals were categorized into the decreased, stable, and increased Charlson-Deyo = 0 categories, respectively, with median annual TJA volumes of 499, 814, and 393 (P.0001). Multivariable models demonstrated that-in hospitals with a stable patient casemix-increased patient comorbidity was associated with increased hospitalization costs (maximum 21.8%, CI 18.9-24.9, P.0001). However, this effect was moderated (maximum 11.1%, CI 8.0-14.2) in hospitals that took on a more comorbid patient casemix. Similar patterns were observed for nonhome discharge.Most studied hospitals show an increase in comorbidity-free TJA patients, suggestive of patient selection. This redistribution of comorbid patients to select hospitals may not necessarily be a negative development as our results suggest more efficient resource utilization for comorbid patients in such hospitals.

Objective To evaluate the 2019 Medicare Physician Fee Schedule, which modifies reimbursement for office evaluation and management (E&M) visits. This policy moves payment to a single rate for levels 2 through 4 office E&M visits, regardless of complexity. Methods Using a 20% sample of 2015 National Medicare claims, we identified urologic practices and their practice organization, academic affiliation, and degree of office focus (ie, proportion of revenues from office visits). Using billing data for each practice, we calculated the revenues expected under the current system and the new policy (both E&M payments and a new add-on code). For each practice, we determined the impact of new payment rates on total Medicare payments. Results We identified 2822 practices: 1372 (48.6%) solo practices, 1033 (36.6%) multispecialty groups, 322 (11.4%) small urology groups, and 95 (3.4%) large urology groups. Under the new reimbursement rates, the median practice would have a 0.9% increase in Medicare Part B payments (range −20.4% to +50.3%) and, with the add-on code, an increase of 6.8% (range −7.5% to +74.9%). Solo practices had the most heterogeneity, with a quarter losing at least 2.3%. The median multispecialty group would increase payments by 0.4% (range −13.7% to 50.3%). However, the 107 (10.4%) academic multispecialty groups had a median gain of only 0.1% (range −2.8% to +8.1%). Conclusion Urology groups would, on average, benefit from the anticipated change in Medicare office E&M visit payments. However, solo practices with a high office focus and academic multispecialty practices may see reduced Medicare payments.

Rising healthcare costs and increasing evidence of variation in quality of healthcare have spurred payment reform initiatives that tie reimbursement to the quality of care provided. Success in these initiatives will require identification of valid and reliable measures of quality and rigorous evaluation of the effects of payment reform implementation on these quality metrics. Despite the support and investment in quality improvement through payment reform, results of these improvement initiatives have been mixed. Providers and researchers must remain invested in the development, evaluation, and selection of quality measures for healthcare policy reform.

Objective This study aims to document 6- and 12-month removal rates for women receiving the contraceptive implant inpatient postpartum versus those receiving the same contraceptive method during an outpatient visit, in a setting where postpartum inpatient long-acting reversible contraceptive (LARC) services (devices plus provider insertion costs) are reimbursed by Medicaid. Study design We conducted a retrospective cohort study among Medicaid-enrolled women using medical record review for all women receiving the etonogestrel implant between July 1, 2007 and June 30, 2014. We compared the percentage of women with the implant removed at 6 and 12 months as well as reasons for early removal, for inpatient postpartum implant insertions vs. delayed postpartum or interval outpatient implant insertions. Results A total of 4% of women (34/776 insertions) had documented implant removal within 6 months post-insertion, with no difference between postpartum inpatient and outpatient (delayed postpartum or interval). A total of 12% (62/518 insertions) of women had documented implant removal within 12 months. A lower percentage of women with postpartum inpatient insertions had the implant removed at 12 months post-insertion, compared to outpatient insertions (7% vs. 14%, p=.04). After controlling for age, parity, race and body mass index, women with postpartum inpatient insertions were less likely to have the implant removed within 12 months (OR=0.44, 95% CI 0.20–0.97). The most commonly stated reason for removal was abnormal uterine bleeding, regardless of insertion timing. Conclusion In a setting with a Medicaid policy that covers postpartum inpatient LARC insertion, a low percentage of women who received an implant immediately postpartum had it removed within 1 year of insertion. Implications A Medicaid payment policy that removes institutional barriers to offering postpartum inpatient contraceptive implants to women free-of-charge may facilitate meeting women's desires and intentions to delay subsequent pregnancy, as evidenced by low removal rates up to 12 months post-insertion. Further research with women is needed to assess how these services meet their postpartum contraceptive needs and desires to postpone or prevent subsequent pregnancy.

Radiology faces at least three major, potentially fatal, threats. First, as care moves out of the hospital, there will be a decrease in demand for imaging. More care in patients' homes and in other nonhospital settings means fewer medical tests, including imaging. Second, payment reform and, in particular, bundled payments and capitation mean that imaging will become a cost rather than a profit center. These shifts in provider payment will decrease the demand for imaging and disrupt the practice of radiology. Potentially, the ultimate threat to radiology is machine learning. Machine learning will become a powerful force in radiology in the next 5 to 10 years and could end radiology as a thriving specialty.

Alternative payment models are proliferating and are being viewed by many as a likely path for improvement in the cost structure of health care delivery. Despite the promise to reduce the increase in spending for government and other payers, of equal importance is the impact on patient outcomes and experience. As data accumulates to address this question, it is critical that developers of such payment models follow key principles that are designed to ensure that such a significant alteration in the payment structures turn out to be beneficial for the recipients of care. Payment reform that results in improvements in factors important to patients are likely to prove durable, whereas those that threaten patient access or experience are not likely to stand.

Healthcare delivery system reform has become a dominant topic of conversation throughout the United States. Driven in part by ever-higher national expenditures on health, an increasing number of payers and provider organizations are working to reduce the costs and improve the quality of healthcare. In this article, we demystify the term "Population Health," review some of the larger payer initiatives currently in effect and discuss specific provider group efforts to improve the quality and cost of healthcare for patients.

[Figure][1] It goes without saying that the existing modus operandi and the trajectory of escalating health care costs are untenable. Evidently, much is still lacking within our system in the United States, pertinent to the quality of care we give, the efficiency in its delivery, and the

ACC Members Show High Level of Satisfaction American College of Cardiology (ACC) members remain satisfied with the organization and its goals of transforming cardiovascular care and helping members thrive in any delivery or reimbursement environment. They are likely to recommend the College to

Mergers and acquisitions are happening in almost every industry. Health care is not immune. With the advent of health care payment reform, it is important that hospitals increase market share, consider population health, and widen the continuum of care. Despite the fact that the terms are often colloquially used interchangeably, mergers are significantly different from acquisitions in their organizational structure but may have similar effects on the participants.

To help support implementation of aligning clinical redesign with payment reforms in practices and institutions throughout the country, we present two cases from Duke University Health System (“Duke”) and University of Colorado Hospital (“Colorado”). The studies provide practical solutions for not only implementing clinical redesign, but also an understanding of how those clinical innovations can be aligned with alternative payment models. The cases will explore the following questions: What challenges or problems encouraged the organization to redesign CHF care? How did the organization select and then align care innovations with payment reforms, including bundled payments and shared savings? What did the organization identify as key success factors and/or challenges? How did these changes impact the organization׳s clinical outcomes or financial position? Finally, what lessons would the organization share with others attempting to implement similar strategies?

Although accountable care organizations (ACOs) are rapidly being deployed in Medicare, little is known about how the model might affect high-risk, high cost groups such as cancer patients. The Physician Group Practice Demonstration, which ran from 2005 to 2010 in 10 physician groups, provides the best current evidence on the likely effectiveness of accountable care organizations for Medicare beneficiaries. Changes in cancer treatment and spending under this program may be indicative of cancer treatment under ACO payment reform.Using Medicare fee-for-service claims data, regression analysis was used to estimate changes in payments for cancer patients using a difference-in-difference design comparing pre- (2001-2004) and post-intervention (2005-2009) trends in spending on cancer patients in PGPD participants to local control groups.Regression models indicate the Physician Group Practice Demonstration was associated with average Medicare spending reductions per cancer patient of $721 annually across participating sites, an annual 3.9% reduction in payments per patient. Savings derived entirely from reductions in acute care payments for inpatient stays. The Demonstration was also associated with a reduction in mortality among cancer patients. There was no significant change in the proportion of deaths occurring in the hospital. There were significant reductions in hospice use, hospital discharges and ICU days, but no reductions in cancer-specific procedures or chemotherapy. Estimates of all measures varied considerably across participating sites.The Physician Group Practice Demonstration was associated with reductions in admissions for inpatient care among beneficiaries with prevalent cancer, with no adverse effect on mortality. Participants in the Physician Group Practice Demonstration did not change the trajectory of spending for cancer-specific treatments.Inpatient care for beneficiaries with cancer may represent a significant source of potential savings for ACOs, but evidence from the Physician Group Practice Demonstration indicates that no changes were made to cancer treatments such as chemotherapy or surgical procedures.

In this issue of Annals, Gabayan et al explore the relationship between measures of emergency department (ED) crowding and 2 outcomes: inpatient admission and death. Examining more than 600,000 discharged patients across a dozen EDs in the Kaiser system in California, they found that no ED crowding measures were associated with 7-day mortality, a rare outcome (0.05%). However, 2 of 6 measures of crowding, the evaluation time and ED length of stay, were associated with nearly 4 times higher risk of return and hospital admission with 7 days. To explain the findings, they reasoned that discharged patients evaluated for longer periods had more complex conditions and may be more likely to require later inpatient care. ED crowding alone did not appear to be harmful. Together, this led the authors to cast doubt on the validity of using ED crowding measures as indicators of quality for discharged patients. During the past decade, the ED crowding literature advanced considerably; similarly, but more recently, priorities of US health care policy have evolved rapidly, particularly with the Patient Protection and Affordable Care Act insurance reforms and focus on cost containment. In 2006, the Institute of Medicine released 3 reports that together painted a picture of a broken emergency care system. One report, Hospital-Based Emergency Care: At the Breaking Point, described ED care as crowded, fragmented, and underfunded, bursting at the seams from 2 decades of year-after-year visit increases that outpaced population growth superimposed on shrinking numbers of EDs. Increased volumes were accompanied by greater ED care intensity: more computed tomography use, more laboratory testing, and greater expectations that every test should be completed in the ED before hospital admission. Despite a stream of new sick patients, ED patients destined for admission often sat in a logjam—boarding—awaiting scarce hospital beds. As a result, ED boarders overwhelmed ED resources, causing new sick and injured patients to wait

The costs of breast cancer care are substantial and growing, and they extend across the spectrum of care. Medical therapies and hospitalizations account for a significant proportion of these costs. Cost-effectiveness analysis (CEA) is the preferred method for assessing the health benefits of medical interventions relative to their costs. Although many CEAs have been conducted for a wide range of breast cancer treatments, these analyses are not used routinely to guide coverage or utilization decisions in the United States. Currently, patients and providers may not consider costs when making most treatment decisions; this is likely to change as payment reform spreads.

Article-at-a-Glance Background A unique statewide multipayer initiative in Pennsylvania was undertaken to implement the Patient-Centered Medical Home (PCMH) guided by the Chronic Care Model (CCM) with diabetes as an initial target disease. This project represents the first broad-scale CCM implementation with payment reform across a diverse range of practice organizations and one of the largest PCMH multipayerinitiatives. Methods Practices implemented the CCM and PCMH through regional Breakthrough Series learning collaboratives, supported by Improving Performance in Practice (IPIP) practice coaches, with required monthly quality reporting enhanced by multipayer infrastructure payments. Some 105 practices, representing 382 primary care providers, were engaged in the four regional collaboratives. The practices from the Southeast region of Pennsylvania focused on diabetes patients (n = 10,016). Results During the first intervention year (May 2008–May 2009), all practices achieved at least Level 1 National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) recognition. There was significant improvement in the percentage of patients who had evidence-based complications screening and who were on therapies to reduce morbidity and mortality (statins, angiotensin-converting enzyme inhibitors). In addition, there were small but statistically significant improvements in key clinical parameters for blood pressure and cholesterol levels, with the greatest absolute improvement in the highest-risk patients. Conclusions Transforming primary care delivery through implementation of the PCMH and CCM supported by multipayer infrastructure payments holds significant promise to improve diabetes care.

To understand whether growth in prostate cancer spending is a result of selected use of expensive services or greater overall usage. Growth in prostate cancer spending continues to outpace that for overall health expenditures, garnering nearly $7 billion annually.We identified patients diagnosed with prostate cancer between January 1, 1992 and December 31, 2003 using Surveillance, Epidemiology, and End Results-Medicare data. Patients were sorted into 12 cohorts based on their diagnosis year. We price-adjusted and tallied all prostate cancer-related Medicare payments for the first 2 years after diagnosis. We characterized the impact of a service by quantifying its contribution to the variation of per capita spending over time. We further assessed whether leading services contributed to spending growth by price or usage.Per capita Medicare expenditures increased by 20% from $8933 to $10,734. Decreases in inpatient expenditures ($3499 to $1504, P value for trend.001) were offset by growth in physician spending ($3317-$6062, P value for trend.001). Androgen deprivation (41.6%) and radiation therapy (19.9%) accounted for the majority of spending growth through increases in quantity. Depending on the service, quantity, as opposed to price, was responsible for 59.0% to 76.4% of the observed spending growth.Medicare spending for prostate cancer care increased by 20% and was fueled by increasing usage of physician services, including androgen deprivation and radiation therapy. Payment reform and bolstering the evidence base can potentially improve the efficiency of prostate cancer care.

Many Medicaid programs and private health plans are implementing new models of maternity care reimbursement, and clinicians face mounting pressure to demonstrate high-quality care at a lower cost. Clinicians will be better prepared to meet these challenges with a fuller understanding of new payment models and the opportunities they present. We describe the structure of maternity care episode payments and recommend 4 ways that clinicians can prepare for success as value-based payment models are implemented: identify opportunities to improve outcomes and experience, measure quality, reduce waste, and work in teams across settings.

We analyze the effects of a largely ignored 1885 legislative reform in Massachusetts requiring that firms provide workers the option of receiving weekly wage payments. Using an inter-temporal model of deferred compensation, we derive conditions on elasticities of labor supply that determine the effects of the reform on workers’ effective wage and utility. We then examine empirically the effects of the reform, using weekly data on mill workers in Lowell. Given the implications of our theoretical analysis, the empirical findings of positive wage and reform elasticities imply that the switch to weekly payment increased workers’ effective wage and well-being.

Objectives Discuss thecharacteristicsof agood(orperhapswellintentioned but not so good) mentor and mentee. Identify potential mentors (and mentees) in your home environment and acquire skills beneficial in initiating and sustaining a mentor-mentee relationship. Discuss how mentoring enables one to better achieve academic, research, and personal goals. Mentoring is paramount for a successful career in research and academia. Indeed, mentored individuals publish more and with greater frequency, demonstrate higher job satisfaction, and are more likely to mature into independent investigators. Moreover, successful mentors often shape successful mentees; a 1977 study showed that more than 50% of US Nobel Prize recipients had Nobel laureates for mentors. But what are the components of ‘‘good’’ mentoring and the characteristics of a ‘‘good’’ mentor for a research and academic medicine career? When you are looking for a mentor or a mentee, what questions should you be asking and how should you go about the process? Are there circumstances to avoid or embrace? The initial speaker, Joann Bodurtha, will present evidence-based, expert-reviewed, and/or anecdotal data on what mentoring is, what makes for good (and bad) mentoring relationships, and how to approach finding a mentor. Also, as in good marriages, every good mentor-mentee relationship is successful in a unique way, and much can be learned from candid and honest discussion from exemplary mentor-mentee teams. Consequently, the bulk of the session will comprise a panel discussion with three all-star HPNA and AAHPM mentorsdAmy Abernethy, Betty Ferrell, and R. Sean Morrisondpaired with their menteesd Arif Kamal, Polly Mazanec, and Laura Gelfman. The panel members will each give a brief history of how their relationship started and evolved. Audience participation and questions will be an important part of the session. Demonstrating the importance of collaboration, the session will be moderated by the mentor-mentee pair of Thomas Smith and Rebecca Aslakson.

Background  Since National Health Insurance (NHI) Program being launched on March 1, 1995 in Taiwan, rapid population ageing, dramatic increases in the number of patients suffering from catastrophic diseases, and the incessant introduction of new medical technologies, pharmaceutical products and devices ,NHI program has faced a serious financial deficit in recent years.  The drug fees of NHI was about 4.4 billion USD in 2012, nearly 25% of total health insurance expenditure, and per capita was 204 USD. Over 16,000 drugs were listed in the Drug Fee Schedule, and the average growth rate on drug fees was 4.87% during 2000 to 2014.  The price was adjusted 8 times from 2000 to 2013.

Concern over rising health care costs has prompted dramatic reform in the United States health care financing system. The United States is moving from a period where providers determined prices into a period where payors set prices; and in certain locations into a period where prices are set by providers, and consumers choose among providers based on price and other factors. Also presented is an analysis of the interrelated events that brought about the changes. Among the factors are the oversupply of physicians and other providers the improvement of case-mix measures and other measures of hospital output, and the political climate toward payment reform. The paper concludes with specific lessons for other countries.