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To assist practices and institutions throughout the country in implementing clinical redesign supported by - and aligned with - payment reform, we present a case study of the New Mexico Cancer Center (NMCC) based on numerous stakeholder interviews, literature reviews, and a comprehensive site visit. This study explores the complex barriers oncologists face in improving the quality and outcomes of cancer care and reducing overall costs in a sustainable way. This case will explore the following questions: How did the NMCC redesign care to improve quality, enhance patient experience and results, and reduce costs? How can an organization demonstrate they are improving quality to enable new payment contracts that enable sustainability? Are alternative payment models sustainable for an independent, community oncology practice?, (Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.)

The Affordable Care Act supports the growth of accountable care organizations (ACOs) as a potentially powerful model for health care delivery and payment. The model focuses on primary care. However, surgeons and other specialists have a large role to play in caring for ACOs' patients. No studies have yet investigated the role of surgical care in the ACO model. Using case studies and a survey, we examined the early experience of fifty-nine Medicare-approved ACOs in providing surgical care. We found that ACOs have so far devoted little attention to surgical care. Instead, they have emphasized coordinating care for patients with chronic conditions and reducing unnecessary hospital readmissions and ED visits. In the years to come, ACOs will likely focus more on surgical care. Some ACOs have the ability to affect surgical practice patterns through referral pressures, but local market conditions may limit ACOs' abilities to alter surgeons' behavior. Policy makers, ACO administrators, and surgeons need to be aware of these trends because they have the potential to affect the surgical care provided to ACO patients as well as the success of ACOs themselves., (Project HOPE—The People-to-People Health Foundation, Inc.)

The Patient Protection and Affordable Care Act established a new public-private entity for comparative effectiveness research: the Patient-Centered Outcomes Research Institute. The institute is charged with identifying priorities, establishing an agenda, and carrying out comparative effectiveness research. The political process through which the institute was formalized greatly influenced its scope and charge, including the organization's goals, its unique private-public composition, and its funding. In this paper I highlight key moments and offer background and insights into what did and did not end up in the final legislation.

The journey of national health reform legislation from concept to President Barack Obama's desk was long and winding, but not without important guideposts. Core elements of Massachusetts' 2006 health reform--near-universal, affordable coverage; changes in the small-group and individual insurance markets; and an individual mandate to obtain insurance--provided a road map for policy makers charting national health reform. Our experience with the Massachusetts reform informed our work on the Senate Health, Education, Labor, and Pensions Committee in 2008 and 2009. We compare national and Massachusetts health reforms and analyze their implications for the future.

Fee-for-service payments encourage high-volume services rather than high-quality care. Alternative payment models (APMs) aim to realign financing to support high-value services. The 2 main components of gastroenterologic care, procedures and chronic care management, call for a range of APMs. The first step for gastroenterologists is to identify the most important conditions and opportunities to improve care and reduce waste that do not require financial support. We describe examples of delivery reforms and emerging APMs to accomplish these care improvements. A bundled payment for an episode of care, in which a provider is given a lump sum payment to cover the cost of services provided during the defined episode, can support better care for a discrete procedure such as a colonoscopy. Improved management of chronic conditions can be supported through a per-member, per-month (PMPM) payment to offer extended services and care coordination. For complex chronic conditions such as inflammatory bowel disease, in which the gastroenterologist is the principal care coordinator, the PMPM payment could be given to a gastroenterology medical home. For conditions in which the gastroenterologist acts primarily as a consultant for primary care, such as noncomplex gastroesophageal reflux or hepatitis C, a PMPM payment can support effective care coordination in a medical neighborhood delivery model. Each APM can be supplemented with a shared savings component. Gastroenterologists must engage with and be early leaders of these redesign discussions to be prepared for a time when APMs may be more prevalent and no longer voluntary. [ABSTRACT FROM AUTHOR]

Cancer care suffers from many of the well-known flaws in the American health care delivery system. Most of the care delivery shortfalls and inefficiencies can be tied, in part, back to payment systems that support high-cost procedures rather than focusing on assisting providers in improving the outcomes of individual patients and the value of care being delivered. We describe various new models of physician payment that can serve as a foundation for a shift away from the current reimbursement system for cancer care to support better outcomes and avoid preventable costs. These recent payment reforms include the implementation of clinical pathways, bundled or episodic payments, payments tied to quality improvements, and the patient-centered oncology medical home. We then describe how these reforms can be supported in a blended payment model that transitions away from, but still contains elements of, fee-for-service payments. [ABSTRACT FROM AUTHOR]

The authors comment on the passage of the medicare physician payment reform in the U.S. in 2013 aimed to avert the reduction in Medicare physician payment rates required by Medicare's sustainable growth rate (SGR) formula. They argue that one of the major challenge to the success of the reform legislation is whether effective alternative payment systems can be developed quickly. They added that one alternative is for Congress to implement a 5-year stabilization of physician payment rates.

The U.S. health care system too often falls short in delivering effective primary care, especially for patients with chronic conditions. One potential solution is the patient-centered medical home, a model that has shown success in individual demonstrations. Evidence from seven of the largest medical home pilots shows that four factors are essential: dedicated care managers; expanded access; perfonnance management tools; and effective incentive payments. Federal policy, including implementation of health insurance reform legislation, should consider how to include these core elements and offer guidance and incentives for executing them effectively. [ABSTRACT FROM AUTHOR]