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Hospitals account for about 40% of all healthcare expenditure in high-income countries and play a central role in healthcare provision. The ways in which they are paid, therefore, has major implications for the care they provide. However, our knowledge about reforms that have been made to the various payment schemes and their country-level effects is surprisingly thin. This study examined the uniquely comprehensive introduction of diagnosis-related groups (DRGs) in Germany, where DRGs function as the sole pricing, billing, and budgeting system for hospitals and almost exclusively determine hospital revenue. The introduction of DRGs, therefore, completely overhauled the previous system based on per diem rates, offering a unique opportunity for analysis. Using aggregate data from the Organisation for Economic Co-operation and Development and recent advances in econometrics, we analyzed how hospital activity and efficiency changed in response to the reform. We found that DRGs in Germany significantly increased hospital activity by around 20%. In contrast to earlier studies, we found that DRGs have not necessarily shortened the average length of stay., (© 2023. The Author(s).)

The Texas Medicaid Waiver, via the Delivery System Reform Incentive Payment (DSRIP) program, has provided a path for Texas to achieve the Triple Aim through its focus on a defined population at the project and system levels, and financial payment policy based on outcomes. Both iterations of the DSRIP program (Waiver 1.0 and 2.0) have helped define populations, created regional collaboration that sets the stage for a true integrator, and provided financial incentives for improving population health, enhancing patient experience, and controlling costs. The flexible design of project menus and measure bundles in DSRIP encouraged a variety of projects, numerous measures of success and (often) overlapping populations of individual served to achieve the ultimate goal of the Triple Aim. This research outlines the major features of Texas DSRIP and demonstrates the Medicaid Waiver effectively contributed to measurable improvements in health, suggesting Texas safety net providers are moving closer to Triple Aim achievement.

Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Health care in the United States is in the midst of a significant transformation from a "fee for service" to a "fee for value" based model. The Medicare Access and CHIP Reauthorization Act of 2015 has only accelerated this transition. Anticipating these reforms, the Society of Gynecologic Oncology developed the Future of Physician Payment Reform Task Force (PPRTF) in 2015 to develop strategies to ensure fair value based reimbursement policies for gynecologic cancer care. The PPRTF elected as a first task to develop an Alternative Payment Model for thesurgical management of low risk endometrial cancer. The history, rationale, and conceptual framework for the development of an Endometrial Cancer Alternative Payment Model are described in this white paper, as well as directions forfuture efforts., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Care coordination is generally viewed as a key to success for health systems seeking to adapt to a range of new value-based payment policies., Purpose: This study explores care coordination staffing in four health systems participating in new payment models, including Medicaid payment reform and Accountable Care Organizations., Methods: Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff at four health systems engaged in value-based contracts., Discussion: Each of the sites engaged in significant task shifting of low-complexity care coordination activities to licensed practical nurses, medical assistants, and other unlicensed personnel freeing up registered nurses and social workers for more complex patients. Few have care coordination experience, requiring a significant investment in on-the-job training., Conclusion: Payment reform is leading to a greater investment in the care coordination workforce. However, demonstrating the return on investment remains a challenge., (Copyright © 2017 Elsevier Inc. All rights reserved.)

This study explores nurses' work settings and educational preparation in the five years before passage of the Affordable Care Act (ACA) and five years after ACA passage, with the aim of identifying areas for nurse educators' attention. The study setting was one small state undergoing rapid transition away from fee-for-service service and thus provided the ideal laboratory to assess the impact of health reform on the nursing workforce. A secondary analysis of data gathered during relicensure compared the nursing workforce at an interval of one decade, with surveys in 2005 (n=4075; 65% response rate) and in 2015 (n=6723; 97% response rate). Findings demonstrated an increase in the proportion of nurses who reported working in ambulatory care and community settings (p=0.001). However, there was no associated decrease in the proportion of nurses who reported working in hospitals. Among respondents who reported employment in the ambulatory care/community settings in 2005, 34.3% had a BSN or higher, a proportion that increased to 41.2% in 2015 (p=0.010); nevertheless, the greatest proportional increase was among AD prepared nurses (34% to 48%). Although new nursing roles emerging as a result of health reform offer baccalaureate nurses the opportunity use the full complement of their knowledge and skills, these data suggest that BS prepared nurses are not fully accessing these opportunities. Implications for nursing education and further research are detailed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The U.S. health care system is currently experiencing profound change. Pressure to improve the quality of patient care and control costs have caused a rapid shift from traditional volume-driven fee-for-service reimbursement to value-based payment models. Under the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, providers will be evaluated on the basis of quality and cost efficiency and ultimately receive adjusted reimbursement as per their performance. Although current performance metrics do not incorporate patient-reported outcome measures (PROMs), many wonder whether and how PROMs will eventually fit into value-based payment reform. On November 17, 2016, the second annual Patient-Reported Outcomes in Healthcare Conference brought together international stakeholders across all health care disciplines to discuss the potential role of PROs in value-based health care reform. The purpose of this article was to summarize the findings from this conference in the context of recent literature and guidelines to inform implementation of PROs in value-based payment models. Recommendations for evaluating key perspectives and measurement goals are made to facilitate appropriate use of PROMs to best benefit and amplify the voice of our patients., (Copyright © 2017 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

The formulation of the triple aim responds to three problems facing the US health care system: high cost, low quality, and poor health status. The purpose of this article is to analyze the potential of the health care system to achieve the triple aim and, specifically, the attempt to improve population health by rewarding providers who contain costs. The first section of the article will consider the task of improving population health through the health care system. The second section of the article will discuss CMS's efforts to pay providers to achieve the triple aim, that is, to improve health care and population health while containing cost. These include Maryland's Global Revenue Budget model, bundled payments, and ACOs, and they highlight the extent to which this version of integration is underwritten by savings achieved by providers for the Medicare program. The conclusion section of the article will consider the politics of payment reform as social reform. It will address proposals that health care payers and providers lead in addressing the social contributors to ill health and urge payment reformers to appreciate more fully the politics and policies of other sectors and the dynamics of their inclusion in population health improvement., (Copyright © 2017 by Duke University Press.)

Policymakers are increasingly interested in reducing healthcare costs and inefficiencies through innovative payment strategies. These strategies may have heterogeneous impacts across geographic areas, potentially reducing or exacerbating geographic variation in healthcare spending. In this paper, we exploit a major payment reform for home health care to examine whether reductions in reimbursement lead to differential changes in treatment intensity and provider costs depending on the level of competition in a market. Using Medicare claims, we find that while providers in more competitive markets had higher average costs in the pre-reform period, these markets experienced larger proportional reductions in treatment intensity and costs after the reform relative to less competitive markets. This led to a convergence in spending across geographic areas. We find that much of the reduction in provider costs is driven by greater exit of "high-cost" providers in more competitive markets., (Copyright © 2017 Elsevier B.V. All rights reserved.)

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., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Policy makers and private health plans are expanding their efforts to implement new payment models that will encourage providers to improve quality and deliver health care more efficiently. Over the past five years, payment reforms have progressed faster in Massachusetts than in any other state. The reasons include a major effort by Blue Cross Blue Shield of Massachusetts to implement global payment, the presence of large integrated systems willing to take on financial risk, and a supportive state policy environment. By 2014, thirty-seven percent of Massachusetts's residents enrolled in health plans were covered under risk-based payment models tied to global budgets. But the expansion of payment reform in Massachusetts slowed between 2012 and 2015 because some commercial enrollment shifted from risk-based health maintenance organization products to fee-for-service preferred provider organization (PPO) plans, and the state Medicaid program fell short of its payment reform goals. Provider groups will not fully commit to population-based clinical models if they believe it will result in large reductions in fee-for-service revenue. The use of alternative payment models will accelerate in 2016 when Blue Cross begins implementing PPO payment reforms, but it is unknown how quickly other payers will follow. Massachusetts's experience illustrates the complexity of payment reform in pluralistic health care markets and the need for complementary efforts by public and private stakeholders., (Copyright © 2016 by Duke University Press.)

Health reform, post the passing of the Patient Protection and Affordable Care Act, has highlighted the need to better address critical issues such as primary care, behavioral health, and payment reform. Much of this need is subsequent to robust data showing the seemingly uncontrollable growth of healthcare costs, and the exacerbation of these costs for patients with comorbid behavioral health and medical conditions. There is increasing recognition that incorporating behavioral health in primary care leads to improved outcomes and better care. To address these problems, primary care will play critical roles across the healthcare system, especially in the delivery of behavioral health services. Psychologists are uniquely positioned to take advantage of this propitious moment and can help facilitate the integration of behavioral and primary care by developing competencies in integrated care, training a capable workforce, and advocating for integrated care as the status quo.

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., (Copyright © 2016 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

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.)

Context: In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States., Methods: As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice., Findings: The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment., Conclusions: From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments., (© 2014 Milbank Memorial Fund.)

Reforming China's public hospitals to curb widespread overtreatment and improve the quality and affordability of care has been the most challenging aspect of that nation's ambitious health reform, which began in 2009. This article describes a pilot project under way in several of China's provinces that combines payment reform with the implementation of evidence-based clinical pathways at a few hospitals serving rural areas. Results to date include reduced length-of-stay and prescription drug use and higher patient and provider satisfaction. These early results suggest that the pilot may be achieving its goals, which may have far-reaching and positive implications for China's ongoing reform.

Background: Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms.Methods: A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms.Results: The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform.Conclusion: The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions.Registration: The study was registered with the Open Science Framework. [ABSTRACT FROM AUTHOR]

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

Access to comprehensive dementia care is limited. Recent changes in billing for professional services, including new physician fee schedule codes, encourage clinicians to provide new services; however, current reimbursement does not cover costs for all needed elements of dementia care. The Payment Model for Comprehensive Dementia Care Conference convened more than 50 national experts from diverse perspectives to review promising strategies for payment reform including ways to accelerate their adoption. Recommendations for reform included payments for services to family caregivers; new research to determine success metrics; education for consumers, providers, and policymakers; and advancing a population health model approach to tier coverage based on risk and need within a health system.

The Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence‐based alternative payment models (APM) to improve health care quality and reduce costs, but its performance in achieving these goals has been mixed. In October 2021, CMMI released its Innovation Strategy Refresh to highlight challenges faced by payment models and suggest new strategic approaches for the upcoming decade. While a welcome recast of organizational goals, the Refresh leaves space for how CMMI will address persistent issues. These include how CMMI can best engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee‐for‐service framework that underlies much of Medicare reimbursement. This article provides guidance to CMMI's vision by examining challenges within CMMI's strategy for model building and offering solutions to mitigate these issues. These strategies include engaging beneficiaries in APM incentives, expanding operational flexibility to improve clinical behaviors (e.g., waivers), rectifying issues with conflicting model incentives, building voluntary short‐term and mandatory long‐term incentives to mitigate selection bias, and transitioning to an overriding population‐based model to constrain net costs. Policy PointsThe Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence‐based alternative payment models (APM) to improve care quality and reduce health care cost, but its performance in achieving these goals has been mixed.In October 2021, CMMI released a "strategic refresh" of its goals but left space for how persistent issues to model development would be addressed.We propose strategies to engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee‐for‐service framework that underlies much of Medicare reimbursement. [ABSTRACT FROM AUTHOR]

Context: A patient classification-based payment system called diagnosis-intervention packet (DIP) was piloted in a large city in southeast China in 2018. Objective: This study evaluates the impact of DIP payment reform on total costs, out-of-pocket (OOP) payments, length of stay (LOS), and quality of care in hospitalised patients of different age. Methods: An interrupted time series model was employed to examine the monthly trend changes of outcome variables before and after the DIP reform in adult patients, who were stratified into a younger (18–64 years) and an older group (≥ 65 years), further stratified into young-old (65–79 years) and oldest-old (≥ 80 years) groups. Results: The adjusted monthly trend of costs per case significantly increased in the older adults (0.5%, P = 0.002) and oldest-old group (0.6%, P = 0.015). The adjusted monthly trend of average LOS decreased in the younger and young-old groups (monthly slope change: -0.058 days, P = 0.035; -0.025 days, P = 0.024, respectively), and increased in the oldest-old group (monthly slope change: 0.107 days, P = 0.030) significantly. The changes of adjusted monthly trends of in-hospital mortality rate were not significant in all age groups. Conclusion: Implementation of the DIP payment reform associated with increase in total costs per case in the older and oldest-old groups, and reduction in LOS in the younger and young-old groups without deteriorating quality of care. [ABSTRACT FROM AUTHOR]

Policy PointsAs essential access points to primary care for almost 29 million US patients, of whom 47% are Medicaid enrollees, health centers are positioned to implement the population health management necessary in value‐based payment (VBP) contracts.Primary care payment reform requires multiple payment methodologies used together to provide flexibility to care providers, encourage investments in infrastructure and new services, and offer incentives for achieving better health outcomes.State policy and significant financial incentives from Medicaid agencies and Medicaid managed care plans will likely be required to increase health center participation in VBP, which is consistent with broader state efforts to expand investment in primary care. Context: Efforts are ongoing to advance value‐based payment (VBP), and health centers serve as essential access points to comprehensive primary care services for almost 29 million people in the United States. Therefore, it is important to assess the levels of health center participation in VBP, types of VBP contracts, characteristics of health centers participating in VBP, and variations in state policy environments that influence VBP participation. Methods: This mixed methods study combined qualitative research on state policy environments and health center participation in VBP with quantitative analysis of Uniform Data System and health center financial data in seven vanguard states: Oregon, Washington, California, Colorado, New York, Hawaii, and Kentucky. VBP contracts were classified into three layers: base payments being transformed from visit‐based to population‐based (Layer 1), infrastructure and care coordination payments (Layer 2), and performance incentive payments (Layer 3). Findings: Health centers in all seven states participated in Layer 2 and Layer 3 VBP, with VBP participation growing from 35% to 58% of all health centers in these states from 2013 to 2017. Among participating health centers, the average percentage of Medicaid revenue received as Layer 2 and Layer 3 VBP rose from 6.4% in 2013 to 9.1% in 2017. Oregon and Washington health centers participating in Layer 1 payment reforms received most of their Medicaid revenue in VBP. In 2017, VBP participation was associated with larger health center size in four states (P <.05), and higher average number of days cash on hand (P <.05) in three states. Conclusions: A multilayer payment model is useful for implementing and monitoring VBP adoption among health centers. State policy, financial incentives from Medicaid agencies and Medicaid managed plans, and health center–Medicaid collaboration under strong primary care association and health center leadership will likely be required to increase health center participation in VBP. [ABSTRACT FROM AUTHOR]

Inadequate treatment of multimorbidity is recognised as a major determinant of the effectiveness of healthcare and also of its inappropriate expenditures. However, current payment systems target, primarily, the treatment of single diseases, thus hindering integrated delivery of care for patients with multimorbidity (PwM). This review aims to assess the effects of targeted reforms of payment systems which could help attain a higher quality of care and reduce unnecessary healthcare utilisation. In June 2020, a search of Medline and EMBASE revealed 13 relevant articles. The most common payment models were the use of bundled payments (n = 4) and diagnosis-related group payments (n = 4). Except for an increase in hospital admissions (n = 3), no outcome showed unambiguous significant effects across more than one study. The two studies which focused explicitly on PwM showed a significant decrease in 30-day hospital readmissions. This, however, was not maintained after 60 days in one study. No general conclusion could be drawn on the effects of targeted payment reforms for PwM. Our findings suggest that reforms should be combined with more multifaceted healthcare delivery to address the complex patterns of healthcare use effectively. Thorough evaluations of targeted payment reforms are needed urgently to contribute to the body of evidence required. [ABSTRACT FROM AUTHOR]

The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p <.001), SIM Round 2 (4.7 vs. 7.0 capabilities, p <.001), and non-SIM (4.2 vs. 6.3 capabilities, p <.001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends. [ABSTRACT FROM AUTHOR]

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned. • Physicians depend on other hospital actors for pursuing value-based payment reform. • Payment reform prompts actors to assess flaws of current payment practices. • Current payment practices persist due to perceived lack of payment reform necessity. • It is important to look beyond the insurer–provider nexus during payment reform. [ABSTRACT FROM AUTHOR]

New alternative payment models aiming to limit preventable or wasteful spending while improving quality are well-suited for the seriously ill, who often receive expensive, fragmented care that does not account for their needs. Accountable Care Organizations in particular support innovative efforts to identify and transform care for this patient population. Improving model components like quality measurement and risk adjustment and building a diverse palliative care-trained workforce will accelerate progress by helping more organizations participate in serious illness models and develop capabilities to improve care. [ABSTRACT FROM AUTHOR]

Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice. • This study reveals three perspectives on payment reform in Dutch maternity care. • There is consensus across perspectives on the need for payment reform. • The perspectives differ in their focus on either outcomes, equality or collaboration. • Disagreement remains on the goal, conditions and desired design of the reform. • Co-creation from the start is crucial to facilitate trust and promote uptake of reform. [ABSTRACT FROM AUTHOR]

Objective: To describe trends in hospice social work visits in the last week of life before and after the introduction of the service intensity add-on (SIA) payment reform in 2016. Background: SIA was introduced to compensate hospices for the intensity of caring for individuals at the end of life; it is an hourly rate paid for registered nurse and social worker visits occurring during the last week of a beneficiary's life. Little is known about how hospices responded to this payment incentive. Design: This is a pre-post descriptive study. Setting/Subjects: Subjects were 2015–2016 hospices caring for Medicare beneficiaries. Results: We find a modest increase in social work visits in the last week of life from 2015 (pre-SIA) to 2016 (post-SIA). This modest increase masks significant variation based on organizational characteristics, such as size, facility type, and participation in payment demonstrations. Discussion: Our findings underscore the importance of examining both the overall impact of this type of policy and the change in distribution to identify whether change is being realized uniformly or is associated with certain types of organizations. A number of potential barriers exist to responding to policy incentives that may not be evenly felt across the hospice community. [ABSTRACT FROM AUTHOR]

States' role in payment as well as coverage will be subject to debate as the administration and the Congress decide how to address the Affordable Care Act (ACA) and otherwise reshape the nation's health policies. Acting as stewards of health care for the entire state population and stimulated by concern about rising costs and federal support under the ACA, the elected and administrative leaders of some states have been using their political influence and authority to improve their state's overall systems of care regardless of who pays the bill. In early 2015 we conducted on-site interviews with key stakeholders in five states to explore their strategies for payment and delivery reform. We found that despite these states' similar goals, differences in their statutory authority and purchasing power, along with their leaders' willingness to use them, significantly influence a state's ability to achieve reform objectives. We caution federal and state policy makers to recognize the reality that state leaders' political desire to exercise stewardship may not be enough to achieve it. [ABSTRACT FROM AUTHOR]

With the introduction of the Medicare Access and Children's Health Insurance Program Reauthorization Act, clinicians who are not eligible for an exemption must choose to participate in 1 of 2 new reimbursement models: the Merit-based Incentive Payment System or Alternative Payment Models (APMs). Although most dermatologists are expected to default into the Merit-based Incentive Payment System, some may have an interest in exploring APMs, which have associated financial incentives. However, for dermatologists interested in the APM pathway, there are currently no options other than joining a qualifying Accountable Care Organization, which make up only a small subset of Accountable Care Organizations overall. As a result, additional APMs relevant to dermatologists are needed to allow those interested in the APMs to explore this pathway. Fortunately, the Medicare Access and Children's Health Insurance Program Reauthorization Act establishes a process for new APMs to be approved and the creation of bundled payments for skin diseases may represent an opportunity to increase the number of APMs available to dermatologists. In this article, we will provide a detailed review of APMs under the Medicare Access and Children's Health Insurance Program Reauthorization Act and discuss the development and introduction of APMs as they pertain to dermatology. [ABSTRACT FROM AUTHOR]

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists. [ABSTRACT FROM AUTHOR]

Background: This article examines uncomfortable realities that the European hospital sector currently faces and the potential impact of wide-spread rationalization policies such as (hospital) payment reform and privatization.Methods: Review of relevant international literature.Results: Based on the evidence we present, rationalization policies such as (hospital) payment reform and privatization will probably fall short in delivering better quality of care and lower growth in health expenses. Reasons can be sought in a mix of evidence on the effectiveness of these rationalization policies. Nevertheless, pressures for different business models will gradually continue to increase and it seems safe to assume that more value-added process business and facilitated network models will eventually emerge.Conclusions: The overall argument of this article holds important implications for future research: how can policymakers generate adequate leverage to introduce such changes without destroying necessary hospital capacity and the ability to produce quality healthcare. [ABSTRACT FROM AUTHOR]

Background: Multistakeholder alliances—groups of payers, purchasers, providers, and consumers that voluntarily work together to address local health goals—have increasingly been used to improve health care quality within their communities. Under the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative, 16 multistakeholder alliances were charged with advancing payment reform as part of a larger effort to achieve dramatic and sustainable quality improvement. Methods: Drawing upon key informant interviews with alliance leaders and document reviews conducted from 2010 to 2014, we describe the payment reform projects undertaken by the AF4Q alliances and the roles that the alliances played to advance them. Results: The most common types of projects pursued by alliances were those that introduced supplemental payments to fee-for-service reimbursement and built upon alliances' ongoing quality improvement initiatives. Alliances advanced payment reform through 4 roles: (1) educating and advocating, (2) designing payment reform projects, (3) recruiting participants, and (4) supporting the operation of projects. However, less than half of alliances' payment reform projects were operational by 2014. Conclusions: Quality improvement-focused multistakeholder alliances may play meaningful roles to advance payment reform, but they are not a panacea for overcoming well-documented barriers to reform. [ABSTRACT FROM AUTHOR]

Introduction/Purpose: With the increasing complexity of physician reimbursement models, understanding reimbursement trends is crucial to the financial sustainability of orthopaedic practices nationwide. Inflation-adjusted Medicare physician reimbursement for total joint arthroplasty has decreased by approximately 33% from 2000 to 2019. Recent trends in orthopaedic foot and ankle reimbursement are unknown. Thus, our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2020 for common orthopaedic foot and ankle surgical procedures. Methods: The financial database of a single academic tertiary care center was queried to identify the CPT codes most frequently utilized in orthopaedic foot and ankle care. Next, the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for the top 30 CPT codes utilized, and physician reimbursement data extracted. Monetary data was subsequently adjusted for inflation utilizing the consumer price index and reported in 2020 US dollars (USD). Average annual and the total percent change in reimbursement were calculated for included procedures. Results: After adjusting for inflation, the average physician reimbursement decreased by 31.6% for all included foot and ankle procedures from 2000 to 2020, with 23/30 codes decreasing by more than 30%. The greatest decrease in reimbursement observed from 2000 to 2020 was for open treatment of calcaneal fracture at 48.3% ($2,254.17 to $1,164.97), followed by flexor tendon repair at 48.2% ($741.02 to $357.39), and open treatment of pilon fracture at 43.9% ($2,451.37 to $1,076.36). Conclusion: Over the past two decades, physician reimbursement for foot and ankle procedures has dramatically decreased by up to 48.3%. Continued downward trends in orthopaedic foot and ankle physician reimbursement may lead to decreased access to quality foot and ankle care. [ABSTRACT FROM AUTHOR]

A remarkable consensus has developed that the fee-for-service (FFS) approach for paying medical providers must be replaced. This payment approach is said to increase the volume of services without improving care coordination. In response to these calls, Medicare and private payers are experimenting with payment systems that combine the basic element of FFS--a fee for each service--with arrangements that allow providers to share the savings if they hold total spending per patient below a targeted amount. Medicare's accountable care organizations (ACOs) embody the shared savings approach to payment reform. Private payers have introduced total cost of care contracting (TCOC) in several locations. This article questions the consensus that FFS must go. If the fees are too high, then someone needs to "bite the bullet" and reduce fees in key areas. Hoping to control overspending by investment in ACOs is wishful thinking. I describe the theory and practice of shared savings payment systems and summarize recent TCOC contracting initiatives in the private sector. Medicare's shared savings approach is likely to be less effective than private contracts. Cutting providers' fees would be more efficient. Finally, the new payment models in the Affordable Care Act will not ease the problem of high prices for private payers. [ABSTRACT FROM AUTHOR]