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Value-Based Payment Models

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Chronic Illness Care

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Abstract

The concept of value-based purchasing (VBP) refers to performance-based payment strategies that link financial incentives to health-care provider performance, within a set of defined measures, in order achieve better value by driving improvements in quality and by slowing the growth in health-care spending. These types of models include Accountable Care Organizations (ACOs), hospital value-based purchasing (VBP) programs, bundled payments, and clinically integrated networks (CINs). Accountable Care Organizations (ACOs) are groups of physicians, hospitals, and other health-care service providers who are aligned with a purpose to integrate care and promote accountability for a defined patient population. A clinically integrated network (CIN) is a network of providers who continuously evaluate and modify their clinical practices in accordance with agreed-upon protocols to control costs and improve quality. Value-based purchasing (VBP) is a health-care reimbursement mechanism that is based on hospital performance and improvement in three areas: quality of care, adherence to best clinical practices, and patient experience. To stabilize rising costs while improving population health, a concerted effort to reduce the duplication of services and assist patients in navigating the care system is needed, and value-based purchasing models seek to incent and reward this approach.

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Abbreviations

ACA:

Affordable Care Act

ACE:

Angiotensin-converting enzyme

ACO:

Accountable Care Organization

ARB:

Angiotensin receptor blocker

BMI:

Body mass index

CAD:

Coronary artery disease

CDC:

Centers for Disease Control

CIN:

Clinically integrated network

CMMI:

Centers for Medicare and Medicaid Innovation

CMP:

Civil Monetary Penalty

CMS:

Centers for Medicare and Medicaid Services

CVD:

Cardiovascular disease

DOJ:

Department of Justice

EHR:

Electronic health record

ESRD:

End-stage renal disease

FFS:

Fee-for-service

FTC:

Federal Trade Commission

HbA1c:

Glycated hemoglobin

HCAHPS:

Hospital Consumer Assessment of Healthcare Providers and Systems

HF:

Heart failure

HHS:

Health and Human Services

IRS:

Internal Revenue Service

IVD:

Ischemic vascular disease

LDL-C:

Low-density lipoprotein cholesterol

LVSD:

Left ventricular systolic dysfunction

MSSP:

Medicare Shared Savings Program

OIG:

Office of Inspector General

PC:

Primary care

PCMH:

Patient-centered medical home

VBP:

Value-based purchasing

References

  1. Kizer KW. Clinical integration: a cornerstone for population health management. J Healthc Manag. 2015;60(3):164.

    Article  PubMed  Google Scholar 

  2. United States Senate Committee on Finance. A Pathway to improving care for Medicare patients with chronic conditions. 2016. http://www.finance.senate.gov/imo/media/doc/99934.pdf.

  3. Centers for Disease Control. The power of prevention: chronic disease…. the public health challenge of the 21st century. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; 2009.

    Google Scholar 

  4. Centers for Medicare & Medicaid Services. National health expenditure fact sheet. 2014. http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet.html. Accessed 27 Sept 2014.

  5. Davis K, Stremikis K, Schoen C, Squires D. Mirror, mirror on the wall, 2014 update: how the US health care system compares internationally. New York: The Commonwealth Fund; 2014.

    Google Scholar 

  6. Damberg CL, Sorbero ME, Lovejoy SL, Martsolf GR, Raaen L, Mandel D. Measuring success in health care value-based purchasing programs. RAND Corp. 2014;4:9.

    Google Scholar 

  7. Scanlon DP, Chernew M, Doty HE, United S, Agency for Health Care P, Research. Evaluating the impact of value-based purchasing: a guide for purchasers. 2002.

    Google Scholar 

  8. Centers for Disease Control and Prevention. 2014 National Diabetes Statistics Report. 2014. http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html. Accessed 1 Nov 2016.

  9. Bodenheimer T. Coordinating care – a perilous journey through the health care system. N Engl J Med. 2008;358(10):1064–71.

    Article  CAS  PubMed  Google Scholar 

  10. Guest D, Campbell D, Larch S, Williams B. Taking smart steps toward clinical integration: using the right approach to build a clinically integrated network (CIN) puts hospitals and health systems in a position to capitalize on the benefits of the CIN business model. Healthc Financ Manag. 2015;69(3):56–65.

    Google Scholar 

  11. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3):166–206.

    Article  Google Scholar 

  12. McDonald KM, Sundaram V, Bravata DM, Lewis R, Lin N, Kraft SA, et al. Closing the quality gap: a critical analysis of quality improvement strategies, vol. 7., Care Coordination. Rockville: Agency for Healthcare Research and Quality; 2007.

    Google Scholar 

  13. Ghandi N. ACO update: a slower pace of growth. 2015. http://www.oliverwyman.com/content/dam/oliver-wyman/global/en/files/insights/health-life-sciences/2015/ACO-Update-2015-v2.pdf. Accessed 27 Mar 2017.

  14. Kessell E, Pegany V, Keolanui B, Fulton BD, Scheffler RM, Shortell SM. Review of medicare, medicaid, and commercial quality of care measures: considerations for assessing accountable care organizations. J Health Polit Policy Law. 2015;40(4):761–96.

    Article  PubMed  Google Scholar 

  15. United States. Compilation of patient protection and affordable care act. 2010. http://housedocs.house.gov/energycommerce/ppacacon.pdf, p. 313, Accessed October 2 2016.

    Google Scholar 

  16. Swank S. A physician’s guide to forming and operating an accountable care organization. Maryland Med MM Publ MEDCHI Maryland State Med Soc. 2012;13(2):11.

    Google Scholar 

  17. McWilliams JM, Chernew ME, Landon BE, Schwartz AL. Performance differences in year 1 of pioneer accountable care organizations. N Engl J Med. 2015;372(20):1927–36.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Tu T, David I, Lawrence I, Ross I. Origins and future of accountable care organizations. Washington, DC: Brookings Institution; 2015.

    Google Scholar 

  19. RTI International. Accountable care organization [all years] program analysis quality performance standards narrative measure specifications. Waltham, MA. 2016. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality-Measures-Standards.html. Accessed 1 Nov 2016.

  20. Huerta TR, Harle CA, Ford EW, Diana ML, Menachemi N. Measuring patient satisfaction’s relationship to hospital cost efficiency: can administrators make a difference? Health Care Manag Rev. 2016;41(1):56–63.

    Article  Google Scholar 

  21. Centers for Medicare and Medicaid Services. Guide to quality performance scoring methods for accountable care organizations. https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/2012-11-aco-quality-scoring-supplement.pdf. Accessed 3 Nov 2016.

  22. Centers for Medicare and Medicaid Services. Pioneer ACO model frequently asked questions. 2016. https://innovation.cms.gov/initiatives/pioneer-aco-model/pioneer-aco-faqs.html. Accessed 6 Nov 2016.

  23. Centers for Medicaid and Medicare Services. Next generation ACO model. 2016. https://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/. Accessed 10 Oct 2016.

  24. Millman Inc. The two Medicare ACO programs: medicare shared savings and pioneer – risk/actuarial differences 2011. http://us.milliman.com/uploadedFiles/insight/health-published/pdfs/14849_Milliman-Report-on-Pioneer-vs-MSSP070811.pdf. Accessed 30 Oct 2016.

  25. Thorpe KE, Howard DH. The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity. Health Aff. 2006;25(5):w378–w88.

    Article  Google Scholar 

  26. Health UDo, Services H. Medicare’s delivery system reform initiatives achieve significant savings and quality improvements: off to a strong start. 2014.

    Google Scholar 

  27. McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early performance of accountable care organizations in Medicare. N Engl J Med. 2016;374(24):2357–66.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Schwartz AL, Chernew ME, Landon BE, McWilliams JM. Changes in low-value services in year 1 of the Medicare pioneer accountable care organization program. JAMA Intern Med. 2015;175(11):1815–25.

    Article  PubMed  PubMed Central  Google Scholar 

  29. McAlearney AS, Song P, Hilligoss B. Accountable care organization development in the private sector: a qualitative study of four organizations. American Journal of Managed Care. 2016; in press.

    Google Scholar 

  30. Kaiser Family Foundation. Payment and delivery system reform in medicare. 2016. http://files.kff.org/attachment/Report-Payment-and-Delivery-System-Reform-in-Medicare.pdf. Accessed 1 Feb 2017.

  31. Shortell SM, Addicott R, Walsh N, Ham C. The NHS five year forward view: lessons from the United States in developing new care models. BMJ Clin Res Ed. 2015;350:h2005.

    Google Scholar 

  32. Zenty TF III, Bieber EJ, Hammack ER. University hospitals: creating the infrastructure for quality and value through accountable care. Front Health Serv Manag. 2014;30(4):21.

    Article  Google Scholar 

  33. DeCamp M, Farber NJ, Torke AM, George M, Berger Z, Keirns CC, et al. Ethical challenges for accountable care organizations: a structured review. J Gen Intern Med. 2014;29(10):1392–9.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Hunt LM, Kreiner M, Brody H. The changing face of chronic illness management in primary care: a qualitative study of underlying influences and unintended outcomes. Ann Fam Med. 2012;10(5):452–60.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Furler J, Hii JW, Liew D, Blackberry I, Best J, Segal L, et al. The “cost” of treating to target: cross-sectional analysis of patients with poorly controlled type 2 diabetes in Australian general practice. BMC Fam Pract. 2013;14(1):1.

    Article  Google Scholar 

  36. Stutz L. Case management as a foundation for an accountable care organization. Prof Case Manag. 2011;16(3):152–5.

    Article  PubMed  Google Scholar 

  37. Federal Trade Commission. Competition in the health care marketplace. https://www.ftc.gov/tips-advice/competition-guidance/industry-guidance/health-care. Accessed 1 Oct 2016.

  38. Kumar P, Levine E. Clinically integrated networks: Can they create value? 2016. http://healthcare.mckinsey.com/sites/default/files/Clinicallyintegratednetworks.pdf. Accessed 2 Feb 2017.

  39. American Hospital Association. Clinical integration–the key to real reform. Trendwatch. 2010;6.

    Google Scholar 

  40. Caradigm. Clinically integrated networks and population health: taking the next step. 2014. https://www.caradigm.com/media/1460/caradigm-clinically-integrated-networks-white-paper.pdf. Accessed 2 Feb 2017.

  41. VUMC. Vanderbilt University Medical Center Strategy Framework 2013. 2013. http://www.mc.vanderbilt.edu/documents/strategy/files/VUMC_strategy_framework_v4.pdf.

  42. Mercy Health. MetroHealth joins largest clinically integrated network. 2016. https://www.mercy.com/en/global/news-and-events/news/2016/january/metrohealth-joins-largest-clinically-integrated-network. Accessed 1 Feb 2017.

  43. CHI Health. The value of our clinically-integrated network. 2017. http://www.chihealth.com/the-value-of-our-clinically-integrated-network. Accessed 1 Feb 2017.

  44. Gosfield A, Reinertsen J. Achieving clinical integration with highly engaged physicians. Available at: https://www.reinertsengroup.com/publications/documents/True%20Clinical%20Integration%20Gosfield%20Reinertsen%202010.pdf

  45. The United States Department of Justice. Statements of antitrust enforcement policy in healthcare. 1996. https://www.justice.gov/atr/statements-antitrust-enforcement-policy-health-care. Accessed 3 Nov 2016.

  46. Abrams MN. Toward population health management. Hospital & Health Networks Daily. 2014. http://www.hhnmag.com/articles/4078-toward-population-health-management?dcrPath=%2Ftemplatedata%2FHF_Common%2FNewsArticle%2Fdata%2FHHN%2FDaily%2F2014%2FJul%2F072914-sackman-population-health-management. Accessed 31 Oct 2016.

  47. Kaufman NS. Three “brutal facts” that provide strategic direction for healthcare delivery systems: preparing for the end of the healthcare bubble. J Healthc Manag. 2011;56(3):163–8.

    Article  PubMed  Google Scholar 

  48. The Camden Group. Clinical integration & ACOs. 2016. http://www.thecamdengroup.com/our-services/accountable-care/clinical-integration-acos/. Accessed 4 Nov 2016.

  49. Fasching J, Johnson LW. Patient experience drives accountable care movement. MGMA Connexion. 2011:29.

    Google Scholar 

  50. American Hospital Association. Guidance for clinical integration. 2010. http://www.aha.org/content/00-10/070417clinicalintegration.pdf. Accessed 3 Feb 2017.

  51. Atkinson JG, Masiulis KE, Felgner L, Schumacher DN. Provider-initiated pay-for-performance in a clinically integrated hospital network. J Healthc Qual. 2010;32(1):42–50.

    Article  PubMed  Google Scholar 

  52. Baker LC, Bundorf MK, Devlin AM, Kessler DP. Hospital ownership of physicians: hospital versus physician perspectives. Med Care Res Rev. 2016. Nov 1:1077558716676018. doi: 10.1177/1077558716676018.

  53. Walker D, Mora A, Scheck MA. Accountable care organization hospitals differ in health IT capabilities. Am J Manag Care. 2016;22(12):802.

    PubMed  Google Scholar 

  54. Centers for Medicaid and Medicare Services. Hospital value-based purchasing. 2015. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed 1 Nov 2016.

  55. Centers for Medicare and Medicaid Services. Value-based purchasing. 2015. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf. Accessed 27 Oct 2016.

  56. Agency for Healthcare Research and Quality. Medicare spending per beneficiary (MSPB): cost to Medicare of services performed by hospitals and other healthcare providers during a MSPB episode. 2015. https://www.qualitymeasures.ahrq.gov/summaries/summary/49205/medicare-spending-per-beneficiary-mspb-cost-to-medicare-of-services-performed-by-hospitals-and-other-healthcare-providers-during-a-mspb-episode. Accessed 2 Nov 2016.

  57. Kahn CN, Ault T, Potetz L, Walke T, Chambers JH, Burch S. Assessing Medicare’s hospital pay-for-performance programs and whether they are achieving their goals. Health Aff. 2015;34(8):1281–8.

    Article  Google Scholar 

  58. VanLare JM, Conway PH. Value-based purchasing—national programs to move from volume to value. N Engl J Med. 2012;367(4):292–5.

    Article  CAS  PubMed  Google Scholar 

  59. Das A, Norton EC, Miller DC, Ryan AM, Birkmeyer JD, Chen LM. Adding a spending metric to Medicare’s value-based purchasing program rewarded low-quality hospitals. Health Aff. 2016;35(5):898–906.

    Article  Google Scholar 

  60. Chatterjee P, Joynt KE, Orav EJ, Jha AK. Patient experience in safety-net hospitals: implications for improving care and value-based purchasing. Arch Intern Med. 2012;172(16):1204–10.

    Article  PubMed  Google Scholar 

  61. Zhao M, Haley DR, Spaulding A, Balogh HA. Value-based purchasing, efficiency, and hospital performance. Health Care Manag. 2015;34(1):4–13.

    Google Scholar 

  62. Wolosin R, Ayala L, Fulton BR. Nursing care, inpatient satisfaction, and value-based purchasing: vital connections. J Nurs Adm. 2012;42(6):321–5.

    Article  PubMed  Google Scholar 

  63. Centers for Medicare and Medicaid Services. Bundled Payments for Care Improvement (BPCI) initiative: general information. 2016. Accessed 1 Nov 2016.

    Google Scholar 

  64. Johnson DJ, Greenberg SE, Sathiyakumar V, Thakore R, Ehrenfeld JM, Obremskey WT, et al. Relationship between the Charlson comorbidity index and cost of treating hip fractures: implications for bundled payment. J Orthop Traumatol. 2015;16(3):209–13.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Struijs J. How bundled health care payments are working in the Netherlands. Harv Bus Rev. 2015.

    Google Scholar 

  66. de Bakker DH, Struijs JN, Baan CA, Raams J, de Wildt J-E, Vrijhoef HJ, et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Aff. 2012;31(2):426–33.

    Article  Google Scholar 

  67. Valuck T, Dugan D, Dubois RW, Westrich K, Penso J, McClellan M. Solutions for filling gaps in accountable care measure sets. Am J Manag Care. 2015;21(10):723–8.

    PubMed  Google Scholar 

  68. Saver BG, Martin SA, Adler RN, Candib LM, Deligiannidis KE, Golding J, et al. Care that matters: quality measurement and health care. PLoS Med. 2015;12(11):e1001902.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Thorpe KE, Ogden LL. Analysis & commentary the foundation that health reform lays for improved payment, care coordination. Preve Health Aff. 2010;29(6):1183–7.

    Article  Google Scholar 

  70. National Priorities Partnership. Input to the Secretary of Health and Human Services on Priorities for the 2011 National Quality Strategy. Washington D.C.: National Quality Forum 2010.

    Google Scholar 

  71. Institute of Medicine. Best care at lower cost the path to continuously learning health care in America. 2012. http://www.iom.edu/~/media/Files/Report Files/2012/Best-Care/Best Care at Lower Cost_Recs.pdf. Accessed 27 Sept 2014.

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Authors and Affiliations

  1. Center for Outcomes Research, Houston Methodist Research Institute, Houston, TX, USA

    Terri Menser

  2. Department of Family Medicine, The Ohio State University, Columbus, OH, USA

    Ann Scheck McAlearney

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  1. Terri Menser
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Correspondence to Terri Menser .

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Editors and Affiliations

  1. Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

    Timothy P. Daaleman

  2. Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

    Margaret R. Helton

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Menser, T., McAlearney, A.S. (2018). Value-Based Payment Models. In: Daaleman, T., Helton, M. (eds) Chronic Illness Care. Springer, Cham. https://doi.org/10.1007/978-3-319-71812-5_41

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