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EVIDENCE FROM A DECADE OF INNOVATIONThe Impact of the Paymentand Delivery System Reformsof the Affordable Care ActCorinne Lewis, Melinda Abrams, Shanoor Seervai, and David Blumenthal, M.D.The U.S. health care system has long been marked by high spending, comparatively poor health outcomes, and waste andinefficiency. To address these issues, the Affordable Care Act (ACA) includes several provisions to reform how the nation organizes,structures, and pays for its health care. The law instituted several mandatory national payment reforms through the Medicareprogram and created the Center for Medicare and Medicaid Innovation, which was funded with 10 billion over 10 years to develop,test, and promote innovative payment and delivery models. Below is a summary of evidence from some of the major innovationstested over the past decade.Overall, these initiatives transformed health care delivery and payment across the United States, and many have reduced costs andimproved quality of care. The results were often mixed, however, and the magnitude of impact was modest in many instances. Toachieve meaningful, sustainable gains, future models of payment and delivery system reform will need to be redesigned based onthe lessons learned from the past 10 years of innovation. Mandatory National Payment Reform Initiatives Accountable Care Organizations Episode-Based Payment Initiatives Primary Care Transformation Innovation in Medicaid and the Children’s Health Insurance Program (CHIP) Improving Care for Dually Eligible Beneficiaries Accelerating the Development, Testing, and Adoption of New Payment and Delivery Models
Mandatory National Payment Reform InitiativesThe Affordable Care Act introduced compulsory value-based payment initiatives through Medicare to reduce hospital readmissions and hospital-acquiredconditions and to improve the overall quality of care that hospitals deliver. Studies evaluating these programs have produced mixed results and have not shownsignificant improvements in outcomes over time. Some evidence suggests one of the models may have increased mortality.DescriptionStatusImpact to dateHospital Readmission Reduction Program (HRRP)Financially penalizes hospitals with the highest relative rates ofunplanned readmissions within 30 days of discharge forMedicare beneficiaries with six clinical conditions.2012–presentIn 2019, 83% of eligible hospitalswere penalized, with 2,583hospitals charged a total of 563million for readmissions Hospital-Acquired Conditions Reduction Program (HACRP)To reduce medical errors and prevent hospital-acquiredconditions (HACs), the ACA imposed a 1% financial penalty forhospitals in the top quartile for preventable HACs.2014–presentHospital Value-Based Purchasing Program (HVBPP)Adjusts Medicare payments to hospitals based on theirperformance on measures of clinical outcomes, patient andcommunity engagement, safety, and efficiency.2013–present 2 Some studies indicate readmissions fell afterimplementation.Other studies found the decline in readmissionswas not significant and resulted from factorsother than HRRP.Mixed evidence on whether HRRP led toincreased mortality.Average annual reduction of 4.5% in HACs from2010 to 2017.Drop in HACs predated ACA, and program doesnot appear to incentivize improvement, withmost penalized hospitals consistently being intop quartile each year.Studies have found no significant difference inquality of care or mortality betweenparticipating hospitals and controls.
Accountable Care Organizations (ACOs)ACOs are networks of physicians, hospitals, and other providers that voluntarily come together to be held accountable for the cost and quality of care forattributed patients. Participants in ACOs can accept either upside-only risk, whereby they can share in savings to Medicare, or two-sided (upside and downside)risk, whereby they can share in savings or pay a penalty depending on the specific model, on performance on quality metrics, and on spending relative tobenchmarks. As of 2019, there were nearly 600 ACOs operating under Medicare.Overall, they appear to produce net savings for Medicare while improving or maintaining quality of care, with ACOs in the Medicare Shared Savings Programshowing the greatest promise. Physician-led ACOs tend to perform better than hospital-led ACOs, and ACO performance appears to improve over time.DescriptionStatusImpact to datePioneer ACOProviders with experience in coordinating careacross multiple care settings take on higher upsideand downside financial risk than in MSSP model (seebelow). Pioneer ACOs that achieved sufficientsavings in first two years were able to move topopulation-based payments in year 3.2012–201632 participated in 2012;dropped to nine byDecember 2016 (manytransitioned to MSSP) Medicare Shared Savings Program (MSSP)Providers that meet specific quality standards andachieve savings by spending less than targets evenlysplit savings with Medicare. Multiple variants exist. In2018, the Centers for Medicare and MedicaidServices (CMS) announced significant changes,requiring providers to take on some downside riskafter two years.2012–present548 participating, covering10.1 million Medicarebeneficiaries as of 2018 3Net savings to Medicare of 134 million in 2012 and 99 millionin 2013.Quality scores improved over time.Reductions in emergency department (ED) visits, particularly forconditions treatable in outpatient settings.Program certified by U.S. Secretary of Health and Human Servicesas cost-effective and worth promoting.Net savings to Medicare of 739.4 million in 2018.Perform better on savings over time.MSSP ACOs led by physicians more likely to produce savings thanthose led by hospitals.ACOs taking on downside risk have greater reductions in spendingthan those taking on upside risk only.Scored well or better on measures of quality, including receipt ofpreventive services, declines in hospital readmissions, andpatient/caregiver experience, compared to fee-for-serviceMedicare providers.Less than 1% have failed to meet quality performance standards.
Next Generation ACO (“Next Gen”)Allows experienced ACOs to take on greater levels ofupside risk in exchange for greater downside risk.Both fee-for-service and population-based paymentsare made to practices. Model participants are alsoallowed to waive some Medicare requirements andenhance certain benefits like telehealth andpostdischarge home visits.2016–present41 participating as of 2019Advance Payment ACOsProvided advanced prepaid shared savingspayments, serving as start-up capital, to encouragephysician-led and rural organizations to participatein ACO program.2012–201535 participated ACO Investment Model (AIM)Building on Advance Payment Model, AIM providesprepaid shared savings to small and/or rural MSSPsto encourage formation and participation and toprepare them to move toward high-risk models.2016–present45 participating as of 2019 95.6 million in AIMpayments made; CMSrecouped approximately 40%of payments as of 2017 4Significantly reduced total Medicare spending for beneficiariesrelative to comparison group by 123.2 million from 2016 to2017; but when factoring in shared savings payments,nonsignificantly increased net Medicare spending by 93.9million.No significant impacts on hospitalizations or unplannedreadmissions, but significant increases in receipt of annualwellness visits.Performed similarly to fee-for-service Medicare beneficiaries notin an ACO on spending and claims-based quality measures.Two-thirds continued to operate as ACO after model ended.Reduced total Medicare spending and utilization compared tosimilar Medicare fee-for-service beneficiaries in first two years ofprogram.Greater savings than similar non-AIM ACOs while maintainingquality of care.63% reported they would not have participated in ACO programwithout AIM funding.Only two of 47 dropped out.
Episode-Based Payment InitiativesEpisode-based payment programs test whether providing a single payment for a defined episode of care can produce savings while maintaining quality oftreatment. Under these models, providers keep savings if spending is below targets or lose money if spending exceeds targets. While on the whole these modelshave not yielded significant savings for Medicare, episode-based payments that are mandatory and those for surgical rather than medical conditions show themost promise for reducing costs without lowering quality.DescriptionStatusImpact to dateBundled Payments for Care Improvement (BPCI) Model 1: Acute CareHospital Stay OnlyHospitals paid predetermined, discounted, episode-based payment forinpatient stays in acute care hospital for all Medicare SeverityDiagnosis Related Groups (MS-DRGs).2013–201624 hospitals participated BPCI Model 2: Retrospective Acute & Postacute Care EpisodeHospitals and physician group practices paid single payment forinpatient stay in acute care hospital and all postacute care andphysician services during episode. Participants chose length ofepisode — either 30, 60, or 90 days after hospital discharge — andselected which of up to 48 clinical conditions they would receiveepisode-based payments for.2013–2018422 hospitals and 277 physiciangroup practices participatedBPCI Model 3: Retrospective Postacute Care OnlyModel 3 was similar to Model 2 except episode-based payment did notinclude inpatient stay itself but rather postacute services after hospitaldischarge only.2013–2018873 skilled nursing facilities, 116home health agencies, nineinpatient rehab facilities, one longterm-care hospital, and 144physician group practicesparticipatedBPCI Model 4: Prospective Acute Care Hospital Stay OnlyHospitals paid single payment covering all services provided byhospital, physicians, and other providers during inpatient stay andrelated readmissions for 30 days postdischarge. Participants couldselect up to 48 MS-DRG conditions to be included.2013–201823 hospitals participated 5Model 1 only: No consistent statisticallysignificant positive or negative impact onMedicare payments per episode or healthoutcomes.Models 2–4: Significantly reduced Medicareper-episode payments and no reduction inquality compared to nonparticipatinghospitals; reduced payments did nottranslate to net savings for Medicare whenaccounting for reconciliation payments.BPCI appears to be less successful formedical than surgical conditions; hospitalparticipation for common medicalconditions was not associated withreductions in Medicare payments,emergency department use, readmissions,or mortality.
BPCI AdvancedBuilding on Models 1 through 4, BPCI Advanced provides single,retrospective bundled payment for 90-day clinical episodes. CMSnarrowed options for clinical episodes from up to 48 MS-DRGs to up to31 inpatient and four outpatient clinical episodes. In addition, not onlycan practices receive additional payment if they spend below targetprice set at beginning of each year, they can also receive adjustmentsto those payments based on performance on set of quality measures.2018–presentMore than 1,200 participating as of2019 Results not yet available.Dropout has been high; 16% left model infirst six months.Comprehensive Joint Replacement (CJR)Hospitals in designated areas receive single, retrospective paymentfor hip and knee replacements that includes inpatient hospitalization,postacute care, and other physician services. Like BPCI, participantsreceive payments if total spending is below predetermined targetprices. CJR was mandatory for all providers in specific geographic areasin first two years but later made voluntary by CMS for some providersand areas. CMS recently issued proposed rule to extend slightly revisedversion of model for three years.2016–presentImplemented in 67 metropolitanstatistical areas (MSAs) with 733hospitals as of 2019 Statistically significant reductions in grossMedicare payments of 997 per episode(3.7% reduction) from 2016 to 2017.When accounting for reconciliationpayments to practices, program resulted innonsignificant 0.5% reduction in payments.Savings accrue primarily from shiftingpostacute care from institutions to othersettings like home.Maintained quality of care as measured byunplanned readmissions, ED visits,mortality, self-reported functional statusgains, and patient satisfaction as of 2017. Oncology Care Model (OCM)Provides episode-based payment for care around chemotherapyadministration over six-month periods to improve care coordinationand access for cancer patients. Practices receive enhanced permember, per month payment and can receive performance-basedpayments as additional incentive. Commercial payers are participatingin program.2016–present175 practices and 10 payersparticipating as of 2018 6No statistically significant differencebetween participants and comparisonpractices on Medicare expenditures orutilization in first year.Case study of one practice found reducedreadmissions and costs.
Primary Care TransformationSeveral federal payment and delivery system innovations have aimed to increase access to and quality of primary care. These programs typically employ theevidence-based patient-centered medical home (PCMH) model, which emphasizes care coordination, teams, patient engagement, and population healthmanagement. Evaluations of these efforts show largely mixed results, with few programs demonstrating meaningful increases in the availability of primary care,reductions in costly forms of utilization, or improvements in quality. Perhaps the most successful model has been Independence at Home, indicating homebased care can be effective for high-need patients.DescriptionStatusImpact to dateMedicare Primary Care Bonus PaymentAuthorized 10% bonus payment for primary care services underMedicare for qualifying physicians, nurse practitioners, andphysician assistants from 2011 to 2015.2011–2015Participating providersreceived averageadditional payment of 3,938 in 2012. Medicaid Fee BumpRequired states to raise Medicaid reimbursement for primarycare services to Medicare levels from 2013 to 2014. Federalgovernment funded the reimbursement increase.2013–201419 states continued feebump after it expired, selffunding the extension73% increase in Medicaidpayments for primarycare during bump One study found significant increase in primary care appointment availability but no difference in appointmentwait times.Two other studies found no effect on appointmentavailability or primary care physicians accepting newMedicaid patients.Comprehensive Primary Care (CPC)Multipayer advanced medical home model in whichparticipating practices received a non-visit-based caremanagement fee ( 20 per member, per month) and had optionto share in savings to Medicare. Practices received incentivesand data about practice performance and technical assistancein exchange for meeting care delivery requirements.2012–2016442 practices across 14regions served more than2.7 million patients 7 No effect on patient visits, quality of primary care, or laborsupply for primary care services.Slight effect (1%–2%) on new Medicare patient visits atindependent practices.Enhanced access to care, improved care coordination forpatients, and slightly slowed growth of ED visits comparedto comparison practices.No effect on quality, patient or physician satisfaction, orMedicare spending when considering care managementfees paid to practices.
Comprehensive Primary Care Plus (CPC )Built on lessons learned from CPC, CPC maintains care deliveryrequirements of CPC but changes payment structure so thatpractices receive performance-based incentive paymentsrather than share in savings. In Track 2, practices can opt out offee-for-service payments in exchange for larger quarterly lumpsum payment.2017–present2,851 practices and 55payers participating in 18regions as of 2019 Practices starting to change care delivery but no significantimpact on service use, quality of care, or expenditurescompared to comparison practices in first year.Independence at Home (IAH)Practices provide home-based primary care for chronically illMedicare beneficiaries using teams of providers. Practices thatachieve cost reductions while maintaining or improving qualityshare in savings to Medicare.2012–present14 sites participating Lowered Medicare expenditures by 25 million, but notclear if net savings were produced when consideringincentive payments paid to practices.Significant decrease in ED visits and hospitalizations.Improved beneficiary and caregiver satisfaction.Multi-Payer Advanced Primary Care Practice (MAPCP)State-sponsored, multipayer program that offered monthly permember, per month care management fees to practicesproviding primary care aligned with medical home model. Feewas intended to cover services to support chronically illbeneficiaries including care coordination and patienteducation.2011–2016Eight states andapproximately 1,200medical homes served900,000 Medicarebeneficiaries Federally Qualified Health Center (FQHC) Advanced PrimaryCare Practice DemonstrationRequires FQHCs to achieve Level 3 PCMH recognition byNational Committee for Quality Assurance (NCQA). To assistpractices in making changes to care delivery, they were offeredtechnical assistance and paid monthly care management feefor each eligible Medicare beneficiary served.2011–2014434 practices served195,000 Medicarebeneficiaries8 One study found Medicare expenditures were 227 millionlower than for comparable beneficiaries receiving care inmedical homes after accounting for payments made topractices, primarily due to reductions in acute careutilization.Other studies found little to no effect on expenditures orutilization and no reduction in Medicaid expendituresamong states.Some states showed improvements in access, quality, andhealth outcomes while others did not.Some significant unfavorable associations of participationand avoidable hospitalizations.Improvements in utilization, spending, and satisfactioncompared to those served by other practices.NCQA medical home recognition, not demonstration,drove improvement.
Medicaid Health Home State Plan OptionStates create health homes in exchange for an enhanced, twoyear federal match of 90% for eligible Medicaid beneficiarieswith chronic conditions and/or behavioral health issues. Statescan designate variety of practices as health homes, includinghospitals, community mental health centers, and primary carepractices, provided they integrate physical and behavioralhealth care and adopt PCMH features.2011–present20 states participated asof 2019Direct ContractingA recently announced Medicare initiative that will allowproviders to take on more financial risk in exchange for loweradministrative burden. Model offers two voluntary risk-sharing,capitated-payment options for primary care services.Expected to begin in2021Program not started.Primary Care FirstSet of Medicare payment models in which practices will be paidpopulation-based payment using less burdensome mechanismand can choose to opt into Seriously Ill Population–specificmodel with modified payment structure.Expected to begin in2021Model will be offered in 26regionsProgram not started.9Few states had resources to conduct evaluations.Early results from some states found, compared tobaseline, reductions in emergency department andhospital visits, improved health outcomes on indicatorssuch as cholesterol levels, and savings to Medicaid programof approximately 150 per member, per month.
Innovation in Medicaid and the Children’s Health Insurance Program (CHIP)The Center for Medicare and Medicaid Innovation tested several innovative payment and delivery models through Medicaid and CHIP. These programs aimed totackle growing issues in Medicaid and CHIP populations by preventing chronic disease, improving birth outcomes, and increasing access to behavioral healthcare. Two of these models — the Medicaid Incentives for the Prevention of Chronic Disease and Strong Start for Mothers and Newborns — improved outcomesfor Medicaid and
Mandatory National Payment Reform Initiatives The Affordable Care Act introduced compulsory value-based payment initiatives through Medicare to reduce hospital readmissions and hospital-acquired conditions and to improve the overall quality of care thathospitals deliver.
Types of Evidence 3 Classification of Evidence *Evidence is something that tends to establish or disprove a fact* Two types: Testimonial evidence is a statement made under oath; also known as direct evidence or prima facie evidence. Physical evidence is any object or material that is relevant in a crime; also known as indirect evidence.
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about evidence-based practice [2] Doing evidence-based practice means doing what the research evidence tells you works. No. Research evidence is just one of four sources of evidence. Evidence-based practice is about practice not research. Evidence doesn't speak for itself or do anything. New exciting single 'breakthrough' studies
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Decade of War, Volume 1. Enduring Lessons from the Past Decade of Operations Joint and Coalition Operational Analysis Division, Joint Staff, Suffolk, Distribution Statement A - The Decade of War, Volume I report is approved for release and dissemination caveat.
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3 THE FLEA THEATER A 24-Decade History of Popular Music: 1776-1836: Work in Progress 3 A 24-DECADE HISTORY OF POPULAR MUSIC I suppose I’ve been subconsciously kicking around the idea for A 24-Decade History of Popular Music for many years. I can pinpoint the catalyst to an AIDS action I attended in 1987.
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