Introduction Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of ...the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. Methods We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. Results We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. Discussion Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
The aftermath of Hurricane Katrina has placed a national spotlight on the shameful state of healthcare for America's poor. In the face of this highly publicized disaster, public health experts are ...more concerned than ever about persistent disparities that result from income and race.This book tells the story of one groundbreaking approach to medicine that attacks the problem by focusing on the wellness of whole neighborhoods. Since their creation during the 1960s, community health centers have served the needs of the poor in the tenements of New York, the colonias of Texas, the working class neighborhoods of Boston, and the dirt farms of the South. As products of the civil rights movement, the early centers provided not only primary and preventive care, but also social and environmental services, economic development, and empowerment.Bonnie Lefkowitz-herself a veteran of community health administration-explores the program's unlikely transformation from a small and beleaguered demonstration effort to a network of close to a thousand modern health care organizations serving nearly 15 million people. In a series of personal accounts and interviews with national leaders and dozens of health care workers, patients, and activists in five communities across the United States, she shows how health centers have endured despite cynicism and inertia, the vagaries of politics, and ongoing discrimination.
Context: In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously "improving the individual experience of care; improving the health of ...populations; and reducing the per capita costs of care for populations." IHI and its close colleagues had determined that both individual and societal changes were needed. Methods: In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim. Findings: Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time. Conclusions: The concept of the Triple Aim is now widely used, because of IHI's work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.
Patient activation is a term that describes the skills and confidence that equip patients to become actively engaged in their health care. Health care delivery systems are turning to patient ...activation as yet another tool to help them and their patients improve outcomes and influence costs. In this article we examine the relationship between patient activation levels and billed care costs. In an analysis of 33,163 patients of Fairview Health Services, a large health care delivery system in Minnesota, we found that patients with the lowest activation levels had predicted average costs that were 8 percent higher in the base year and 21 percent higher in the first half of the next year than the costs of patients with the highest activation levels, both significant differences. What's more, patient activation was a significant predictor of cost even after adjustment for a commonly used "risk score" specifically designed to predict future costs. As health care delivery systems move toward assuming greater accountability for costs and outcomes for defined patient populations, knowing patients' ability and willingness to manage their health will be a relevant piece of information integral to health care providers' ability to improve outcomes and lower costs.
•Use of nurse practitioners and physician assistants has expanded considerably.•Greater provider supply had minimal impact on the office-based healthcare market.•Utilization modestly more responsive ...to supply in states with greater provider autonomy.•Minimal impact of provider supply on prices.
Nurse practitioners (NPs) and physician assistants (PAs) now outnumber family practice doctors in the United States and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. I find that expanded NP and PA supply has had minimal impact on the office-based healthcare market overall, but utilization has been modestly more responsive to supply increases in states permitting greater autonomy. Results suggest the importance of laws impacting the division of labor, not just its quantity.
Global and national initiatives focused on health systems strengthening, universal health coverage, health security, and resilience suffer when these terms are not well understood or believed to be ...different ways of saying the same thing. Conceptual clarity is essential for a systematic approach to policy-making. Confusion and inefficiency arise when health system strengthening is defined as an objective and also when universal health coverage, health security or resilience are described as separate programmes to be implemented. So here is a simple guide: health system strengthening is what they do; universal health coverage, health security and resilience are what they want.
Healthcare decision makers in search of reliable information that compares health interventions increasingly turn to systematic reviews for the best summary of the evidence. Systematic reviews ...identify, select, assess, and synthesize the findings of similar but separate studies, and can help clarify what is known and not known about the potential benefits and harms of drugs, devices, and other healthcare services. Systematic reviews can be helpful for clinicians who want to integrate research findings into their daily practices, for patients to make well-informed choices about their own care, for professional medical societies and other organizations that develop clinical practice guidelines.
Too often systematic reviews are of uncertain or poor quality. There are no universally accepted standards for developing systematic reviews leading to variability in how conflicts of interest and biases are handled, how evidence is appraised, and the overall scientific rigor of the process.
In Finding What Works in Health Care the Institute of Medicine (IOM) recommends 21 standards for developing high-quality systematic reviews of comparative effectiveness research. The standards address the entire systematic review process from the initial steps of formulating the topic and building the review team to producing a detailed final report that synthesizes what the evidence shows and where knowledge gaps remain.
Finding What Works in Health Care also proposes a framework for improving the quality of the science underpinning systematic reviews. This book will serve as a vital resource for both sponsors and producers of systematic reviews of comparative effectiveness research.
Quality in a lean health care setting has one ultimate goal-to improve care delivery and value for the patient. The purpose of this book is to provide a blueprint to hospitals, healthcare ...organizations, leaders, and patient-facing workers with tools, training, and ideas to address quality within their organization. Examples from health care an other industries are provider to illustrate lean methodology and learn their application in quality. The reader can learn how other organizations improve quality, what their roles are, and what they do daily. By the end of the book, you will have learned actionable concepts and have the tools and resources to start improving quality.
Are advanced industrialized countries converging on a market response to reform their systems of social protection? By comparing the health care reform experiences of Britain, Germany, and the United ...States in the 1990s, Susan Giaimo explores how countries pursue diverse policy responses and how such variations reflect distinctive institutions, actors, and reform politics in each country.
In Britain, the Thatcher government's plan to inject a market into the state-administered national health service resulted in a circumscribed experiment orchestrated from above. In Germany, the Kohl government sought to repair defects in the corporatist arrangement with doctors and insurers, thus limiting the market experiment and designing it to enhance the solidarity of the national health insurance system. In the United States, private market actors foiled Clinton's bid to expand the federal government's role in the private health care system through managed competition and national insurance. But market reform continued, albeit led by private employers and with government officials playing a reactive role. Actors and institutions surrounding the existing health care settlement in each country created particular reform politics that either militated against or fostered the deployment of competition.
The finding that major transformations are occurring in private as well as public systems of social protection suggests that studies of social policy change expand their focus beyond statutory welfare state programs. The book will interest political scientists and policymakers concerned with welfare state reform in advanced industrial societies; social scientists interested in the changing balance among state, market, and societal interests in governance; and health policy researchers, health policymakers, and health care professionals.
Susan Giaimo is an independent scholar. She completed her Ph.D. in Political Science at the University of Wisconsin-Madison. She also earned an MSc in Politics from the London School of Economics and Political Science, with the Politics and Government of Western Europe as the branch of study. After completing her doctorate, she was a postdoctoral fellow in the Robert Wood Johnson Foundation Scholars in Health Policy Research Program, University of California at Berkeley, and the Robert Bosch Foundation Scholars Program in Comparative Public Policy and Comparative Institutions, American Institute for Contemporary German Studies, Johns Hopkins University. She taught in the Political Science Department at Massachusetts Institute of Technology for five years. During that period she won the Society for the Advancement of Socio-Economics Founder's Prize for "Adapting the Welfare State: The Case of Health Care Reform in Britain, Germany, and the United States," a paper she coauthored with Philip Manow. She has also worked for health maintenance organizations (HMOs) and medical practices in the United States.
Objective
To develop claims‐based measures of comprehensiveness of primary care physicians (PCPs) and summarize their associations with health care utilization and cost.
Data Sources and Study ...Setting
A total of 5359 PCPs caring for over 1 million Medicare fee‐for‐service beneficiaries from 1404 practices.
Study Design
We developed Medicare claims‐based measures of physician comprehensiveness (involvement in patient conditions and new problem management) and used a previously developed range of services measure. We analyzed the association of PCPs’ comprehensiveness in 2013 with their beneficiaries’ emergency department, hospitalizations rates, and ambulatory care‐sensitive condition (ACSC) admissions (each per 1000 beneficiaries per year), and Medicare expenditures (per beneficiary per month) in 2014, adjusting for beneficiary, physician, practice, and market characteristics, and clustering.
Principal Findings
Each measure varied across PCPs and had low correlation with the other measures—as intended, they capture different aspects of comprehensiveness. For patients whose PCPs’ comprehensiveness score was at the 75th vs 25th percentile (more vs less comprehensive), patients had lower service use (P < 0.05) in one or more measures: involvement with patient conditions: total Medicare expenditures, −$17.4 (−2.2 percent); hospitalizations, −5.5 (−1.9 percent); emergency department (ED) visits, −16.3 (−2.4 percent); new problem management: total Medicare expenditures, −$13.3 (−1.7 percent); hospitalizations, −7.0 (−2.4 percent); ED visits, −19.7 (−2.9 percent); range of services: ED visits, −17.1 (−2.5 percent). There were no significant associations between the comprehensiveness measures and ACSC admission rates.
Conclusions
These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries of PCPs providing more comprehensive care had lower hospitalization rates, ED visits, and total Medicare expenditures.
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