Future of Healthcare Reform: Expect New Payment and Delivery Models

August 2013, Vol 6 ADA 2013 Highlights - Health Economics
Wayne Kuznar

San Francisco, CA—Reform to the healthcare system did not end with passage of the Affordable Care Act. The rise in healthcare costs may force capitated payments, integrated-care payment methods, and alternate forms of care delivery, according to presenters in a session on healthcare reform at the 2013 American College of Cardiology (ACC) meeting.

Costs and Reimbursement Concerns
Cost versus quality, progressive integration of medicine, and increased measurement of outcomes should be 3 areas of focus in the healthcare reform, suggested R. Scott Wright, MD, Professor of Medicine, Mayo Clinic College of Medicine, Rochester.

“Medicare should stop paying for treatments that offer no benefit or offer harm, and it should only pay for things that work and are optimal,” Dr Wright said.

Progressive integration of medicine can help eliminate duplication of services to increase value, according to Dr Wright. Expect more providers in any area of medicine to be employed by hospitals in the coming years, as well as more integration of healthcare delivery through contracts with accountable care organizations, he said.

Value-Based Payment Models
Inaccurate attribution is one of the problems with using claims-only data to measure value, said Thomas J. Lewandowski, MD, president of the Wisconsin chapter of the ACC and a cardiologist at Appleton Cardiology, ThedaCare, WI. The lack of information in coding and billing prevents using these data sets to detect any differences in clinical outcomes between providers.

Medicare is taking quality metrics and outcomes into consideration in promoting a value-based purchasing model in which penalties or bonuses are awarded based on performance. In 9 states, the Centers for Medicare & Medicaid Services is disseminating Quality and Resource Use Reports to Medicare physicians paid on a fee-for-service basis in an effort to improve care and reward value rather than volume, said Dr Lewandowski.

The Quality and Resource Use Reports provide information to providers on the clinical care and costs to Medicare beneficiaries of other physicians as a comparison. The reports show the various types of services (eg, inpatient hospital stays, outpatient visits) used by Medicare beneficiaries whose care the physician directed. As part of these reports, risk-adjusted per-capita costs are calculated. The value modifier will be applied to some physicians starting in 2015.

Attribution remains a problem with the Quality and Resource Use Reports, Dr Lewandowski said. “Fifty percent of the imaging studies in my state are ordered by the primary care community. Those studies are attributed to me, because I’m the one who billed for them. Rather than empowering me to make a change, it is more likely to make me walk away from the process.”

Bundling payments involves a new payment model that could cover an entire episode of care or be broken into smaller bundles. The hope is that this model could help eliminate unnecessary procedures, reduce administrative burdens related to prior authorization of individual services, and result in better coordinated care across the many clinical sources and sites.

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Last modified: October 8, 2013
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