Delivery System Redesign

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) creates strong incentives for physicians to participate in Alternative Payment Models (APMs), and it specifically encourages the development of “Physician-Focused Payment Models” in order to address the many problems with current payment systems that Merit-Based Incentive Payment Systems cannot solve. This report explains the provisions of MACRA relating to APMs and describes the actions HHS should take in the following areas: the regulations defining APMs and alternative payment entities; the processes for soliciting, reviewing, and approving Physician-Focused Payment Models; and the systems and resources to implement Physician-Focused Alternative Payment Models.

Today, there are roughly 750 ACOs across the nation serving 23.5 million people insured by Medicare, Medicaid, and commercial insurance. This evolving model strives to fulfill the Triple Aim of better health, improved patient experience, and lower costs by shifting more accountability for health outcomes to providers. While not all ACOs have been able to deliver better outcomes at lower costs, many have been able to realize these goals. This brief explores promising trends, emerging opportunities, and potential barriers identified by ACO stakeholders across the country. It also examines how ACOs can build upon initial successes and informs policymakers, researchers, and foundations about key considerations to further the development of effective ACO approaches across the health care market.

With rapid health care transformation efforts underway across the nation, there is increasing attention on improving outcomes and reducing avoidable health care costs for the small subset of individuals who account for the majority of health care spending. Significant gaps in understanding remain—including how to identify and engage individuals, segment populations into meaningful subgroups with tailored interventions; measure quality outcomes, and align financial incentives across systems. This report aims to identify those opportunities that warrant further exploration, with hopes of targeting future investments and pilot activities to help fill the gaps that remain.

The Centers for Medicare and Medicaid Services (CMS) is implementing the Bundled Payments for Care Improvement (BPCI) initiative to test four different alternative payment models based on episodes of care that involve an inpatient hospital stay. One model focuses on care provided during the hospital stay, while the other three models include post-acute care provided once the patient is released from the hospital. CMS hopes that by paying for related care as part of a broad payment bundle, different providers who treat a patient during a single episode will have incentives to better coordinate care, avoid unnecessary services, and improve patient health. This brief describes the different models being tested and CMS’s experience with the project to date.
 

There is widespread agreement that changes in healthcare payment systems are needed to achieve higher quality, more affordable healthcare. To date, however, most payment reform initiatives have had relatively little impact on either healthcare spending or quality.  This report describes seven different alternative payment models that can enable physicians in every specialty to redesign the way they deliver care in order to control spending and improve quality for their patients.