Delivery System Redesign

The Centers for Medicare and Medicaid Services and states are partnering to transform health care systems by creating and testing new models of care delivery and payment. Interviews with officials from states participating in the State Innovation Models (SIM) Initiative reveal that the readiness of providers and payers to adopt innovations varies, requiring different starting points, goals, and strategies. State governments also have policy levers to encourage efficient deployment of a diverse health care workforce. As federal officials review states’ innovation plans, set timetables, and provide technical assistance, they can also take steps to accommodate the budgetary, political, and time constraints that states are facing.

This article describes how a geographic health information system in Durham, North Carolina, links health system and social and environmental data via shared geography to provide a multidimensional understanding of individual and community health status and vulnerabilities. Geographic health information systems can be useful in supporting the Institute for Healthcare Improvement’s Triple Aim Initiative to improve the experience of care, improve the health of populations, and reduce per capita costs of health care. A geographic health information system can also provide a comprehensive information base for community health assessment and intervention for accountable care that includes the entire population of a geographic area.

In recent years there has been a significant expansion in the use of provider performance measures for quality improvement, payment, and public reporting. Using data from a survey of health plans, this study characterizes the use of such performance measures by private payers, and also compares the use of these measures among selected private and public programs. Twenty-three health plans with 121 million commercial enrollees, representing 66 percent of the national commercial enrollment, were studied. The authors found that there was much variation in the use of performance measures in both private and public payment and care delivery programs, despite common areas of focus that included cardiovascular conditions, diabetes, and preventive services. 

Around the country, models are emerging to link primary care providers not only to other medical service providers but also to resources and services in the community. This report—the first in a series supported by The Commonwealth Fund to explore opportunities for improvement in federal and state policy—highlights relevant policy levers and federal and state initiatives to integrate these resources. It also discusses opportunities for policy improvement identified during a Commonwealth Fund-supported discourse among high-level state and federal officials hosted by NASHP. 

This brief calls for an approach to payment reform that harnesses the inherent motivation that doctors and patients have to make good decisions about health care. The authors reject the assumption that health care costs will drop and quality will improve if policymakers and payers simply find the right mix of rewards (“carrots”) and punishments (“sticks”). The report draws on a large body of research that shows external incentives designed to change simple behaviors, like improving productivity in rote tasks, do not work for more complex behaviors. The report also analyzes cost and quality variability data for over 20 health conditions, identifying those (such as diabetes and coronary heart disease) most ripe for incentive experimentation and reform.

The need to readmit a patient to the hospital soon after discharge can be an indicator of poor care coordination. Hospital readmissions are also extremely costly to the health system overall. Commonwealth Fund–supported researchers identified several strategies that hospitals could use to lower their 30-day readmission rates, among them: partnering with community physicians or physician groups, making nurses responsible for medication reconciliation, and arranging follow-up appointments before leaving the hospital.

In the United States, per capita spending on health care is more than double that in most other high-income, industrialized countries, including Australia, Germany, Japan, and Sweden. Yet performance on many health outcome measures in the U.S. lags these lower-spending nations. A New England Journal of Medicine Perspective examines two effective cost-containment strategies from abroad: Germany’s bundled payment system and Japan’s volume-driven pricing adjustment.

A medical home is an enhanced model of primary care that provides whole person, accessible, comprehensive, ongoing and coordinated patient-centered care. First advanced by the American Academy of Pediatrics in the 1960’s, the concept gained momentum in 2007 when four major physician groups agreed to a common view of the patient-centered medical home (PCMH) model defined by seven “Joint Principles.” NASHP’s medical home map allows you to click on a state to learn about its PCMH efforts.

Bundled payment is the concept of paying a fixed dollar amount to cover a set of services, as an episode of care over a defined period. Because of the fixed price, providers are encouraged to hold variable costs down; yet BP programs usually require providers to satisfy a minimum set of quality metrics in order to receive payment, thus ensuring providers do not skimp on care. This paper examines issues confronted by two AF4Q communities that are considering or implementing BP initiatives.

This Neiman Report highlights two of several emerging models being developed by the Harvey L. Neiman Health Policy Institute designed to align provision and payment of specialty care with efforts to ensure a sustainable, high quality health care system.