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payment innovation

Ursula Koch, Somava Stout, Bruce E Landon, Russell S Phillips
Innovations in payment are encouraging clinical-community partnerships that address health determinants. However, little is known about how healthcare systems transform and partner to improve population health. We synthesized views of population health experts from nine organizations and illustrated the resulting model using examples from four health systems. The transformation requires a foundation of primary care, connectors and integrators that span the boundaries, sharing of goals among participants, aligned funding and incentives, and a supporting infrastructure, all leading to a virtuous cycle of collaboration...
September 28, 2016: Healthcare
Lisa Simon
Since the founding of dental schools as institutions distinct from medical schools, dentistry-its practice, service delivery, and insurance coverage, for example-and dental care have been kept separate from medical care in the United States. This separation is most detrimental to undeserved groups at highest risk for poor oral health. As awareness grows of the important links between oral and general health, physicians and dentists are collaborating to develop innovative service delivery and payment models that can reintegrate oral health care into medical care...
2016: AMA Journal of Ethics
David T Feinberg, Mark B McClellan
No abstract text is available yet for this article.
September 26, 2016: JAMA: the Journal of the American Medical Association
Gonzalo Barinaga, Monique C Chambers, Mouhanad M El-Othmani, Richard B Siegrist, Khaled J Saleh
Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services' Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures...
October 2016: Orthopedic Clinics of North America
Lee Revere, Adele Semaan, Nicole Lievsay, Jessica Hall, Zheng M Wang, Charles Begley
The Texas Medicaid 1115 Transformation Waiver reforms the state's safety net systems by creating a Delivery System Reform Incentive Payment incentive pool for innovative healthcare delivery. The Waiver supports the design and implementation of transformative projects. As part of the Waiver requirements, regions created Learning Collaboratives to collaborate on project implementation and outcomes. This paper describes the experience of one region in adapting the Institute for Healthcare Improvement Breakthrough Series (IHI BTS) model, as a framework for their Learning Collaborative...
September 13, 2016: Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality
John Kimberly, Imran Cronk
The world of health care is changing dramatically, as reflected in the number, magnitude, and scope of innovative new approaches-to how illness is treated and how better health is promoted-that are being implemented around the globe. The changes triggered by these initiatives affect both how care is organized, managed, and paid for and the kinds of approaches that are being developed to keep people healthy. Underlying these changes is a more fundamental paradigm shift, a shift in the priority given to "value" in the formulation of policy and management practice...
September 6, 2016: Annals of the New York Academy of Sciences
Michael-Holger Wilke, Markus Rathmayer
BACKGROUND: New procedures in endoscopy take time to be incorporated in the German diagnosis-related groups (DRG) system. Depending on the extent of innovation and the costs, several pathways are possible. METHODS: This article provides an overview of possible pathways to implement new procedures in the German DRG payment system. Additionally, we compare the results of 2 surveys on the system of New Diagnostic and Treatment Methods (Neue Untersuchungs- und Behandlungsmethoden; NUB)...
February 2016: Visc Med
Hui Zhang, Christian Wernz, Danny R Hughes
Payment innovations that better align incentives in health care are a promising approach to reduce health care costs and improve quality of care. Designing effective payment systems, however, is challenging due to the complexity of the health care system with its many stakeholders and their often conflicting objectives. There is a lack of mathematical models that can comprehensively capture and efficiently analyze the complex, multi-level interactions and thereby predict the effect of new payment systems on stakeholder decisions and system-wide outcomes...
September 1, 2016: Health Care Management Science
Matthew C Nattinger, Keith Mueller, Fred Ullrich, Xi Zhu
PURPOSE: The Centers for Medicare & Medicaid Services (CMS) has facilitated the development of Medicare accountable care organizations (ACOs), mostly through the Medicare Shared Savings Program (MSSP). To inform the operation of the Center for Medicare & Medicaid Innovation's (CMMI) ACO programs, we assess the financial performance of rural ACOs based on different levels of rural presence. METHODS: We used the 2014 performance data for Medicare ACOs to examine the financial performance of rural ACOs with different levels of rural presence: exclusively rural, mostly rural, and mixed rural/metropolitan...
August 24, 2016: Journal of Rural Health
Jesse M Pines, Frank McStay, Meaghan George, Jennifer L Wiler, Mark McClellan
Current alternative payment models (APMs) that move away from traditional fee-for-service payment often have explicit goals to reduce utilization in episodic settings, such as emergency departments (ED). We apply the new HHS payment reform taxonomy to illustrate a pathway to success for EDs in APMs. Despite the unique challenges faced by EDs, a variety of category 2 and 3 APMs may be applicable to EDs in the short- and long term to improve efficiency and value. Full and partially capitated models create incentives for longitudinal and episodic ED providers and payers to unite to create interventions to reduce costs...
August 2016: American Journal of Managed Care
Brent C James, Gregory P Poulsen
Recent studies suggest that at least 35%--and maybe over 5o%--of all health care spending in the U.S. is wasted on inadequate, unnecessary, and inefficient care and suboptimal business processes. But efforts to get rid of that waste face a huge challenge: Under current payment methods, the providers who develop more-cost-effective approaches don't receive any of the savings. Instead, the money goes mainly to insurers. The providers, who are paid for the volume of services delivered, end up actually losing money, which undermines their finances and their ability to invest in more cost-saving innovations...
July 2016: Harvard Business Review
Adam J Olszewski, Steven P Treon, Jorge J Castillo
INTRODUCTION: Waldenström macroglobulinemia/lymphoplasmacytic lymphoma (WM) is a rare lymphoma affecting older patients. Its management largely relies on small phase II trials and it is unclear how their results translate into clinical practice in the community. METHOD: We evaluated changes in the presentation, management, and survival among 2,666 Medicare beneficiaries diagnosed with WM between 1994 and 2011, using Medicare claims linked to Surveillance, Epidemiology and End Results data...
July 29, 2016: Oncologist
O Sagna, I Seck, A T Dia, F L Sall, S Diouf, J Mendy, O Ka, B Kassoka
In Senegal, the informal and rural sector that accounts for over 80% of the population is covered only up to 7% by a health insurance system. That is why, for the implementation of development strategy of the universal health coverage (UHC) through mutual health insurance providers, the Government of Senegal has focused on this sector. The objective of this study was to assess the consumer's preference on the UHC development strategies through mutual health insurance providers. This was a qualitative and exploratory study based on a literature review, and indepth interview with the heads of households...
August 2016: Bulletin de la Société de Pathologie Exotique
Charles Begley, Jessica Hall, Amrita Shenoy, June Hanke, Rebecca Wells, Lee Revere, Nicole Lievsay
Texas is one of 8 states that have received a Medicaid 1115 Transformation Waiver in which federal supplemental payments are being used to incentivize delivery system reform. Under the Texas Transformation Waiver's 5-year Delivery System Reform Incentive Payment (DSRIP) program, hospitals and other providers have established regional health care partnerships, conducted regional needs assessments, and developed and implemented projects addressing local gaps in service. The projects were selected from menus, supplied by the Texas Health and Human Services Commission and the Centers for Medicare & Medicaid Services, which defined acceptable infrastructure development and/or program innovation and redesign initiatives...
July 25, 2016: Population Health Management
Ana Clopes, Montse Gasol, Rosana Cajal, Luis Segú, Ricard Crespo, Ramón Mora, Susana Simon, Luis A Cordero, Candela Calle, Antoni Gilabert, Josep R Germà
BACKGROUND: In 2011 the first payment-by-results (PbR) scheme in Catalonia was signed between the Catalan Institute of Oncology (ICO), the Catalan Health Service, and AstraZeneca (AZ) for the introduction of gefitinib in the treatment of advanced EGFR-mutation positive non-small-cell lung cancer. The PbR scheme includes two evaluation points: at week 8, responses, stabilization and progression were evaluated, and at week 16 stabilization was confirmed. AZ was to reimburse the total treatment cost of patients that failed treatment, defined as progression at weeks 8 or 16...
July 21, 2016: Journal of Medical Economics
Joseph White
No abstract text is available yet for this article.
July 14, 2016: New England Journal of Medicine
Jason Furman, Matthew Fiedler
No abstract text is available yet for this article.
July 14, 2016: New England Journal of Medicine
Glen Stream, Jennifer E DeVoe, Lauren S Hughes, Robert L Phillips
This paper was prepared in follow up to the G. Gayle Stephens Keystone IV Conference by authors who attended the conference and are also members of the Family Medicine for America's Health board of directors ( It connects the aspirations of the current strategic and communications efforts of FMAHealth with the ideas developed at the conference. The FMAHealth project is sponsored by 8 national family medicine organizations and seeks to build on the work of the original Future of Family Medicine project...
July 2016: Journal of the American Board of Family Medicine: JABFM
Anna Hung, Eleanor M Perfetto
BACKGROUND: Medicare Prescription Drug Plans (PDPs) do not have incentives to consider long-term outcomes and costs associated with both medical and pharmacy benefits (LTOCMP) when making formulary decisions. OBJECTIVE: To identify existing quality measures, payment models, and public reporting tools for PDPs that are related to formulary decision making and that could be used as potential incentives for PDPs to consider LTOCMP. METHODS: PubMed, Google, and quality measure databases, as well as Center for Medicare and Medicaid Innovation and Centers for Medicare & Medicaid Services (CMS) websites, were searched for appropriate quality measures, payment models, and public reporting tools...
July 2016: Journal of Managed Care & Specialty Pharmacy
Christine Rodriguez, Andrew Reynolds
Hepatitis C virus (HCV) is an illustrative example of the dilemma faced by patients in the American healthcare landscape: HCV is a chronic, progressive disease for which a cure exists, but at such high prices that cost-sharing innovations create significant barriers to care, treatment, and cure. Previous HCV treatments were ineffective and had a wide range of severe side effects, so much so, that both patients and their providers chose to wait for newer and more effective options. Yet, once these options became available, cost-sharing mechanisms, such as plan premiums, deductibles, co-payments, and coinsurance, created barriers to treatment, producing a large pool of patients infected with HCV who are willing but unable to access a cure...
March 2016: American Journal of Managed Care
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