Using incentives to motivate higher value care by increasingly tying payment to value through alternative payment models

The current system for deriving payment for professional services is, at its core, governed by a complex interplay between several committees of the American Medical Association, the Center for Medicare and Medicaid Services (CMS), and private insurers.4 ,5 In this system the majority of specialists are paid on a fee-for-service basis.6 ,7

As part of the evolving healthcare payment policy, many providers—including neuroendovascular specialists—are already participating in programs that link their fee-for-service payments to quality and value metrics. While there are challenges with the metrics that have been chosen, it is clear that the incremental incentives and disincentives associated with quality and value are attractive to CMS and that Burwell's articulated goal of having 85% of all Medicare fee-for-service payments tied to quality or value by 2016 (and 90% by 2018) are likely to be realized. One could argue that this represents change around the margin.

Alternative payment models are widely considered to be a more disruptive approach than value or quality incentives or penalties. Ms Burwell indicates ambitious near-term targets for use of these types of models. Currently, 20% of Medicare payments to providers are through these alternative structures. HHS plans to increase this to 30% of Medicare payments tied to alternative payment models by the end of 2016, and 50% of payments by the end of 2018.

It is important to note that the term ‘alternative payment models’ is deliberately general. An assumption that a 30% target in less than 2 years is achievable because such models have been explicitly defined would be incorrect. The ‘alternative payment model’ universe includes accountable care organizations (ACOs) as well as other bundled payment arrangements likely familiar to readers of this article. What readers may be less familiar with is how far from mature these ‘at risk’ arrangements are. It is clear that HHS and its branch CMS plan to significantly diminish the role of fee-for-service payments in the near future. Questions remain about whether payment for professional services will be based on historic claims data, physician-run ACOs, or health system-based programs that control physician payments—to name just a few of the possible scenarios.

Of specific interest to readers of this article is Ms Burwell's stated plan to develop new payment models for specialty care. The New England Journal of Medicine article notes that these new payment models will start with care of cancer patients. Reflecting on some of the imperfections in the rollout of these models over the last few years, Ms Burwell commits that HHS will continue to make efforts to build consensus on quality measures and will address issues related to risk adjustment in these new models.

It is worth noting that the Burwell plan might allow for different solutions for varying circumstances, but the overriding element will be the sought-after dramatic shift away from fee-for-service. She points out that this is “the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare”.3

Changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health

There are elements of the second goal that should be attractive to readers of this article. It is clear that patients suffering from cerebrovascular challenges often require the coordinated care of multiple specialists including neurologists, neuroradiologists, neurosurgeons, emergency room physicians, hospitalists, rehabilitation specialists, and non-physician providers. These services occasionally occur across institutions. Currently, these integrative services are, in essence, provided without a specific plan for how to compensate that coordination. There is little doubt that improving the way we coordinate among the services is a valuable goal. If professional payments represent a zero sum game, it will be important to know where the money will come from.

There are a variety of mechanisms through which HHS plans to implement this focus on greater teamwork and integration. We draw particular attention to the CMS Innovation Center (the Innovation Center) that was established by the Social Security Act. The Innovation Center was created for the purpose of testing “innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care for those individuals who receive Medicare, Medicaid, or Children's Health Insurance Program (CHIP) benefits”.8

An initial budget was granted by Congress of $10 billion with a task of returning at least that amount in 10 years’ time. To date, the Innovation Center has had two rounds of fund releases totaling roughly $2 billion. Landmark innovations, including the funding and creation of ACOs, have been launched by this initiative. One initiative receiving far less press, but having potentially more impact on the neuroendovascular community, is Bundled Payments for Care Improvement (BPCI). This initiative is testing four models, one of which includes acute care hospital stay only (Model 4).

“Under Model 4, CMS will make a single, prospectively determined bundled payment to the hospital that would encompass all services furnished during the inpatient stay by the hospital, physicians, and other practitioners. Physicians and other practitioners will submit ‘no-pay’ claims to Medicare and will be paid by the hospital out of the bundled payment. Related readmissions for 30 days after hospital discharge will be included in the bundled payment amount. Participants can select up to 48 different clinical condition episodes.”9 Of the 48 episodes being tested, table 1 shows diagnostic related groups traditionally paid under the Inpatient Prospective Payment System of specific interest to NeuroInterventionalists that are currently being evaluated.

An additional example of an initiative directed towards communication and teamwork is the Transforming Clinical Practice Initiative. In this, $800 million will be invested in providing hands-on support to 150 000 providers “for developing the skills and tools needed to improve care delivery and transition to alternative payment models”.3 The sheer dollar investment within this initiative demonstrates the administration's resolve. It is also worth noting that CMS is under no obligation to wait for the results of these Innovation Center projects.

Harnessing the power of information to improve care for patients

While the third major agenda item seems straightforward, it is—not surprisingly—a more complex issue than one might at first perceive. Certainly, nobody can or should argue with the value of harnessing the power of information to improve care. The issue is that one group's perception is often different from another's reality. There was a remarkably low participation in federally-funded Meaningful Use Programs which, by their nature, were designed to increase utilization of electronic health records (EHRs). Burwell points to massive increases from 18% to 78% of physicians using EHRs between 2001 and 2013. It is difficult to know to what extent meaningful use incentives and penalties impacted on this process. What is certain is that the limited participation resulted in very divergent payments across the US healthcare system. Indeed, monolithic approaches to the implementation of information technology solutions within a complex healthcare endeavor can lead to a variety of unintended problems with resultant consequences, as exampled by large-scale security breaches that can literally be pulled right out of the day's news.10 ,11

Burwell describes recent efforts to enhance transparency in the healthcare marketplace.12 We are cautiously optimistic about the opportunities that come with price transparency; optimistic because an educated healthcare consumer should be beneficial for quality providers, and cautious as we remember the data dump that represented the CMS foray into sharing provider payments this past year. This data release occurred without any effort at providing context, such that patients were left to derive their information from a variety of sources that few would argue at times were less than ideal.13 Additionally, there are many elements that are reflected in physician charges and potentially quality ratings that require significant education beyond simply comparing numbers. Examples include in-office payments versus community hospital versus tertiary care environments.

A portion of Ms Burwell's discussion is directed to harnessing information related to the Patient Centered Outcomes Research Institute (PCORI). PCORI is one of two independent boards that were created by the ACA. Its activities relate to comparative effectiveness research (CER).14 We recently reviewed the progressive development of PCORI.15 The authors of this article are supportive of efforts to enhance the availability and utilization of CER.16 Indeed, many professional societies that have as their members neuroendovascular specialists formally supported its creation and development. With that support in mind, it is relevant to note that some of the interventions that neuroendovascular specialists consider a routine part of their practice are potentially vulnerable in an environment that is managed through CER.