Better care, smarter spending, healthier people—the Triple Aim. The Health Care Payment Learning & Action Network (LAN) has been working to support health care providers in achieving these goals by speeding adoption of effective alternative payment models (APMs). We and our partners—HHS, states, private payers, providers, employers, consumer groups and others—believe that by better aligning health care payments with higher-value approaches to care, we can drive improvements across the delivery system that translate to better patient outcomes.
We know the payment reform journey is messy and difficult. But with rising health care costs, unfulfilled opportunities to improve care, and increasing frustrations with fee-for-service (FFS) payment methods, it is a necessary and increasingly urgent journey.
The LAN aims to promote effective payment reforms by highlighting innovations, aggregating expertise, sharing lessons learned on what is working and not working, and identifying promising ways health care payers can work together more effectively to implement reforms. We are committed to laying the groundwork for the accelerated development and implementation of APMs that provide better support and more flexibility to serve the needs of patients and providers.
As a start on accelerating progress, the LAN has offered a common vocabulary for describing and discussing APMs. The LAN’s APM Framework and white paper show a progression of categories from traditional fee-for-service, or volume-based, payments to value-based payments that consider care quality and clinical and cost effectiveness. In particular, LAN Category 3 payments include APMs that remain based on a FFS structure (e.g., an accountable care organization (ACO) with providers paid by FFS but with shared savings if quality and total cost benchmarks are met), and Category 4 APMs are based primarily on population-level payments (e.g., a bundled episode payment model paid prospectively or a partial capitation model like Medicare’s Next Generation ACO program). As illustrated in the figure below (reproduced from the Framework white paper), the Framework does not suggest all health care payments should be fully capitated. Rather, given broad recognition of significant problems with FFS-only payments—and widespread efforts to reform those payments—the aim is to support a successful shift toward value-based care, by establishing a common array of terms and set of conventions for measuring the use and impact of different APMs.
The Urban Institute Brief And Health Affairs Blog Post
In a September 19, 2016, brief released by the Urban Institute with an accompanying Health Affairs Blog post, Robert Berenson et al. discuss the LAN’s APM Framework as a guide for value-based payment reform. The authors highlight important challenges in addressing operational barriers to provider adoption of APMs—challenges the many contributors to the LAN are working to address as they implement payment reforms. The authors imply the LAN Framework is intended as a march to capitated payment, rather than a guide for supporting effective payment reform. As use of the Framework to track payment reforms increases, we view this as an opportunity to clarify its intended use, as well as describe some of the LAN’s payment reform tools and activities alongside the Framework.
No One-Size-Fits-All-Solution
The purpose of the LAN is not to advocate for a one-size-fits-all solution, but to make it easier for members of the health care community to link payments to value. Effective APMs should improve coordination of care, enhance health investments, eliminate incentives for inappropriate procedures, and reduce administrative burdens for providers, all of which can improve health outcomes and lower costs.
We intend to update the Framework on a regular basis and keep it sufficiently flexible to accommodate the changing APM landscape while building on critical momentum. The APM Framework white paper includes several principles, which provide important terminology clarifications (e.g., payment models are distinct from delivery models and when more than one payment model occurs, models are classified according to the dominant mode of payment), definitional statements (e.g., models that do not account for quality and value are not considered APMs), and operational considerations (e.g., payment reforms should be substantial enough to support investments in better care models and reach practitioners on the front lines of care delivery). The white paper as a whole is a much needed model for building recognition that current methods can be improved and that models in Categories 3 and 4 hold the most promise to achieve the Triple Aim.
We understand that due to a range of factors—financial considerations, clinical considerations, employer benefit structures, physician and hospital practice alignment, and organizational constraints—there will always be situations where Category 4 APMs may not be appropriate or possible. We have emphasized this point in the Framework’s graphic depiction of our desired “Future State.” We have also noted that methods for evaluating APMs are in an early stage of development, and the models have not been universally proven and need further refinement.
The LAN’s Focus On Addressing The Challenges And Unintended Consequences Of Payment Reform
Indeed, the APM Framework is contributing to a larger body of LAN products and collaborations that focus on learning what works and does not work, and on taking action to advance payment innovation. Among these are a national effort to measure the status of APM adoption, and a Payment Reform Evaluation Hub, supported by the Laura and John Arnold Foundation, to gather more evidence on the impacts of payment reforms.
Along with the Framework, LAN participants have given considerable thought to such challenges as risk adjustment, implementation of episode payments, and approaches for compensating providers. Recommendations to ensure equitable treatment of providers and patients and discourage gaming and other undesirable effects of payment reforms are available on the LAN website in our series of white papers, which reflect the work of diverse LAN stakeholders and constructive public comments. For example, the LAN addresses the importance of properly risk-adjusting population-based payments in a paper by its Population-Based Payment Work Group. Other papers begin to address some of the operational challenges associated with implementing episode payments. The LAN’s Clinical Episode Payment Models White Paper addresses methods for selecting condition codes to include in a clinical episode payment, and offers recommendations for doing so in a way that fairly evaluates and compensates providers.
These and other challenges are why most payment reforms so far have provided relatively modest incentives—to date, most have been “shared savings only” approaches in which the vast majority of provider payments remain based on FFS. But as Berenson and Chernew have noted, modest reforms are likely to have only modest impacts on care delivery, and more substantial APMs (as well as supporting reforms in FFS payments) will likely be needed to support greater improvements in health care value. With this in mind, we believe work by the LAN and many others on these important operational issues must have the sense of urgency and practicality that only comes with real implications for payment flows. Maintaining the status quo until payment reform models are perfected is not sensible, or even possible, since learning about what works best requires implementation of progressively more substantial payment reforms.
Working With Stakeholders On The Operational Issues Of Payment Reform
Building on its foundational work of establishing a common terminology, the LAN’s focus is now shifting to Action Collaboratives to address the essential operational issues that inevitably arise as health care professionals implement the principles and recommendations offered in LAN white papers. We are beginning to work with states, commercial payers, and providers to support the design and implementation of APMs, as well as capture knowledge gained from these efforts and distill it into implementation tools for use across the country.
As we enter this important new phase of our work, we recognize the process is complex with many models still unproven. We will continue to promote discussion of these critical issues and encourage the development and sharing of experience and evidence on what payment reforms work best in the diverse circumstances of patient care. The LAN will continue to encourage input and participation from stakeholders though public comment periods and the opportunity to become committed partners among other means. The goal of better health and more affordable health care for individuals and families is challenging, but it is more urgent than ever—and by continuing to build on the LAN’s collaborative methods, it is also more achievable than ever.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/2eN0buw
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