For the health care marketplace to advance, purchasers, health plans, providers and benefits consultants need rigorous, standard evaluations of payment and delivery reforms and benefit and network designs and results need to be shared broadly.
How? Purchasers, health plans, and providers should be open to providing independent researchers with access to data about these programs so that they can conduct thorough, unbiased evaluations of their impact on cost and quality.
For purchasers to invest and agree to participate in certain payment and delivery reforms and benefit and network designs, they need comprehensive, meaningful information about the performance of these programs.
How? Health plans must provide purchasers with comprehensive, meaningful and standardized reports on the performance of these programs so that purchasers can understand their value–whether they are leading to more affordable, higher quality care.
For payment and delivery reform programs to succeed, reforms need to move away from incentivizing volume and toward incentivizing value. Many of the value-based payment arrangements piloted and implemented today rely on fee-for-service. Therefore, to truly move away from volume-based incentives, the underlying fee schedule must be modified so that payers are paying appropriate amounts for services.
How? Health plans must work with contracted providers to ensure that the relative amounts they pay for care are appropriate and necessary. For example, pay less for services that are over-valued (e.g., interpreting the results of an electrocardiogram), and more for services that are undervalued (e.g., visits with patients to diagnose and treat depression).
Tools & resources to help push this agenda item: 2018 RFI and Contract Language, Fee Schedules for Physicians and Other Health Professionals, Good news! CMS will continue to provide oversight on physician fee schedule, MYTHBUSTER: Fee-for-service has no place, How Medicare’s Flawed Physician Fee Schedule Harms Patients, Finding Value in Unexpected Places—Fixing the Medicare Physician Fee Schedule
For employers and state Medicaid agencies, maternity care is a high cost clinical area with highly-varied clinical outcomes. Therefore, an important priority for purchasers is to encourage adherence to clinical guidelines for maternity care.
How? Consumer and provider education as well as policy mechanisms are important vehicles to push maternity care to be more evidence-based, but payment and delivery reform is an underutilized vehicle. Blended payment for vaginal births and cesarean deliveries or non-payment for early elective cesareans are methods to reduce the cesarean section rate, as are other strategies.
Tools & resources to help push this agenda item: 2018 RFI and Contract Language, How-To Guide: Non-Payment for Early Elective Deliveries, Action Brief: Maternity Care Payment