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Institutional special-needs plans could warrant further investigation as a value-based model for financing care provided to long-stay nursing home residents.

The Comprehensive Primary Care Initiative (CPC), a health care delivery model developed by the Centers for Medicare and Medicaid Services (CMS), tested whether multipayer support of 502 primary care practices across the country would improve primary care delivery, improve care quality, or reduce spending. We evaluated the initiative's effects on care delivery and outcomes for fee-for-service Medicare beneficiaries attributed to initiative practices, relative to those attributed to matched comparison practices. CPC practices reported improvements in primary care delivery, including care management for high-risk patients, enhanced access, and improved coordination of care transitions. The initiative slowed growth in emergency department visits by 2 percent in CPC practices, relative to comparison practices. However, it did not reduce Medicare spending enough to cover care management fees or appreciably improve physician or beneficiary experience or practice performance on a limited set of Medicare claims-based quality measures. As CMS and other payers increasingly use alternative payment models that reward quality and value, CPC provides important lessons about supporting practices in transforming care.

Though the Centers for Medicare and Medicaid Services focuses primarily on health care delivery for its beneficiaries, it is working at the practice, delivery-system, and broader-population levels to encourage incremental progress toward population health. There is an emerging consensus that to improve health as much as possible, we must adopt population health strategies addressing underlying causes of poor health. 1 The term “population health” has been used to describe both a clinical perspective focused on delivering care to groups enrolled in a health system and a broader perspective that focuses on the health of all people in a given geographic area and emphasizes multisector approaches and incorporation of nonclinical interventions to address social determinants of health. 2 , 3 As a health care payer, the Centers for Medicare and Medicaid Services (CMS) focuses primarily on health care . . .

Pain is a significant public health problem that needs policy at the national and local level to resolve incidents of insufficient, ineffective, and disparate pain treatment while limiting the risk of inadvertently increasing the use of treatment such as opioids that can result in public harm. The National Pain Strategy serves as the first comprehensive approach to address pain and provides a roadmap with substantial broad and specific policy implications. Although much has been accomplished to date, transitions in political power, available data and funding, and the current opioid epidemic continue to have an impact on implementation of the National Pain Strategy. A sustained, coordinated effort with multipronged policies in many forms on both federal and state levels via regulations, laws, and guidelines is warranted. However, research is needed to evaluate the impact and potential unintended consequences of increased legislation and regulation. Nevertheless, policy related to the management of pain may provide the path to new treatments and models of care to reduce the impact of pain as a public health crisis in this country.

In 2015, the Centers for Medicare and Medicaid Services will introduce a non–visit-based payment for chronic care management. The new policy reflects an investment in primary care that may contribute to the development of a value-oriented health system. Many efforts to reform U.S. health care delivery focus on creating a high-performing primary care system that improves value through increased emphasis on access, prevention, and care coordination. Reformers recognize that the fee-for-service system, which restricts payments for primary care to office-based visits, is poorly designed to support the core activities of primary care, which involve substantial time outside office visits for tasks such as care coordination, patient communication, medication refills, and care provided electronically or by telephone. 1 But this system is about to change. In 2015, the Centers for Medicare and Medicaid Services (CMS) will introduce a non–visit-based payment . . .

COVID-19 has delayed the transition to Oncology Care First, but the forthcoming model could help.

In 2012, the Centers for Medicare and Medicaid Services (CMS) initiated the Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organization (ACO) programs. Organizations in the MSSP model shared cost savings they generated with CMS, and those in the Pioneer program shared both savings and losses. It is largely unknown what hospital and environmental characteristics are associated with the development of CMS ACOs with one- or two-sided risk models. The aim of this study was to assess the organizational and environmental characteristics associated with hospital participation in the MSSP and Pioneer ACOs. Hospitals participating in CMS ACO programs were identified using primary and secondary data. The ACO hospital sample was linked with the American Hospital Association, Health Information and Management System Society, and other data sets. Multinomial probit models were estimated that distinguished organizational and environmental factors associated with hospital participation in the MSSP and Pioneer ACOs. Hospital participation in both CMS ACO programs was associated with prior experience with risk-based payments and care management programs, advanced health information technology, and location in higher-income and more competitive areas. Whereas various health system types were associated with hospital participation in the MSSP, centralized health systems, higher numbers of physicians in tightly integrated physician-organizational arrangements, and location in areas with greater supply of primary care physicians were associated with Pioneer ACOs. Favorable hospital characteristics were, in the aggregate, more important than favorable environmental factors for MSSP participation. MSSP ACOs may look for broader organizational capabilities from participating hospitals that may be reflective of a wide range of providers participating in diverse markets. Pioneer ACOs may rely on specific hospital and environmental characteristics to achieve quality and spending targets set for two-sided contracts. Hospital and ACO leaders can use our results to identify hospitals with certain characteristics favorable to their participation in either one- or two-sided ACOs.

By 2017, the value-based payment modifier will be used to reward or penalize all Medicare physicians on the basis of the relative calculated value of the care they provide. But a physician's overall value cannot be assessed with current or foreseeable measures. Perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs. In keeping with this notion of paying for value rather than volume, the Affordable Care Act (ACA) created the “value-based payment modifier,” or “value modifier,” a pay-for-performance approach for physicians who actively participate in Medicare. By 2017, physicians will be rewarded or penalized on the basis of the relative calculated value of the care . . .

Background: The Centers for Medicare and Medicaid Services (CMS) promulgated regulations commencing October 1, 2008, which deny payment for selected conditions occurring during the hospital stay and are not present on admission. Three of the 10 hospital-acquired conditions covered by the new CMS policy involve healthcare-associated infections, which are a common, expensive, and often preventable cause of inpatient morbidity and mortality. Objective: To outline a research agenda on the impact of CMS's payment policy on the healthcare system and the prevention of healthcare-associated infections. Methods: An invitational daylong conference was convened in April 2009. Including the planning committee and speakers there were 41 conference participants who were national experts and senior researchers. Results: Building upon a behavioral model and organizational theory and management research a conceptual framework was applied to organize the wide range of issues that arose. A broad array of research topics was identified. Thirty-two research agenda items were organized in the areas of incentives, environmental factors, organizational factors, clinical outcomes, staff outcomes, and financial outcomes. Methodological challenges are also discussed. Conclusions: This policy is a first significant step to move output-based inpatient funding to outcome-based funding, and this agenda is applicable to all hospital-acquired conditions. Studies beginning soon will have the best hope of capturing data for the years preceding the policy change, a key element in nonexperimental research. The CMS payment policy offers an excellent opportunity to understand and influence the use of financial incentives for improving patient safety.

Hospice developed in the United States in the 1970s as a way to address unmet needs for end-of-life care: support for pain and symptom management provided in the location and manner that the patient and family prefer. In Europe and Australia, hospice is available from the time of diagnosis of an advanced life-limiting illness onward, but in the United States, the Medicare hospice benefit restricts eligibility for these services to patients who no longer receive curative treatment. We provide background and analysis of the first Medicare hospice demonstration in 35 years that will test the concurrent provision of curative and hospice services for terminally ill individuals with a life expectancy of six months or less. This demonstration is a harbinger of potential policy changes to hospice and palliative care in the United States that could reduce barriers to end-of-life care that aligns with patient and family preferences as the demand for care increases with an aging population.