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We aim to assess the healthcare value achieved from a shared savings program for pediatric appendectomy. All appendectomy patients covered by our health plan were included. Quality targets were 15% reduction in time to surgery, length of stay, readmission rate, and patient satisfaction. Quality targets and costs for an appendectomy episode in two 6-month performance periods (PP1, PP2) were compared to baseline. 640 patients were included (baseline:317, PP1:167, PP2:156). No quality targets were met in PP1. Two quality targets were met during PP2: readmission rate (−57%) and patient satisfaction. No savings were realized because the cost reduction threshold (−9%) was not met during PP1 (+1.7%) or PP2 (−0.4%). Payer-provider partnerships can be a platform for testing value-based reimbursement models. Setting achievable targets, identifying affectable quality metrics, considering case mix index, and allowing sufficient time for interventions to generate cost savings should be considered in future programs. •Assessed the medical value of a Shared Savings Program for pediatric appendicitis.•Quality targets included time to surgery, length of stay, readmission, and patient satisfaction.•Two quality targets were met during the study period, readmission and satisfaction.•However, no savings were realized because the cost threshold was not met.•Payer-provider partnerships can be a platform for testing value-based reimbursement.

Value-based health insurance designs (VBIDs) are one approach to increase adherence to highly effective medications and simultaneously contain rising health care costs. The objective of this systematic review was to identify VBID effects on adherence and incentive designs within these programs that were associated with higher effects. Eight economic and medical databases were searched for literature. Random effects meta-analyses and mixed effects meta-regressions were used to synthesize VBID effects on adherence. Thirteen references with evaluation studies, including 12 patient populations with 79 outcomes, were used for primary meta-analyses. For qualitative review and sensitivity analyses, up to 19 references including 20 populations with 119 outcomes were used. Evidence of synthesized effects was good, because references with high risk of bias were excluded. VBIDs significantly increased adherence in all indication areas. Highest effects were found in medications indicated in heart diseases (4.05%-points, p < 0.0001). Each additional year increased effects by 0.15%-points (p < 0.01). VBIDs with education were more effective than without education, but the difference was not significant. Effects of VBIDs with full coverage were more than twice as high as effects of VBID without that option (4.52 vs 1.81%-points, p < 0.05). These findings were robust in most sensitivity analyses. It is concluded that VBID implementation should be encouraged, especially for patients with heart diseases, and that full coverage was associated with higher effects. This review may provide insight for policy-makers into how to make VBIDs more effective.

Background Many glaucoma patients do not adhere to their medication regimens because they fail to internalize the (health) costs of non-adherence, which may not occur until years or decades later. Behavioural economic theory suggests that adherence rates can be improved by offering patients a near-term benefit. Our proposed strategy is to offer adherence-contingent rebates on medication and check-up costs. This form of value pricing (VP) ensures that rebates are granted only to those most likely to benefit. Moreover, by leveraging loss aversion, rebates are expected to generate a stronger behavioural response than equivalent financial rewards. Methods/Design The main objective of the Study on Incentives for Glaucoma Medication Adherence (SIGMA) is to test the VP approach relative to usual care (UC) in improving medication adherence. SIGMA is a randomized, controlled, open-label, single-centre superiority trial with two parallel arms. A total of 100 non-adherent (Morisky Medication Adherence Scale ≤6) glaucoma patients from the Singapore National Eye Centre are block-randomized (blocking factor: single versus multiple medications users) into the VP and UC arms in a 1:1 ratio. The treatment received by VP patients will be strictly identical to that received by UC patients, with the only exception being that VP patients can earn either a 50 % or 25 % rebate on their glaucoma-related healthcare costs conditional on being adherent on at least 90 % or 75 % of days as measured by a medication event monitoring system. Masking the arm allocation will be precluded by the behavioural nature of the intervention but blocking size will not be disclosed to protect concealment. The primary outcome is the mean change from baseline in percentage of adherent days at month 6. A day will be counted as adherent when the patients take all their medication(s) within the appropriate dosing windows. Discussion This trial will provide evidence on whether adherence-contingent rebates can improve medication adherence among non-adherent glaucoma patients, and more generally whether this approach represents a promising strategy to cost-effectively improve chronic disease management. Trial registration NCT02271269 . Registered on 19 October 2014.

The federal CMMI was created to assess new payment and service delivery models for improving health care nationwide. This review reports that during the agency’s first decade of operation, some of the value-based models saved money and improved quality but most did not. The lessons learned and future directions are discussed.

Under value-based payment models, there is a misalignment between organizations’ incentives to spend wisely and individual physicians’ incentives to reduce malpractice liability risk. One idea that has been proposed to correct this mismatch is enterprise liability.

Diabetes process and outcome measures are common quality measures in payment reform models, including Alternative Payment Models (APMs) and value-based insurance design (VBID). In this commentary we review evidence from selected research to examine whether these payment models can improve the value of diabetes care. We found that higher-risk APMs yielded greater improvements in diabetes process measures than lower-risk APMs, and that VBID models appeared to improve medication adherence but not other quality measures. We argue that these models are promising first steps in redesigning the payment system to improve diabetes care. However, greater coordination and alignment across models is needed to enhance their impact on providers' behavior, diabetes care processes, and patient health outcomes.

Abstract Inflammatory bowel disease (IBD) is a chronic inflammatory disease associated with significant resource utilization and health care burden. It is emerging as a global disease affecting an increasing proportion of the population. Along with evolving epidemiological trends, the paradigm of managing IBD has also changed. With a burgeoning repertoire of therapeutic options, improved use of health informatics, and emphasis on health care value, the treatment paradigm for IBD has experienced seismic shifts. In this review, we focused on value-based health care (VBHC)-a health care model that emphasizes monitoring outcomes to emphasize patient-centered, cost-effective IBD patient care. Several quality initiatives have been developed worldwide, and successful models of care were created for proper implementation of these initiatives. Although there are significant challenges to scale these models to a national level, it is still possible to successfully implement VBHC models within health systems to improve the quality of care provided to patients with IBD.

An insightful overview of health insurers and a guide to sustainability for provider organizations.Physicians experience ongoing frustrations in their relationships with health plans. Even as they struggle to keep up with accelerating clinical advances, they face daunting challenges from payers that are transitioning from traditional fee-for-service contracts to complex alternative payment models. In Health Plans Unmasked, Martin Lustick, MD, offers insights and guidance for those who face the herculean task of transforming their business practices to achieve financial stability while improving outcomes for their patients.By explaining both how and why insurance companies behave the way they do, Dr. Lustick helps providers avoid mistakes and take advantage of opportunities for success. He provides information on:• The evolution of health care financing in the United States• The nuts and bolts of health plan capabilities and the real motives of health plan administrators• Tips for successful contracting strategies • Alternative payment models and the promises of value-based careWith a career spanning five decades as a practicing pediatrician, chief operating officer of a medical group, chief medical officer of a hospital, and chief medical officer of a health plan, Dr. Lustick provides a straightforward guide to sustainability for provider organizations. Physicians, office managers, and anyone in a health-related field will benefit from his breaking down the role of health plans in our health care ecosystem.

Medicaid holds significant responsibility for improving maternal and infant health in the US. Utilizing value-based care (VBC) that offers additional support to providers is one strategy by which the Medicaid system can improve these outcomes. In this analysis, we examined a Medicaid managed care plan's incentive-only VBC program, which is supported by a provider enablement team to assist care providers in meeting program goals. Cross-sectional analysis of deliveries occurring between July 2020 and June 2022 from Elevance Health-affiliated Medicaid managed care plans operating in 16 states. This study primarily relied on medical claims data to compare maternal, infant, and cost outcomes in Medicaid members with a care provider participating in a supported VBC program vs those with a care provider not participating in supported VBC. A propensity-balanced multivariable regression model was used to estimate the impact of participation vs nonparticipation in supported VBC on delivery, cost, and quality outcomes. Members with a care provider supported in the VBC program had significantly lower neonatal intensive care unit (NICU) lengths of stay, preterm births, and low birth weights; significantly better timeliness and adequacy of prenatal care rates; and significantly lower birth costs, NICU costs, and maternal and infant costs in the first year after birth. These results provide insight into how payers and care providers can partner to improve maternal and infant outcomes among Medicaid members and subsequently experience cost savings.