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The American Journal of Managed Care August 2014
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Synchronization of Coverage, Benefits, and Payment to Drive Innovation
Annemarie V. Wouters, PhD; and Nancy McGee, JD, DrPH
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Synchronization of Coverage, Benefits, and Payment to Drive Innovation

Annemarie V. Wouters, PhD; and Nancy McGee, JD, DrPH
Implementation of payment reform, without a corresponding change to coverage, benefit, and other payment requirements, creates conflicting incentives that may nullify the intended aim of payment reform: to improve health outcomes, while saving costs.

Moving away from volume-based fee-for-service payment methods to value-based payments is widely recognized by many as a way to incentivize patient-centric, high-quality, innovative, and efficient care in the Medicare program. Making the unit of payment broader and tying payments to performance measures is helpful for setting the direction for health- system change, but it will not be sufficient. The myriad of payment, coverage, and benefit policies—and the processes for establishing them— were created during the era of payment silos. They now will need to be revisited and redesigned if we are to fully realize the objectives of payment reform. As in the commercial payer world, how fast this occurs will depend on the CMS’s appetite for change, the PAB’s ability to take on these new responsibilities, and Congressional action to support change. 

Author Affiliations: Manatt Health Solutions, Washington, DC (AW, NM).


Funding Source: None reported.


Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (AW, NM); acquisition of data (AW); analysis and interpretation of data (AW); drafting of the manuscript (AW, NM); critical revision of the manuscript for important intellectual content (AW, NM); provision of study materials or patients (AW); administrative, technical, or logistic support AW); and supervision (AW).


Address correspondence to: Annemarie V. Wouters, PhD, Manatt Health Solutions, 700 12th St, NW, Ste 1100, Washington, DC 20005. E-mail: awouters@manatt.com.

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