The United States is in the throes of multiple experiments aimed to shift care delivery from a volume-based to a value-based system. This issue of AJAC examines a number of cutting-edge strategies.
The United States is in the throes of multiple experiments aimed to shift care delivery from a volume-based to a value-based system. The American Journal of Accountable Care (AJAC) strives to be a trusted source for balanced information regarding the development, implementation, and evaluation of emerging solutions to increase efficiency. This issue of AJAC examines a number of cutting-edge strategies including accountable care organizations (ACOs),1 patient-centered medical homes (PCMHs),2 and innovative payment models such as bundled payments,3 which are intended to improve quality, enhance the consumer experience, and constrain cost growth.
As these manuscripts attest, a substantial amount of energy, sophistication, and resources are being applied to “supply side” initiatives aimed at changing clinician practice, such as payment reform, health information technology, and practice redesign. For the sake of discussion, I refer to provider-facing initiatives as “peanut butter.” Unfortunately, these “supply-side” initiatives have historically paid little attention to consumer decision making or the “demand side” of care-seeking behavior. I designate these consumer-facing strategies, such as literacy programs, shared decision making, price transparency, and benefit designs, as “the jelly.” Consumer engagement initiatives that motivate individuals to access care based on quality and cost information—including incentives tied to clinical necessity—can enhance the quality of care and reduce healthcare spending.
As we embrace models that provide incentives to clinicians to recommend the right care, to the right patient, in the right venue, at the right price, it is of critical importance that consumer incentives be similarly aligned. For a physician practicing in a quality-driven reimbursement program, it is incomprehensible that insurance plans increasingly place barriers which restrict patient access to those exact high-quality services for which the clinician, the PCMH, and the ACO are benchmarked. It makes no sense to offer clinicians a financial bonus to get their diabetic patients’ blood sugar under control or eyes examined, when those same patients are increasingly enrolling in a benefit design that makes it prohibitively expensive to fill their prescription or visit the ophthalmologist. While the obvious synergies of combining peanut butter and jelly are exemplary of “the sum greater than the parts,” high cost-sharing for services established as quality metrics (eg, National Quality Forum, National Committee for Quality Assurance) is a classic illustration of misaligned incentives.
When healthcare purchasers align provider and consumer incentives around value—not price alone—the goals of the Triple Aim are more likely to be achieved than with either one alone. This alignment will facilitate a shift toward a delivery system that rewards both patients and providers for delivery of high-value care.1. Higgins TL, Hodnicki D, Artenstein AW. Sharing care in the ACO era. AJAC. 2014 2(3):27-30.
2.. Solberg L, Stuck L, Crain LA, et al. Patient experience and physician/staff satisfaction in transforming medical homes. AJAC. 2014 2(3):11-15.
3. Delbanco S, Lansky D. Creating an ACO: advice for employers and purchasers. AJAC. 2014; 2(3):46-57.
Traditional Medicare Supplemental Insurance and the Rise of Medicare Advantage
May 7th 2024Rising Medicare Advantage enrollment occurred alongside declines in enrollment in traditional Medicare with employer-sponsored supplemental coverage and traditional Medicare without supplemental coverage.
Read More
Examining Low-Value Cancer Care Trends Amidst the COVID-19 Pandemic
April 25th 2024On this episode of Managed Care Cast, we're talking with the authors of a study published in the April 2024 issue of The American Journal of Managed Care® about their findings on the rates of low-value cancer care services throughout the COVID-19 pandemic.
Listen
Access Denied: CMS’ Action Hurts Patients With Cancer in Rural America
May 6th 2024CMS rules hindered the access of rural patients with cancer to medically integrated pharmacies in 2023. The authors discuss the impact on equity in health care, emphasizing the need for regulatory change.
Read More
Oncology Onward: A Conversation With Penn Medicine's Dr Justin Bekelman
December 19th 2023Justin Bekelman, MD, director of the Penn Center for Cancer Care Innovation, sat with our hosts Emeline Aviki, MD, MBA, and Stephen Schleicher, MD, MBA, for our final episode of 2023 to discuss the importance of collaboration between academic medicine and community oncology and testing innovative cancer care delivery in these settings.
Listen
Forging a Patient-Centric Path to Revolutionize and Redefine Value-Based Care
April 30th 2024Optum Life Sciences and Takeda Pharmaceuticals are partnering on an innovative virtual care pilot program for inflammatory bowel disease meant to both continue the mission of the current value-based health care landscape and raise the bar for personalized care delivery optimization.
Read More