Review Article

Will the “Fixes” Fall Flat? Prospects for Quality Measures and Payment Incentives to Control Healthcare Spending

Authors: Erik Hauswald, BA, David Sklar, MD

Abstract

Payment systems in the US healthcare system have rewarded physicians for services and attempted to control healthcare spending, with rewards and penalties based upon projected goals for future spending. The incorporation of quality goals and alternatives to fee-for-service was introduced to replace the previous system of rewards and penalties. We describe the history of the US healthcare payment system, focusing on Medicare and the efforts to control spending through the Sustainable Growth Rate. We describe the latest evolution of the payment system, which emphasizes quality measurement and alternative payment models. We conclude with suggestions for how to influence physician behavior through education and payment reform so that their behavior aligns with alternative care models to control spending in the future.

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References

1. Reinhardt UE, Hussey PS, Anderson GF. U.S. health care spending in an international context. Health Aff (Millwood) 2004;23:10-25.
 
2. Davis K, Stremikis K, Squires D, et al. Mirror, mirror on the wall, 2014 update: how the U.S. health care system compares internationally. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror. Published June 2014. Accessed April 26, 2016.
 
3. Murray CJ, Frenk J. Ranking 37th-measuring the performance of the U.S. health care system. N Engl J Med 2010;362:98-99.
 
4. Health, United States, 2013: With Special Feature on Prescription Drugs. Hyattsville, MD: National Center for Health Statistics, 2014.
 
5. Global Health Expenditure Database. NHA indicators. http://apps.who.int/nha/database/ViewData/Indicators/en. Published 2014. Accessed October 5, 2015.
 
6. Emanuel EJ, Steinmetz A. Will physicians lead on controlling health care costs? JAMA 2013;310:374-375.
 
7. Tilburt JC, Wynia MK, Sheeler RD, et al. Views of US physicians about controlling health care costs. JAMA 2013;310:380-388.
 
8. Gornick ME, Warren JL, Eggers PW, et al. Thirty years of Medicare: impact on the covered population. Health Care Financ Rev 1996;18:179-237.
 
9. Vladeck BC. Medicare hospital payment by diagnosis-related groups. Ann Intern Med 1984;100:576-591.
 
10. Zuvekas SH, Cohen JW. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Aff (Millwood) 2016;35:411-414.
 
11. Hsiao WC, Braun P, Yntema D, et al. Estimating physicians’ work for a resource-based relative-value scale. N Engl J Med 1988;319:835-841.
 
12. Becker ER, Dunn D, Hsiao WC. Relative cost differences among physicians’ specialty practices. JAMA 1988;260:2397-2402.
 
13. Hsiao WC, Braun P, Dunn D, et al. Results and policy implications of the resource-based relative-value study. N Engl J Med 1988;319:881-888.
 
14. Roper WL. The Resource-Based Relative Value Scale: a methodological and policy evaluation. JAMA 1988;260:2444-2446.
 
15. Roper WL. Perspectives on physician-payment reform. The resource-based relative-value scale in context. N Engl J Med 1988;319:865-867.
 
16. Hackbarth GM. Moving forward from the Sustainable Growth Rate (SGR) system. Medicare Payment Advisement Committee. http://democrats.energycommerce.house.gov/sites/default/files/documents/Testimony-Hackbarth-Health-SGR-Medicare-Payment-2013-2-14.pdf. Accessed June 6, 2015.
 
17. Government Accountability Office. Medicare physician payments. Trends in service utilization, spending, and fees prompt consideration of alternative payment approaches. http://www.gao.gov/new.items/d061008t.pdf. Published July 25, 2006. Accessed June 27, 2015.
 
18. Ginsburg PB. Rapidly evolving physician-payment policy-more than the SGR. N Engl J Med 2011;364:172-176.
 
19. Alhassani A, Chandra A, Chernew ME. The sources of the SGR “hole”. N Engl J Med 2012;366:289-291.
 
20. Steinbrook R. The repeal of Medicare’ sustainable growth rate for physician payment. JAMA 2015;313:2025-2026.
 
21. Wilensky GR. Medicare physician payments: where we’ve been where we need to go. http://www.finance.senate.gov/imo/media/doc/Wilensky%20Statement.pdf. Published May 10, 2012. Accessed June 15, 2015.
 
22. Scully T. Medicare physician payments: understanding the past so we can envision the future. http://www.finance.senate.gov/imo/media/doc/Scully%20Statement.pdf. Accessed June 20, 2015.
 
23. Aaron HJ. Three cheers for logrolling-the demise of the SGR. N Engl J Med 2015;372:1977-1979.
 
24. Wilensky GR. Improving value in Medicare with an SGR fix. N Engl J Med 2014;370:1-3.
 
25. Oberlander J, Jones DK. The children’ cliff-extending CHIP. N Engl J Med 2015;372:1979-1981.
 
26. H.R.2--Medicare Access and CHIP Reauthorization Act of 2015. https://www.congress.gov/bill/114th-congress/house-bill/2. Accessed May 4, 2016.
 
27. Findlay S. Health policy brief: Medicare' new physician payment system. http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=156. Published April 21, 2016. Accessed May 4, 2016.
 
28. Ebeler J, Neuman T, Cubanski J. The Independent Payment Advisory Board: a new approach to controlling Medicare spending. https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8150.pdf. Accessed April 26, 2016.
 
29. Aaron HJ. The Independent Payment Advisory Board-Congress’ “good deed”. N Engl J Med 2011;364:2377-2379.
 
30. Cohen SB, Uberoi N. Statistical brief #421: differentials in the concentration in the level of health expenditures across population subgroups in the U.S 2010. http://meps.ahrq.gov/mepsweb/data_files/publications/st421/stat421.shtml. Accessed March 7, 2016.
 
31. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA 2012;307:1513-1516.
 
32. Powers BW, Chaguturu SK. ACOs and high-cost patients. N Engl J Med 2016;374:203-205.
 
33. Dow AW, Bohannon A, Garland S, et al. The effects of expanding primary care access for the uninsured: implications for the health care workforce under health reform. Acad Med 2013;88:1855-1861.
 
34. Pines J, Venkatesh A. Taking control of quality measurements. http://epmonthly.com/article/taking-control-of-quality-measurements. Accessed November 5, 2015.
 
35. Berenson RA, Pronovost PJ, Krumholz HMM. Achieving the potential of health care performance measures. http://www.urban.org/research/publication/achieving-potential-health-care-performance-measures. Accessed October 11, 2015.
 
36. Damberg CL, Sorbero ME, Lovejoy SL, et al. Measuring success in health care value-based purchasing programs. Findings from an environmental scan, literature review, and expert panel discussions. http://www.rand.org/pubs/research_reports/RR306.html. Published 2014. August 10, 2016.
 
37. Serumaga B, Ross-Degnan D, Avery AJ, et al. Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study. BMJ 2011;342:d108.
 
38. Hussey PS, Mulcahy AW, Lowsky D, et al. Flattening the trajectory of health care spending. Foster efficient and accountable providers. http://www.rand.org/pubs/research_briefs/RB9690z2.html. Published 2012. Accessed April 29, 2016.
 
39. Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N Engl J Med 2010;363:2530-5239.
 
40. Casalino LP, Gans D, Weber R, et al. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff (Millwood) 2016;35:401-406.
 
41. McWilliams JM, Chernew ME, Landon BE, et al. Performance differences in year 1 of pioneer accountable care organizations. N Engl J Med 2015; 372:1927-1936.
 
42. Press MJ, Rajkumar R, Conway PH. Medicare's new bundled payments: design, strategy, and evolution. JAMA 2016;315:131-132.
 
43. Hussey PS, Ridgely MS, Rosenthal MB. The PROMETHEUS bundled payment experiment: slow start shows problems in implementing new payment models. Health Aff (Millwood) 2011;30:2116-2124.
 
44. Song Z, Safran DG, Landon BE. The "Alternative Quality Contract,” based on a global budget, lowered medical spending and improved quality. Health Aff (Millwood) 2012;31:1885-1894.
 
45. Osborne NH, Nicholas LH, Ryan AM, et al. Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. JAMA 2015;313:496-504.
 
46. Ryan AM. Effects of the premier hospital quality incentive demonstration on Medicare patient mortality and cost. Health Serv Res 2009;44:821-842.
 
47. Crosson FJ. Change the microenvironment: delivery system reform essential to controlling costs. http://www.commonwealthfund.org/publications/commentaries/2009/apr/change-the-microenvironment. Published April 2009. Accessed May 26, 2016.
 
48. Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff (Millwood) 2010;29:1569-1577.
 
49. Spatz ID. Health reform accelerates changes in the pharmaceutical industry. Health Aff (Millwood) 2010;29:1331-1336.
 
50. Judson TJ, Volpp KG, Detsky AS. Harnessing the right combination of extrinsic and intrinsic motivation to change physician behavior. JAMA 2015;314:2233-2234.
 
51. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med 2010;363:501-504.
 
52. Centers for Medicare & Medicaid Services. Medicare and Medicaid EHR incentive program basics. https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/basics.html. Published 2015. Accessed January 7, 2016.
 
53. Mennemeyer ST, Menachemi N, Rahurkar S, et al. Impact of the HITECH act on physicians’ adoption of electronic health records. J Am Med Inform Assoc 2016;23:375-379.
 
54. US Department of Health and Human Services. Doctors and hospitals’ use of health IT more than doubles since 2012. http://www.hhs.gov/about/news/2013/05/22/doctors-and-hospitals-use-health-it-more-than-doubles-in-2012.html. Published May 22, 2013. Accessed January 7, 2016.
 
55. DesRoches CM, Charles D, Furukawa MF, et al. Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in 2012. Health Aff (Millwood) 2013;32:1478-1485.
 
56. Himmelstein DU, Ariely D, Woolhandler S. Pay-for-performance: toxic to quality? Insights from behavioral economics. Int J Health Serv 2014;44:203-214.
 
57. Sklar DP, Lee R. Commentary: what if high-quality care drove medical education? A multiattribute approach. Acad Med 2010;85:1401-1404.
 
58. Wong BM, Holmboe ES. Transforming the academic faculty perspective in graduate medical education to better align educational and clinical outcomes. Acad Med 2016;91:473-479.
 
59. Iams W, Heck J, Kapp M, et al. A multidisciplinary housestaff-led initiative to safely reduce daily laboratory testing. Acad Med 2016;91:813-820.
 
60. Barsuk JH, McGaghie WC, Cohen ER, et al. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med 2009;37: 2697-2701.
 
61. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-2732.
 
62. Brehaut JC, Colquhoun HL, Eva KW, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med 2016; 164:435-441.