PUBPOL Prelim 3

D.16 Paying for Pop Health

What do we mean by paying for value/performance?

Value Eq = _ / _

quality (outcomes + patient exp) / cost (direct + indirect)

Despite growth in VBC what are 3 challenges? So what are 3 things future models must do?

1. most providers still paid thru FFS

2. participation widely vary across markets

3. mixed/modest results

1. easy to join

2. have meaningful financial incentives

3. work for rural/safety-net providers

What does this show about APMs?

goal is to make more payment contracts under APMs for value (Cat 3 & 4) not for volume (Cat 1 & 2)

What are 5 additional challenges to VBC & APMs?

1. need standardized quality goal measurements

2. no risk adjustment

3. how to define care episode for bundled payment initiatives

4. how to prove quality inc if services reduced

5. must return cost savings for innovation if services reduced

What are 2 ways to prevent under-treatment since it is a risk?

1. risk adjustment: payment adjusted for illness/complexity severity & prevent avoidance of high-need patients

2. quality metrics: track if appropriate care delivered & payment bonuses/penalties based on performance

Answer questions:

1. How to ensure providers don’t meet cost targets by under-providing as payer?

2. What makes shared savings payment model financially appealing to PCP paid thru FFS?

3. Which payment model most appealing to risk-averse PCP paid thru FFS but want to transition toward VBP?

1. req providers to meet set of quality benchmarks that are pre-defined in payment model

2. shared savings b/c you get portion of shared savings if you hit quality benchmarks

3. pay for performance b/c no financial risk while continuing FFS billing but now need to measure quality & hit benchmarks = bonuses

What did COVID show about VBP?

during COVID, volume dropped b/c ppl told to stay at home so providers w/larger share w/VBP did better than providers w/just FFS