Current State of Value-Based Purchasing Programs

Abstract

The United States healthcare system is rapidly moving toward rewarding value. Recent legislation, such as the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act (MACRA), solidified the role of value-based payment in Medicare. Many private insurers are following Medicare’s lead. Much of the policy attention has been on programs such as accountable care organizations and bundled payments; yet, value-based purchasing (VBP) or pay-for-performance, defined as providers being paid fee-for-service with payment adjustments up or down based on value metrics, remains a core element of value payment in MACRA and will likely remain so for the foreseeable future. This review article summarizes the current state of VBP programs and provides analysis of the strengths, weaknesses, and opportunities for the future. Multiple inpatient and outpatient VBP programs have been implemented and evaluated, with the impact of those programs being marginal. Opportunities to enhance the performance of VBP programs include improving the quality measurement science, strengthening both the size and design of incentives, reducing health disparities, establishing broad outcome measurement, choosing appropriate comparison targets, and determining the optimal role of VBP relative to alternative payment models. VBP programs will play a significant role in healthcare delivery for years to come, and they serve as an opportunity for providers to build the infrastructure needed for value-oriented care.

Reasons for Guideline Nonadherence at Heart Failure Discharge

“…In the current era of alternative payment models, this assessment of quality has significant implications for provider and hospital reimbursement21, 22 and for the ranking of hospital programs. The lack of adequate adjustment for severity of heart disease and comorbidities risks penalizing providers and hospitals that care for more advanced HF patients or more vulnerable populations.…”

Increased resource utilization and overall morbidity are associated with general versus regional anesthesia for carotid endarterectomy in data collected by the Michigan Surgical Quality Collaborative

“…The implications that these findings might have on the ability to be competitive for value-based purchasing are compelling as Medicare and private insurance companies are increasingly moving toward this focus. 21 Our data suggest lower cost of care and less morbidity with RA vs GA for CEA. This has implications for enterprise resource planning initiatives and the CEA value proposition in general, which is of special interest to both hospitals and payers.…”

“…[18][19][20][21] There was a significantly increased LOS with the GA group as well as a significant increase in ED visits and readmissions. The major reasons for readmission and ED visits appear to be procedure and carotid disease related.…”

The Digital Outcome Measure

“…Most actual current outcome measurements in practice are not granular condition-specific metrics, but reflect blunt outcomes such as mortality. CMS has a host of such programs [10,20] that aim to improve outcomes, but copy the model of blunt outcome measures plus additional measures that only indirectly address condition-specific outcomes [20].…”