The transformational change occurring in health care has a focus on value: meeting patient needs while promoting good health. However, developing health care delivery and payment models to achieve the Triple Aim will be challenging. Changes in care delivery include new partnerships among payers, providers, government, the community and across the care continuum; greater use of technology to empower clinicians and patients with increased access to information; and a relentless focus on high reliability and safety. Hospitals and health care systems will have to develop care delivery systems focused on the whole person while improving the health of the communities they serve. All this must be done in the context of a payment and financing system that rewards high-quality outcomes as well as individual and population health.
The American Hospital Association 2015 Committee on Research and 2015 Committee on Performance Improvement studied new care delivery systems and innovative payment models to transform health care. In January, the committees released a joint report, “Care and Payment Models to Achieve the Triple Aim.” This report covers how hospitals and health care systems can develop new care delivery and payment methods that meet the needs of their organizations and communities.
Redesigning Care Delivery: Seven Principles
The 2015 AHA Committee on Performance Improvement discussed design and redesign of the care delivery system and identified seven key principles:
1. Design the care delivery system with the whole person at the center.
2. Empower people and the care delivery system with information, technology and transparency to promote health.
3. Build care management and coordination systems.
4. Integrate behavioral health and social determinants of health with physical health.
5. Develop collaborative leadership.
6. Integrate care delivery into the community.
7. Create safe and highly reliable health care organizations.
Each of these principles characterizes the requirements for a care delivery system to meet the Triple Aim. In addition, hospitals and health care systems need to determine which payment models will help to achieve these principles and fit best within their organizations.
Designing Innovative Payment Models
The 2015 AHA Committee on Research discussed several payment models that have emerged as health care transforms to a value-based care system. All of these models derive from one of three fundamental payment approaches: service-based, which is based on the fee-for-service mechanism and focuses on volume rather than value; bundled-based, which aggregates different services and providers (such as hospitals, physicians and post-acute providers that bundle costs for hip replacements); or population-based, which seeks to aggregate total care and costs across the continuum (such as an accountable care organization for a defined population).
While service-, bundled- and population-based payment models all are options, critical to any model are the incentives related to value, teaching, socioeconomic status of the population served and transition support. Depending on hospital type and size and on community needs, organizational leaders can pursue a mix of payment models. The inclusion of quality, safety, efficiency and patient experience incentives means that all models will serve as a fee-for-value payment model.
Short- and long-term policies are needed to assist hospitals and health care systems in implementing new payment models. These policies should target stress points that can impede the movement from volume-based to value-based care. Stress points include obtaining available data; supporting the infrastructure and bridge among payment models; and getting better tools and methods, such as risk adjustment, that more accurately reflect the intended design of the payment models.
Pragmatic, Flexible Strategies for Hospitals
Developing an ideal care delivery system is not practical, as each health care market is unique. Identifying foundational strategies on which to build a new care delivery system provides a pragmatic approach to assisting hospitals and health care systems, so they are adaptable and flexible in using care delivery and payment models to meet patient and community needs.
“Care and Payment Models to Achieve the Triple Aim” describes the seven principles and short- and long-term policy recommendations, and includes case studies from several hospitals and health systems. To download the report and related resources, click here.
Michael G. Rock, M.D., chair of the 2015 AHA Committee on Research, is chief medical officer at Mayo Clinic Hospitals/Mayo Foundation in Rochester, Minn. Thomas W. Burke, M.D., chair of the 2015 AHA Committee on Performance Improvement, is an executive vice president at the University of Texas MD Anderson Cancer Center, Houston.