Policymakers, health care providers, and policy analysts continue to call for “delivery system reform”—changes to the way health care is provided and paid for in the United States—to address concerns about rising costs, quality of care, and inefficient spending. The Affordable Care Act (ACA) established several initiatives to identify and test new health care payment models that focus on these issues.
The accountable care organization (ACO) is a new organizational form to manage patients across the continuum of care. There are numerous questions about how ACOs should be optimally structured, including compensation arrangements with primary care physicians.
What's the difference between a bundled payment and an episode payment? How are prospective payments different from fee-for-service payments? What are the differences between regression-based risk adjustment and clinical category risk adjustment, and between prospective and concurrent risk adjustment systems? And what exactly are APMs, APCs, CMGs, CRGs, DSRIPs, ECRs, G-Codes, GPCIs, IBNR, MIPS, MLR, OCM, PCOP, RUGs, and TCOC?
Chairman Pitts, Ranking Member Green, and members of the subcommittee, thank you for the opportunity to testify today on a crucial topic for our nation’s health care delivery system.
Since implementation of the Affordable Care Act (ACA), more than 10 million people in 30 states (including the District of Columbia) that expanded Medicaid have gained Medicaid or CHIP coverage, and the collective rate of uninsured individuals in expansion states has fallen from 18 percent to less than 11 percent.
As efforts to move away from fee-for-service payment have accelerated on both federal and state levels, public and private payers have been experimenting with different payment models. There is tremendous heterogeneity in approaches across states1-3; for example, some of these reforms only focus on Medicaid, while some include additional payers. Some rely on global payments and some on bundled payments for selected episodes.
This year’s Patient-Centered Primary Care Collaborative (PCPCC) Annual Review of the Evidence summarizes new results from primary care patient-centered medical home (PCMH) initiatives published from September 2013 through November 2014 (since the publication of the previous Annual Review). Selected cost and utilization outcomes from a combination of peer-reviewed studies, state program evaluations, and industry publications are aggregated to present an overview of PCMH and primary care innovations happening across the country.
Six states—Arkansas, Indiana, Iowa, Michigan, New Hampshire, and Pennsylvania—have expanded eligibility for their Medicaid programs using alternative approaches allowed under what are known as Section 1115 demonstration waivers. In April, the Montana legislature approved expansion, and lawmakers there expect that their program will also proceed as a Section 1115 demonstration. These waivers enable states to tailor their expansions to meet practical and political realities.
