Paying for quality and coordination: Aligning provider payments with global goals

American Journal of Medical Quality

Volumn 24, Issue 6, 2009, Pages 480-488

  Goldfield, Norbert I ^a   Fuller, Richard L ^a   Averill, Richard F ^a  

^a 3M COMPANY   (United States)

Author keywords

Classification; Outcomes assessment (health care); Prospective payment systems; Reimbursement incentive; Systems integration

Indexed keywords

ARTICLE; ECONOMICS; HEALTH CARE COST; HEALTH CARE QUALITY; ORGANIZATION; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PROSPECTIVE PAYMENT; REIMBURSEMENT; STANDARD;

CONTINUITY OF PATIENT CARE; HEALTH EXPENDITURES; ORGANIZATIONAL OBJECTIVES; PROSPECTIVE PAYMENT SYSTEM; QUALITY OF HEALTH CARE; REIMBURSEMENT, INCENTIVE;

EID: 70449397113     PISSN: 10628606     EISSN: 1555824X     Source Type: Journal    
DOI: 10.1177/1062860609341195     Document Type: Article

References (42)

1. American Hospital Association. AHA Hospital Statistics 2008. Chicago, IL: Health Forum of the American Hospital Association; 2008.
2. Keehan S., Sisko A., Truffer C.,et al;National Health Expenditure Accounts Projections Team. Health spending projections through 2017: the baby-boom generation is coming to Medicare. Health Aff (Millwood). 2008;27:w145-w155.
3. The Commonwealth Fund Commission on a High Performance Health. Why not the best? Results from the national scorecard on US health system performance, 2008. http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2008/Jul/Why-Not-the-Best--Results-from-theNational-Scorecard-on-U-S--Health-System-Performance-2008.aspx. Accessed June 13, 2009.
4. MedPAC. Report to Congress: promoting greater efficiency in Medicare. June 2007. Chapter 5: Payment policy for inpatient readmissions. http://www.medpac.gov/documents/Jun07_EntireReport.pdf. Accessed June 13, 2009.
5. Orszag PR Opportunities to Increase Efficiency in Health Care. Washington, DC: Congressional Budget Office; 2008. http://www.cbo.gov/ftpdocs/93xx/doc9384/06-16-HealthSummit.pdf.
6. American College of Physicians. Information on cost-effectiveness: an essential product of a national comparative effectiveness program. Ann Intern Med. 2008; 148:956-961.
7. Arrow K. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;LIII:941-973.
8. Haas-Wilson D. Arrow and the information market failure in health care: the changing content and sources of health care information. J Health Care Politics Policy Law. 2001;26: 1031-1044.
9. Paulus R., Davis K., Steele G. Continuous innovation in health care: implications of the Geisinger experience. Health Aff (Millwood). 2008;27:1235-1245.
10. Florida Agency for Health Care Administration. Florida Health Finder. http://www.floridahealthfinder.gov/. Accessed July 15, 2008.
11. Maxwell S., Zuckerman S., Berenson R. Use of physicians' services under Medicare's resource-based payments. N Engl J Med. 2007;356:1853-1861.
12. MedPAC. Medicare payment basics: outpatient hospital services payment system. http://www.medpac.gov/documents/MedPAC_Payment_Basics_08_OPD.pdf. Accessed June 13, 2009.
13. Goldfield N., Averill R., Eisenhandler J., Grant T. Ambulatory Patient Groups, Version 3.0-a classification system for payment of ambulatory visits. J Ambul Care Manage. 2008; 31:2-16.
14. Medicare severity DRGs (MS-DRGs). Fed Regist. 2007;72(162):47155. http://bulk.resource.org/gpo.gov/register/2007/2007_47155.pdf. Accessed June 13, 2009.
15. Sandy LG, Rattray MC, Thomas JW Episode-based physician profiling: a guide to the perplexing. J Gen Intern Med. 2008;23:1521-1524.
16. Goldfield N. Episodes of illness: a summary of the state of the art and future directions. J Ambul Care Manage. 1997;20:33-36.
17. Forthman MT, Dove HG, Wooster LD Episode Treatment Groups (ETGs): a patient classification system for measuring outcomes performance by episode of illness. Top Health Inf Manage. 2000;21:51-61.
18. Crippen D. Disease Management in Medicare: Data Analysis and Benefit Design Issues. Washington, DC: Congressional Budget Office. http://aging.senate.gov/events/hr89dc.pdf. Accessed June 13, 2009.
19. Wolff J., Starfield B., Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med. 2002;162:2269-2276.
20. De Brantes F., Rastogi A. Evidence-informed case rates: paying for safer, more reliable care. Issue Brief (Commonw Fund). 2008;40:1-13.
21. Goldfield N., Averill R., Fuller R., Vertrees J. A response to the Prometheus proposal-well intended but impossible to implement. Am J Med Qual. 2008;23:85-89.
22. Young WW, Kohler S., Kowalski J. PMC Patient Severity Scale: derivation and validation. Health Serv Res. 1994; 29:367-390.
23. MedPAC. Report to the Congress: reforming the delivery system. June 2008. Chapter 1: Direction for delivery system reform. http://www.medpac.gov/documents/Jun08_EntireReport.pdf. Accessed June 13, 2009.
24. Averill RF, Goldfield NI, Hughes JS, Eisenhandler J., Vertrees JC Developing a prospective payment system based on episodes of care. J Ambul Care Manage. 2009 Jul-Sep;32(3): 241-51.
25. MedPAC. Report to the Congress: Medicare payment policy. March 2006. Chapter 4: Post-acute care providers: an overview of issues. http://www.medpac.gov/documents/Mar06_EntireReport.pdf. Accessed June 13, 2009.
26. Sedman AB, Bahl V., Bunting E.,et al.Clinical redesign using all patient refined diagnosis related groups. Pediatrics. 2004;114:965-969.
27. Hughes JS, Averill RF, Eisenhandler J.,et al.Clinical Risk Groups (CRGs): a classification system for risk-adjusted capitation-based payment and health care management. Med Care. 2004;42:81-90.
28. Hughes JS, Averill RF, Goldfield NI,et al.Identifying potentially preventable complications using a present on admission indicator. Health Care Financ Rev. 2006;27(3):63-82.
29. Agency for Health Care Administration leads the nation with latest health information transparency [press release]. Tallahassee, FL: AHCA-Florida Agency for Health Care Administration; June 26, 2008. http://ahca.myflorida.com/Executive/Communications/Press_Releases/pdf/FloridaCenterPPRrates62608_2_.pdf. Accessed July 16, 2008.
30. Wu AW The measure and mismeasure of hospital quality: appropriate risk-adjustment methods in comparing hospitals. Ann Intern Med. 1995;122:149-150.
31. Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care. 2001;13:475-480.
32. Kripalani S., LeFevre F., Phillips C., Williams M., Basaviah P., Baker D. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007;297:831-841.
33. 2008 Physician Quality Reporting Initiative (PQRI) Eligible Professional Quality Measures. http://www.facs.org/ahp/pqri/pdfs/2008measureslist.pdf. Accessed June 13, 2009.
34. FNX Corporation and Trustees of Dartmouth College. About HowsYourHealth. http://www.howsyourhealth.org/html/whereWhy.html. Accessed June 3, 2008.
35. O'Malley AJ, Zaslavsky AM, Elliott MN, Zaborski L., Cleary PD Case-mix adjustment of the CAHPS Hospital Survey. Health Serv Res. 2005;40(6 pt 2):2162-2181.
36. Hibbard JH, Mahoney ER, Stock R., Tusler M. Do increases in patient activation result in improved self-management behaviors? Health Serv Res. 2007;42:1443-1463.
37. Goldfield N., Averill R., Vertrees J.,et al.Reforming the primary care physician payment system: eliminating E & M codes and creating the financial incentives for an advanced medical home. J Ambul Care Manage. 2008;31;24-31.
38. Fox SI Human Physiology. 10th ed. New York, NY: McGraw-Hill Higher Education; 2008:4.
39. Thompson JD, Averill RF, Fetter RB Planning, budgeting, and controlling-one look at the future: case-mix cost accounting. Health Serv Res. 1979;14:111-125.
40. Institute for Health Policy Solutions. Supplement E: risk adjustment methods and their relevance to pay-or-play. Supplement to: Challenges and alternatives for employer pay or play design: an implementation and alternative scenario analysis of California's Health Insurance Act of 2003 (SB 2). http://www.ihps.org/pubs/2005_Apr_IHPS_SB2_ESup_Risk_Adj.pdf. Accessed June 13, 2009.
41. Goldfield NI, McCullough EC, Hughes JS, Tang AM, Eastman B., Rawlins LK, Averill RF Identifying potentially preventable readmissions. Health Care Financ Rev. 2008 Fall;30(1): 75-91.
42. Averill RE, Hughes JS, Goldfield NI, McCullough EC Hospital complications: Linking payment reduction to preventability. Jt Comm J Qual Patient Saf. 2009 May;35(5): 283-5.