Despite the apparent "mixed bag" that payment reform success seems to be at this point, the missteps thus far should not outweigh an overall sense that they can bring value and yield cost savings. That's the word from Health Affairs blog post 'What should we conclude from 'mixed' results in payment reform evaluations?"
First, shared savings ACOs or the Medicare Shared Savings Program proved disappointing and appeared to actually cost Medicare $216 million on net by the end of 2015, the authors wrote. The lack of downside risk for the Shared Savings Program ACOs meant that the losses were "uncapped" for the program as a whole. However, a recent summary showed that early ACOs are currently saving Medicare "absolute dollars on net", performing better than those who entered the program recently, suggesting a years' long progression before any success is realized.
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Bundled payments' most notable result was a 3 percent savings in orthopedics and cardiology through the Bundled Payments for Care Improvement Model 2, which includes prospective acute and postacute. The savings was seen from inpatient status through 90 days after discharge but only through postacute use savings. The spinal surgery bundle yielded a 10 percent increase in total costs and Model 4, which includes prospective for hospital and physician for inpatient only, showed results that were "insignificant all around," the post said.
"Bundled payment models are promising incentive and care changing tools, but clearly parameters need adjusting since broad savings may be initially possible only in postacute use choices. That's something but quite a bit less than hoped for by advocates to be sure," authors wrote.
Authors called the Comprehensive Primary Care Initiative evaluation of a medical home model for Medicare beneficiaries "sobering." It included more than 2,000 clinicians in more than 450 practices in seven states or regions who took part from 2012 through 2015. Total costs did not decline in any given year, on average, and just two regions reported net savings in any one year.
A big part of the issues, authors propose, is that the above initiatives attempted "wholesale practice transformation," which yielded little financial gain or improvements in quality. The programs might have fared better had they honed their efforts on a smaller group of patients and a more narrowly-tailored goal.
"Too much emphasis was put on building capacity to provide all services to all patients and not enough on the fact that cost and quality improvements might be more efficiently pursued by first identifying a subset of patients on which to focus more targeted yet patient-centered resources."
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Not surprisingly, two key takeaways from their evaluation included the idea that improvement in care and cost performance takes time and identifying target patients may be better trying to build capacity to provide patient-centered care to all, all at once.
They also said care transformation "while bending the cost curve" can be tough and needs up-front investment and a "shared commitment to data sharing and incentive realignment" to work.
Twitter: @BethJSanborn