The 2020s require a new strategy that moves from a short-term focus on testing new payment models to a long-term focus on expanding models that are most likely to generate substantial savings and improve quality. This white paper outlines a new direction for the federal government—primarily through the Centers for Medicare and Medicaid Services (CMS)—to chart over the next decade aimed at completing the transition to a health care system that pays for value and reduced health disparities, rather than high volumes of services.
A decade of innovation and experimentation has failed to transform the health care system to one that pays for value rather than volume. It is now time to reconsider how value-based payment models can generate substantial savings and improve quality and health equity. Experts from the University of Pennsylvania, with input from a national panel of experts, reviewed the effectiveness of past payment reforms implemented by the Centers for Medicare and Medicaid Services (CMS) and made recommendations about how to accelerate and complete the nation’s transformation to value-based payment. This brief summarizes recommendations that provide a path toward widespread adoption and success of alternative payment models, producing better health outcomes for all Americans, reducing wasteful spending, improving health equity, and more effectively stewarding taxpayer funds to support other national priorities.
To expand access to health care during the COVID-19 pandemic, many states relaxed or waived regulations that deﬁne the scope of health professional practice. This experience highlights the need to ensure that all health care professionals practice to the full extent of their capabilities—an issue that predates and will outlast the pandemic. In a virtual conference on November 20, 2020, Penn LDI and Penn Nursing brought together experts in law, economics, nursing, medicine, and dentistry to discuss current gaps in health professional scope of practice, what we have learned from COVID-19, and how to rethink scope of practice to better meet community and public health needs.
Pennsylvania is one of 28 states that has not expanded the scope of practice in its licensure laws for certified registered nurse practitioners (NPs), who must maintain formal collaborative agreements with physicians to practice. For many years, proposals to update licensure and adapt it to make it more compatible with current models of collaborative care could not overcome legislative logjams. Recognizing an opportunity to break the logjam, the University of Pennsylvania held a virtual workshop on November 20, 2020, bringing together researchers, health professionals, and consumers to chart a new path forward. This policy brief summarizes their recommendations to update scope of practice regulation to better meet the primary care needs of Pennsylvanians.
Among adults in rural Malawi, population health screening for high blood pressure (BP) led to a 22-percentage point drop in the likelihood of being hypertensive four years later. Individuals with elevated BP received a referral letter upon initial screening; at follow-up, they had lower BP and higher self-reported mental health than individuals with similar BP who were just below the threshold for referral. Population health screenings can reduce the burden of non-communicable diseases in low-income countries.
Despite concerns that duty hour reform might adversely affect the performance of new surgeons, this national study found no impact on patient outcomes, including 30-day mortality rates, failure-to-rescue, length of stay, and use of intensive care units. These findings should allay fears that reduced work hours during residency would produce surgeons less prepared for practice than their more experienced colleagues.
In this national study of 438,895 physicians, 45% provided care to hospitalized patients and 7% provided critical care. At the high estimate of patients requiring hospitalization at the projected peak of the pandemic, 18 states and Washington, DC would have patient to physician ratios greater than 15:1 (a level associated with poor outcomes among hospitalized patients). There was considerable geographic variation in the availability of physicians: 41% of hospital service areas did not have a physician with critical care experience.
How do leader tactics influence the creativity, implementation, and evolution of quality improvement (QI) ideas from clinicians and staff at federally qualified community health practices?
Mifepristone, a drug used to manage early miscarriage or end an early pregnancy, carries unique restrictions imposed by the U.S. Food and Drug Administration (FDA). Patients are required to pick up the drug in person
from a doctor or a clinic, even though they can take the drug at home. In July, a federal court ruled that the FDA must suspend these restrictions during the COVID-19 pandemic, for patients seeking an early abortion,
although the ruling did not apply to women with an early pregnancy loss. But the challenges to FDA restrictions on mifepristone predate the pandemic. This Issue Brief provides the context for this ongoing controversy, and
reviews recent evidence on the clinical and cost effectiveness of mifepristone for the medical management of first trimester miscarriage.
A study of hospitals in New York and Illinois at the start of the COVID-19 pandemic found that most did not meet benchmark patient-to-nurse staffing ratios for medical-surgical or intensive care units. New York City hospitals had especially low staffing ratios. Understaffed hospitals were associated with less job satisfaction among nurses, unfavorable grades for patient safety and quality of care, and hesitance by nurses and patients to recommend their hospitals.
COVID-19 has had a major impact on U.S. nursing homes, resulting in a large and disproportionate share of COVID-19 deaths. Starting in April 2020, nursing homes were required to report COVID-19 cases to their state health department. Linking these reports to Medicare quality data, the authors examined the characteristics of 8,943 nursing homes in 23 states and Washington, D.C. Using data collected between April 22 and 29, they described the differences between facilities that reported COVID-19 cases (34%) and those that did not report cases.
From choosing a doctor to selecting an insurance plan, choices pervade nearly all aspects of our health care system. However, there is little agreement among policymakers and the public about what constitutes “choice,” which choices are important, and how and whether patients should be asked to make various health care choices. Although Americans claim to value having health insurance choices, research shows that when presented with options, people do not actually like to choose. Other studies suggest that people frequently make health insurance decisions that leave them worse off, or not much better than before. At Penn LDI’s Medicare for All and Beyond conference, a panel of researchers and policy experts discussed the current evidence around health insurance choice and implications for future health care reform efforts. This brief summarizes the panel’s key takeaways.
Any effort to reform health insurance in the United States must tackle the prices we pay for health care. There are many complex challenges to addressing prices. Some proposals build on the existing Medicare fee schedule, while others suggest promoting alternative payment mechanisms—or even starting from scratch. The stakes are substantial, as many reform proposals rely on reining in prices to achieve the savings necessary to expand health insurance to the uninsured. At Penn’s LDI Medicare for All and Beyond conference, a panel of researchers, hospital administrators, and policy experts considered issues related to health care payment and pricing that any health care reform proposal must address, including the implications of rate setting for providers and patients. At what level should these rates be set to assure access and quality of care, while incentivizing innovation and rewarding excellence?
In the run-up to the presidential election, the affordability of health care remains a top concern of the American voting public. But how do we know when health care is affordable? On a policy level, how do we set a standard for affordability that can be implemented in a reformed system? Sometimes policy debates about affordability focus only on whether insurance premiums are affordable, although consumers tend to be concerned about both premiums and out-of-pocket costs. At Penn LDI’s Medicare for All and Beyond conference, a panel of researchers, policy experts, and consumer advocates discussed and debated affordability in theory and practice. This issue brief summarizes the panel’s insights.
One in five U.S. children has a mental health condition, but little is known about their health care use and spending. The authors looked at 2016 Medicaid claims for approximately 775,000 children (ages 3-17) with a mental health diagnosis and at least 11 months of continuous Medicaid coverage. They compared utilization and spending of "top spenders" (patients who spent the most overall on health care, or the top 1%) and "typical spenders" (patients with more usual spending, the remaining 99%).