Payment & Delivery

How insurers and providers are organized and paid to deliver care. Research by LDI Senior Fellows examines the shift from fee-for-service payments to newer models of paying for and delivering value, such as Accountable Care Organizations and Patient-Centered Medical Homes.

Meeting the Moment at Penn LDI’s Health Reform Conference

May. 25, 2021

"There are decades when nothing happens, and there are weeks when decades happen...that describes what's happening right now,” said Sen. Tom Daschle, at Penn LDI’s recent conference on health care reform. An unusual mix of optimism and pragmatism pervaded the conference sessions, as participants acknowledged the serious ideological divides that threaten any large-scale reforms.

Hospital Revenue Loss from Delayed Elective Surgeries

Mar. 17, 2021

Hospitals lost more than $20 billion in revenue when the pandemic led to an unprecedented nationwide shutdown in elective surgical procedures from March to May 2020. In a new Annals of Surgery study, we quantified this impact and analyzed the potential implications of a widespread interruption in elective surgeries for patients, health disparities, and the financial health of hospitals.

The Future of Value-Based Payment: A Road Map to 2030

Feb. 18, 2021

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.

The Future of Value-Based Payment

Feb. 18, 2021

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.

Safety-Net Hospitals After Medicaid Expansion

Feb. 15, 2021

In states that expanded Medicaid after the Affordable Care Act (ACA), safety-net hospitals (SNHs) saw their operating margins improve and levels of uncompensated care decrease. But a new study finds that while SNHs were also able to scale up some safety-net services—such as inpatient psychiatric care—these changes did not translate into measurable improvements in quality.

Developing the eMedical Student (eMS)-A Pilot Project Integrating Medical Students Into the Tele-ICU During the COVID-19 Pandemic and Beyond

Jan. 14, 2021

Joshua Ho, Philip Susser, Cindy Christian, Horace DeLisser, Michael J. Scott, Lynn A. Pauls, Ann M. Huffenberger, C. William Hanson 3rd, John M. Chandler, Lee A. FleisherKrzysztof Laudanski

Abstract [from journal]

The COVID-19 pandemic has accelerated the demand for virtual healthcare delivery and highlighted the scarcity of telehealth medical student curricula, particularly tele-critical care. In partnership with the Penn E-lert program and the Department of Anesthesiology and Critical Care, the Perelman School of Medicine (PSOM) established a tele-ICU rotation to support the care of patients diagnosed with COVID-19 in the Intensive Care Unit (ICU). The four-week course had seven elements: (1) 60 h of clinical engagement; (2) multiple-choice


Micro-Costing in Health and Medicine: A Critical Appraisal

Jennifer Prah Ruger, PhD, MSc, MA, MSL
Jan. 6, 2021

Xiao Xu, Christina M. Lazar, Jennifer Prah Ruger

Abstract [from journal]

Background: Concerns about rising health care costs require rigorous economic study to inform clinical and policy decision-making. Micro-costing is a cost estimation methodology employing detailed resource utilization and unit cost data to generate precise estimates of economic costs. Micro-costing studies have not been critically appraised.

Methods: Critical appraisal of micro-costing studies in English. Studies fully or predominantly employing micro-costing were appraised for methodological


It’s Not Just the Money: The Role of Treatment Ideology in Publicly Funded Substance Use Disorder Treatment

Jan. 1, 2021

Rebecca E. Stewart, Courtney Benjamin Wolk, Geoffrey Neimark, Ridhi Vyas, Jordyn Young, Chris Tjoa, Kyle Kampman, David T. Jones, David S. Mandell

Abstract [from journal]

Medications for opioid use disorder (MOUD) are a first-line treatment for opioid use disorder, yet national surveys indicate that most substance use treatment facilities do not offer MOUD. This article presents the results of a qualitative analysis of interviews with leaders from 25 treatment organizations in Philadelphia, Pennsylvania, that investigated attitudes and barriers toward MOUD. Most treatment organizations that we interviewed are adopting at least one MOUD, suggesting that Philadelphia exceeds the national average of


Patient Experiences of Integrated Care in Medicare Accountable Care Organizations and Medicare Advantage Versus Traditional Fee-For-Service

Dec. 2, 2020

Molly Frean, Christian Covington, Maike Tietschert, Hassina Bahadurzada, Jodi So, Sara J. Singer

Abstract [from journal]

Background: Health insurance design can influence the extent to which clinical care is well-coordinated. Through alternative payment models, Medicare Advantage (MA) and Accountable Care Organizations (ACOs) have the potential to improve integration relative to traditional fee-for-service (FFS) Medicare.

Objective: To characterize patient experiences of integrated care within Medicare and identify whether MA or ACO beneficiaries perceive greater integration than FFS beneficiaries.


National Shifts in Outpatient Care for Patients With Cirrhosis

Nov. 24, 2020

As the U.S. enters the tenth month of the COVID-19 pandemic, it is hard to imagine a time when telemedicine was not a mainstay of health care delivery, particularly in the care of vulnerable patients. However, few studies have examined the scale of how outpatient care has changed at the national level, and whether the changes have been sustained beyond the early months of the pandemic.

Understanding Racial and Ethnic Disparities in Autism-Related Service Use Among Medicaid-Enrolled Children

Nov. 21, 2020

Lucy A. Bilaver, Sarah A. Sobotka, David S. Mandell

Abstract [from journal]

Racial and ethnic disparities in the use of nine common autism-related services among Medicaid-enrolled children with autism spectrum disorder (ASD) were examined, distinguishing between school and other community-based outpatient settings. Using 2012 Medicaid Analytic Extract data, we identified 117,848 continuously enrolled children with ASD. Several racial and ethnic disparities were found, varying by geography. Black, Asian, and Native American/Pacific Islanders received fewer outpatient services compared with white children, but


Using Nationally Representative Percentiles to Interpret PROMIS Pediatric Measures

Christopher B. Forrest, MD, PhD
Nov. 17, 2020

Adam C. Carle, Katherine B. Bevans, Carole A. Tucker, Christopher B. Forrest 

Abstract [from journal]

Purpose: This study's aim was to use a representative sample of the US pediatric population to estimate percentiles for several PROMIS pediatric measures: Anger, Anxiety, Depressive Symptoms, Family Relationships, Fatigue, Global Health, Life Satisfaction, Meaning and Purpose, Pain Behavior, Pain Interference, Physical Activity, Physical Function Mobility, Physical Function Upper Extremity, Physical Stress Experiences, Positive Affect, Psychological Stress Experiences, Sleep Disturbance, Sleep Impairment, and Peer