Searching for Solutions

Click on a title -- or scroll down to read all

Medicare is Integral to the Whole Health System
Value-Based Purchasing Opportunities in Traditional Medicare
Value-Based Purchasing for the Most Vulnerable Populations
Statutory and Regulatory Analysis to Support Value-Based Purchasing
Governance Paper

“Medicare is Integral to the Whole Health System”
(Author to be announced)

Medicare’s policies often shape the whole health system. This paper will examine where Medicare might lead reform, where the private sector might lead, and where there is greater need for collaboration. The paper will look at the symmetries, interactions, and feedback loops between Medicare and the delivery system, private insurers (including Medicare Advantage plans), and Medicaid; explaining the advantages, disadvantages, and cost-shifting that occurs in a pluralist system.

“Value-Based Purchasing Opportunities in Traditional Medicare”
Larry Casalino, M.D., Assistant Professor, Department of Health Studies at the University of Chicago and a member of the Advisory Council

The paper is to be a broad look at opportunities for improving the quality and efficiency of the program, while being better able to manage costs. Although the previously described paper will focus on the interactions Medicare has with other payers and how it helps shape health care delivery, the value-based purchasing paper will take advantage of lessons learned from private sector plan and payer initiatives, adjusting for the particular role Medicare plays in health care. This paper will provide a “soup-to-nuts” overview of purchasing opportunities, including medical management techniques (coordinating care, pay-for-performance, disease management), payment reform (DRG re-basing, physician fee schedule reform, episode-based payment), coverage policy (more extensive use of comparative effectiveness, cost-effectiveness research, and international comparisons), and promoting new delivery models (virtual group practices, a role for hospitals in disease management, etc.)

“Value-Based Purchasing for the Most Vulnerable Populations”
Chad Boult, M.D., Professor of Public Health (with joint appointment in Medicine); Director, Lipitz Center for Integrated Health Care, Department of Health Policy and Management at Johns Hopkins University School of Medicine

Discussion of how the poor and unhealthy would fare in the above system produced the concept for this paper, which would do two things: (1) Focus on approaches that might be particularly appropriate to the subset of Medicare beneficiaries who are particularly vulnerable and might be “lost” in broad value-based purchasing approaches. These patients might include those in the last months of life, those with multiple and severe chronic conditions and many dual eligibles. (2) Secondly, the paper will also consider the value-based purchasing approaches developed previously from the perspective of vulnerable populations to identify protections that might be needed to avoid unacceptable consequences from an aggressive value-based purchasing regime. In this context, the paper will clarify the difference between prudent cost containment activities and overt rationing of care and make clear under what circumstances the latter actually becomes a policy issue.

“Statutory and Regulatory Analysis to Support Value-Based Purchasing”
Tim Jost, Robert L. Willett Family Professor of Law at Washington and Lee University School of Law

The value-based purchaser paper also confirmed the need for another paper to review the set of proposals elucidated and perform a legal and regulatory analysis to determine which approaches could be implemented without legal impediment, which could be implemented through regulatory action, and which could be implemented only with new statutory authority. It will also look at international approaches to institutionalizing value-based purchasing.

“Governance Paper”
(Author to be announced)

The project’s governance paper will explore alternative governance structures that would facilitate the transformation of Medicare into a more efficient, more equitable, and more sustainable health program, both fiscally and politically. It will analyze the implications and identify the pros and cons of different kinds of decision authority resting with Congress, with the executive branch, with quasi-public and private entities, and with new public-private collaborations. The proper role of advisory commissions, whether ongoing (MEDPAC) or occasional (e.g., Breaux-Thomas, created by the Balanced Budget Act) will also be addressed, as will alternative ways to hold officials of the Medicare program accountable to the American public. It will start from the premise that change is necessary, since the current structure is clearly biased in favor of cost growth and weak accountability for mediocre providers as well as limited ability to reward providers who deliver exceptional value per dollar.