Payment

States are pursuing a broad range of payment strategies to support multi-payer delivery system models, from enhanced fee-for-service payment to support patient-centered medical homes to pay for performance, shared savings, bundled payment, and global payment models.

Also see the Aligning Reimbursement & Purchasing section of NASHP’s Medical Home Map and the Payment section of NASHP’s State Accountable Care Activity Map.


Payment to Support Patient-Centered Medical Homes:

Pay for Performance:

  • Rhode Island Chronic Care Sustainability Initiative. 2011. “Chronic Care Sustainability Initiative Common Contract.”Common contract between all practices and payers participating in Rhode Island’s multi-payer medical home program, the Chronic Care Sustainability Initiative (CSI). Includes a detailed description of the CSI payment model and performance metrics.
  • Pope, Gregory C. 2011. “Overview of Pay for Performance Models and Issues.” In Pay for Performance in Health Care: Methods and Approaches, ed. Cromwell, Jerry, Michael G. Trisolini, Gregory C. Pope, Janet B. Mitchell, and Leslie M. Greenwald. RTI International.Defines and describes pay for performance models, including performance measures and provider incentives. Discusses the risks and limitations of pay for performance models.

Shared Savings:

  • D’Andrea, Guy. 2013. “Controlling for Random Variation in Shared Savings Programs” (presentation). Discern Consulting. Recording available here.Discusses methods for controlling for patient- and population-level variation in shared savings models and provides a framework for evaluating controls.
  • Ben Steffen. “Reimbursement in the Maryland Multi-payer PCMH Program.” Maryland Healthcare Commission.Describes the payment model used in Maryland’s multi-payer Patient-Centered Medical Home Program, which combines fee-for-service plus per-member per-month care coordination payments and shared savings.

Bundled or Episode-Based Payments:

  • Arkansas Health Care Payment Improvement Initiative. 2012. “Health Care Payment Improvement Initiative.” http://www.paymentinitiative.org/Pages/default.aspxUnder the Arkansas Health Care Payment Improvement Initiative, three payers (including Arkansas Medicaid and two commercial insurers) have begun to implement an episode-based payment model for select conditions.
  • National Academy for State Health Policy. 2012. “Arkansas.” State “Accountable Care” Activity Map. https://nashp.org/aco/arkansas.Profiles of the Arkansas Health Care Payment Improvement Initiative across seven domains: project scope, authority, governance, criteria for participation, payment, support for infrastructure, and measurement and evaluation.
  • Pham, Hongmai, Paul Ginsburg, Timothy Lake, and Myles Maxfield. 2010. “Episode-Based Payments: Charting a Course for Health Care Payment Reform.” National Institute for Health Care Reform.Discusses key policy considerations around episode-based payment models – including defining episodes of care, setting payment rates, and identifying providers to participate – as well as identifying some challenges of implementing episode-based payment and strategies for overcoming these.

Global Budgets:

  • Robinow, Ann. 2010. “The Potential of Global Payment: Insights from the Field.” The Commonwealth Fund.Discusses the potential of global payment models to reduce cost of care while improving quality with a focus on avoiding past problems with capitation models and identifying potential challenges that could arise.