Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

Background Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care. Methods We performed a cross-sectional analysis of visits in the United States’ National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use. Results About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics. Conclusions Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.

Payment Systems for Telemedicine: Comparative Study (Preprint)

BACKGROUND Many researchers have addressed the lack of reimbursement for telemedicine as one of the most important barriers to telemedicine adoption. However, little is known on how telemedicine should be implemented in reimbursement policy, how it must be financed, and what the right incentives are for an effective and efficient telemedicine use. OBJECTIVE To help future researchers to provide reimbursement policy recommendations, and to facilitate reimbursement decision-making, this paper analyzed and compared the telemedicine payment models of ten countries. METHODS A convenience sample was created of Western countries inside and outside Europe that already reimburse to some extent telemedicine. Ten countries met this criterion: Australia, Belgium, Denmark, France, Germany, Luxembourg, the Netherlands, Canada (Ontario province), Switzerland, and the United Kingdom. The study was based on the countries’ official physician fee schedules, listing all reimbursed medical services performed by physicians, including telemedicine. Based on the fee schedules, a comparative analysis of the payment models of telemedicine was conducted. RESULTS Televisits are reimbursed in all countries, which is not the case for telemonitoring and tele-expertise services. Telemonitoring is often restricted for patients with implanted cardiac devices. Telemedicine services are mainly paid fee-for-service, except for the telemonitoring of patients with implanted cardiac devices, which is paid through an episodic payment system in Australia. Payment parity exists across televisits and visits in person in France, Luxembourg, the Netherlands, and Switzerland, meaning that an equal fee is given for both services. CONCLUSIONS Our findings show that fees for telemedicine are lacking, especially for telemonitoring and tele-expertise. As telemedicine might enlarge disparities in healthcare access, policymakers should consider payment parity across televisits and face-to-face visits, and across telephone and video visits. Furthermore, an episodic physician payment system complemented with bonuses for quality outcomes, should be considered by policymakers for telemonitoring as it might capture the specificities of telemonitoring better than a fee-for-service system. Future research is needed on payment models, including research linking cost-effectiveness analyses with analyses on payment models, to allow profound reimbursement recommendations and a faster decision-making process for the reimbursement of telemedicine.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.