States Encouraging Value-Based Payment: Lessons From CMS's State Innovation Models Initiative.

Policy Points Six states received $250 million under the federal State Innovation Models (SIM) Initiative Round 1 to increase the proportion of care delivered under value-based payment (VBP) models aligned across multiple payers. Multipayer alignment around a common VBP model occurred within the context of state regulatory and purchasing policies and in states with few commercial payers, not through engaging many stakeholders to act voluntarily. States that made targeted infrastructure investments in performance data and electronic hospital event notifications, and offered grants and technical assistance to providers, produced delivery system changes to enhance care coordination even where VBP models were not multipayer. CONTEXT: In 2013, six states (Arkansas, Massachusetts, Maine, Minnesota, Oregon, and Vermont) received $250 million in Round 1 State Innovation Models (SIM) awards to test how regulatory, policy, purchasing, and other levers available to state governments could transform their health care system by implementing value-based payment (VBP) models that shift away from fee-for-service toward payment based on quality and cost. METHODS: We gathered and analyzed qualitative data on states' implementation of their SIM Initiatives between 2014 and 2018, including interviews with state officials and other stakeholders; consumer and provider focus groups; and review of relevant state-produced documents. FINDINGS: State policymakers leveraged existing state law, new policy development, and federal SIM Initiative funds to implement new VBP models in Medicaid. States' investments promoted electronic health information going from hospitals to primary care providers and collaboration across care team members within practices to enhance care coordination. Multipayer alignment occurred where there were few commercial insurers in a state, or where a state law or state contracting compelled commercial insurer participation. Challenges to health system change included commercial payer reluctance to coordinate on VBP models, cost and policy barriers to establishing bidirectional data exchange among all providers, preexisting quality measurement requirements across payers that impede total alignment of measures, providers' perception of their limited ability to influence patients' behavior that puts them at financial risk, and consumer concerns with changes in care delivery. CONCLUSIONS: The SIM Initiative's test of the power of state governments to shape health care policy demonstrated that strong state regulatory and purchasing policy levers make a difference in multipayer alignment around VBP models. In contrast, targeted financial investments in health information technology, data analytics, technical assistance, and workforce development are more effective than policy alone in encouraging care delivery change beyond that which VBP model participation might manifest.

Medicaid Accountable Care Organizations in Four States: Implementation and Early Impacts.

Policy Points Maine, Massachusetts, Minnesota, and Vermont leveraged State Innovation Model awards to implement Medicaid accountable care organizations (ACOs). Flexibility in model design, ability to build on existing reforms, provision of technical assistance to providers, and access to feedback data all facilitated ACO development. Challenges included sustainability of transformation efforts and the integration of health care and social service providers. Early estimates showed promising improvements in hospital-related utilization and Vermont was able to reduce or slow the growth of Medicaid costs. These states are sustaining Medicaid ACOs owing in part to provider support and early successes in generating shared savings. The states are modifying their ACOs to include greater accountability and financial risk. CONTEXT: As state Medicaid programs consider alternative payment models (APMs), many are choosing accountable care organizations (ACOs) as a way to improve health outcomes, coordinate care, and reduce expenditures. Four states (Maine, Massachusetts, Minnesota, and Vermont) leveraged State Innovation Model awards to create or expand Medicaid ACOs. METHODS: We used a mixed-methods design to assess achievements and challenges with ACO implementation and the impact of Medicaid ACOs on health care utilization, quality, and expenditures in three states. We integrated findings from key informant interviews, focus groups, document review, and difference-in-difference analyses using data from Medicaid claims and an all-payer claims database. FINDINGS: States built their Medicaid ACOs on existing health care reforms and infrastructure. Facilitators of implementation included allowing flexibility in design and implementation, targeting technical assistance, and making clinical, cost, and use data readily available to providers. Barriers included provider concerns about their ability to influence patient behavior, sustainability of provider practice transformation efforts when shared savings are reinvested into the health system and not shared with participating clinicians, and limited integration between health care and social service providers. Medicaid ACOs were associated with some improvements in use, quality, and expenditures, including statistically significant reductions in emergency department visits. Only Vermont's ACO demonstrated slower growth in total Medicaid expenditures. CONCLUSIONS: Four states demonstrated that adoption of ACOs for Medicaid beneficiaries was both possible and, for three states, associated with some improvements in care. States revised these models over time to address stakeholder concerns, increase provider participation, and enable some providers to accept financial risk for Medicaid patients. Lessons learned from these early efforts can inform the design and implementation of APMs in other Medicaid programs.

Cognitive interventions to reduce diagnostic error: a narrative review.

BACKGROUND: Errors in clinical reasoning occur in most cases in which the diagnosis is missed, delayed or wrong. The goal of this review was to identify interventions that might reduce the likelihood of these cognitive errors. DESIGN: We searched PubMed and other medical and non-medical databases and identified additional literature through references from the initial data set and suggestions from subject matter experts. Articles were included if they either suggested a possible intervention or formally evaluated an intervention and excluded if they focused solely on improving diagnostic tests or provider satisfaction. RESULTS: We identified 141 articles for full review, 42 reporting tested interventions to reduce the likelihood of cognitive errors, 100 containing suggestions, and one article with both suggested and tested interventions. Articles were classified into three categories: (1) Interventions to improve knowledge and experience, such as simulation-based training, improved feedback and education focused on a single disease; (2) Interventions to improve clinical reasoning and decision-making skills, such as reflective practice and active metacognitive review; and (3) Interventions that provide cognitive 'help' that included use of electronic records and integrated decision support, informaticians and facilitating access to information, second opinions and specialists. CONCLUSIONS: We identified a wide range of possible approaches to reduce cognitive errors in diagnosis. Not all the suggestions have been tested, and of those that have, the evaluations typically involved trainees in artificial settings, making it difficult to extrapolate the results to actual practice. Future progress in this area will require methodological refinements in outcome evaluation and rigorously evaluating interventions already suggested, many of which are well conceptualised and widely endorsed.

System-related interventions to reduce diagnostic errors: a narrative review.

BACKGROUND: Diagnostic errors (missed, delayed or wrong diagnosis) have recently gained attention and are associated with significant preventable morbidity and mortality. The authors reviewed the recent literature and identified interventions that address system-related factors that contribute directly to diagnostic errors. METHODS: The authors conducted a comprehensive search using multiple search strategies. First, they performed a PubMed search to identify articles exclusively related to diagnostic error or delay published in English between 2000 and 2009. They then sought papers from references in the initial dataset, searches of additional databases, and subject matter experts. Articles were included if they formally evaluated an intervention to prevent or reduce diagnostic error; however, papers were also included if interventions were suggested and not tested to inform the state of the science on the subject. Interventions were characterised according to the step in the diagnostic process they targeted: patient-provider encounter; performance and interpretation of diagnostic tests; follow-up and tracking of diagnostic information; subspecialty and referral-related issues; and patient-specific care-seeking and adherence processes. RESULTS: 43 articles were identified for full review, of which six reported tested interventions and 37 contained suggestions for possible interventions. Empirical studies, although somewhat positive, were non-experimental or quasi-experimental and included a small number of clinicians or healthcare sites. Outcome measures in general were underdeveloped and varied markedly among studies, depending on the setting or step in the diagnostic process. CONCLUSIONS: Despite a number of suggested interventions in the literature, few empirical studies in the past decade have tested interventions to reduce diagnostic errors. Advancing the science of diagnostic error prevention will require more robust study designs and rigorous definitions of diagnostic processes and outcomes to measure intervention effects.

Measuring meaningful use.

To qualify for new federal funds intended to promote the widespread adoption and use of electronic health records, U.S. physician practices must meet the government's "meaningful use" benchmarks. Our analysis indicates that among physicians who have electronic health records, between 75-85 percent are already using functions that meet some of the proposed criteria for demonstrating meaningful use. But gaps remain. We provide a new analysis of baseline use of specific electronic health record functions among primary care physicians and medical and surgical specialists. The analysis can help researchers and policy makers measure more accurately the success of ongoing efforts to expand effective use of health information technology.

Is signed consent for influenza or pneumococcal polysaccharide vaccination required?

Each year, thousands of preventable deaths and hospitalizations result from complications of influenza and pneumococcal disease, mostly in elderly persons, despite the availability of vaccines. Obtaining signed consent prior to administering the vaccines represents an obstacle to achieving the Healthy People 2010 goals for vaccinating individuals against influenza and pneumococcal disease. Signed consent is neither legally mandated nor a guarantee that the patient (or proxy) has given informed consent. Nonetheless, many health care providers and institutions currently require signed consent before administering these vaccines. Rather, health care providers should use the Vaccine Information Sheets developed by the Centers for Disease Control and Prevention to inform patients about the risks and benefits associated with these vaccines. Requiring signed consent before administering these low-risk, high-benefit vaccines is inconsistent with the current practice of not requiring signed consent before prescribing other common treatments, eg, antibiotic treatment, whose risk levels are the same or higher.

Admission and continued-stay criteria for assisted living facilities.

As residents in assisted living facilities (ALFs) try to "age in place" but decline in health, the facilities, families, and residents must find a balance between protecting the health and safety of residents in ALFs and maintaining their desire to live independently. The assisted living industry incorporates resident autonomy into its goals, but with regard to resident health and safety, recent reports have found that ALF staff are struggling to provide adequate care for residents with increasingly complex needs. Moreover, state regulations are not consistent in obligating ALFs to prioritize adequate health care and protection for residents over resident autonomy, or vice versa. A set of admission and continued stay criteria for individuals residing in assisted living that could serve as a guideline for state regulations in addressing the balance between safety and autonomy in ALFs is recommended.

Approaches to quality improvement in nursing homes: lessons learned from the six-state pilot of CMS's Nursing Home Quality Initiative.

BACKGROUND: In November 2002, the Centers for Medicare & Medicaid Services (CMS) launched a Nursing Home Quality Initiative that included publicly reporting a set of Quality Measures for all nursing homes in the country, and providing quality improvement assistance to nursing homes nationwide. A pilot of this initiative occurred in six states for six months prior to the launch. METHODS: Review and analysis of the lessons learned from the six Quality Improvement Organizations (QIOs) that led quality improvement efforts in nursing homes from the six pilot states. RESULTS: QIOs in the six pilot states found several key outcomes of the Nursing Home Quality Initiative that help to maximize the potential of public reporting to leverage effective improvement in nursing home quality of care. First, public reporting focuses the attention of all stakeholders in the nursing home industry on achieving good quality outcomes on a defined set of measures, and creates an incentive for partnership formation. Second, publicly reported quality measures motivate nursing home providers to improve in certain key clinical areas, and in particular to seek out new ways of changing processes of care, such as engaging physicians and the medical director more directly. Third, the lessons learned by QIOs in the pilot of this Initiative indicate that certain approaches to providing quality improvement assistance are key to guiding nursing home providers' desire and enthusiasm to improve towards a using a systematic approach to quality improvement. CONCLUSION: The Nursing Home Quality Initiative has already demonstrated the potential of public reporting to foster collaboration and coordination among nursing home stakeholders and to heighten interest of nursing homes in quality improvement techniques. The lessons learned from this pilot project have implications for any organizations or individuals planning quality improvement projects in the nursing home setting.