Plastic Surgeon Financial Compensation-Incentivization Models in Surgical Care Delivery: The Past, Present, and Future.

BACKGROUND: Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS: This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS: The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION: This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Redesigning provider payment: Opportunities and challenges from the Hawaii experience.

OBJECTIVES: To describe the process of developing a new physician payment system based on value and transitioning away from a fee-for-service payment system STUDY DESIGN: Descriptive. This paper describes a recent initiative involving redesign of primary care provider payment in the State of Hawaii. While there has been extensive discussion about switching payment from volume to value in recent years, much of this change has happened at the organizational level and this initiative focused on changing the incentives for individual providers. METHODS: Descriptive paper. In this paper we discuss the approach taken to shift incentives from fee-for-service towards value using behavioral economics as a conceptual framework for program design. We summarize the new payment system, challenges in its design, and our approach to piloting of different behavioral economic strategies to improve performance. RESULTS: None. CONCLUSIONS: This paper will provide useful guidance to health plans or health delivery systems considering shifting primary care payment away from fee-for-service towards value highlighting some of the design challenges and necessary compromises in implementing such a system at scale.

MACRA and the Quality Payment Program: How Does It Relate to Orthopaedic Nursing?

The introduction of 2017 also brought with it the beginning of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation related to the Quality Payment Program (QPP), in addition to alternative payment models and the merit-based incentive payment system. The successful implementation of the QPP within the specialty of orthopaedics will rely heavily on the active involvement of orthopaedic nurses when it comes to improving quality, lowering costs, and incorporating value. It is important for orthopaedic nurses to understand the QPP and the role it plays in determining value-based payment of orthopaedic care delivery, in addition to how the structure of the QPP correlates with nursing diagnoses and respective plans of care delivery.

Countervailing incentives in value-based payment.

Payment reform has been at the forefront of the movement toward higher-value care in the U.S. health care system. A common belief is that volume-based incentives embedded in fee-for-service need to be replaced with value-based payments. While this belief is well-intended, value-based payment also contains perverse incentives. In particular, behavioral economists have identified several features of individual decision making that reverse some of the typical recommendations for inducing desirable behavior through financial incentives. This paper discusses the countervailing incentives associated with four behavioral economic concepts: loss aversion, relative social ranking, inertia or status quo bias, and extrinsic vs. intrinsic motivation.

A new approach to clinical research: Integrating clinical care, quality reporting, and research using a wound care network-based learning healthcare system.

The disparity between ideal evidence from randomized controlled trials and real-world evidence in medical research has prompted the United States Food and Drug Administration to consider the use of real-world data to better understand safety and effectiveness of new devices for a broader patient population and to prioritize real-world data in regulatory decision making. As the healthcare system transitions from volume- to value-based care, there is a growing need to harness the power of real-world data to change the paradigm for wound care clinical research and enable more generalizable clinical trials. This paper describes the implementation of a network-based learning healthcare system by a for-profit consortium of wound care clinics that integrates wound care management, quality improvement, and comparative effectiveness research, by harnessing structured real-world data within a purpose-built electronic health record at the point of care. Centers participating in the consortium submit their clinical data and quality measures to a qualified clinical data registry for wound care, enabling benchmarking of their data across this national network. The common definitional framework of the purpose-built electronic health record and the 21 wound-specific quality measures help to standardize the potential sources of bias in real-world data, making the consortium data useful for comparative effectiveness research. This consortium can transform wound care clinical research and raise the standards of care, while helping physicians achieve success with the Merit-Based Incentive Payment System.

A Look at MACRA: What to Expect in 2017.

The Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 fundamentally changes how physicians who care for Medicare patients will be paid. Although physicians won't see changes in their payments in 2017, they need to understand that their performance in 2017 will be the basis for the payments made to them starting in 2019. This article summarizes the two paths for determining future Medicare payments established by the law: the merit-based incentive payment system and advanced alternative payment models.

For Medicare's New Approach To Physician Payment, Big Questions Remain.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for Medicare physician payment. Designed to stabilize uncertain payment rates for Medicare's fee-for-service (FFS) system and incentivize physicians to move into new alternative payment systems, MACRA contains several uncertainties of its own. In a textbook illustration of why it's important to be careful what you wish for, it's increasingly easy to predict that implementation of MACRA will be delayed as a result of both regulatory and legislative breaches of its statutory timeline. This article traces the contemporary history of the Medicare physician payment system and efforts to implement additional changes.

Policy-Oriented Research on Improved Physician Incentives for Higher Value Health Care.

Policy makers (both public and private) are seeking ways to improve the value delivered within our health care system, that is, using fewer resources to provide the same benefit to patients, or using equivalent resources to provide more benefit. One strategy is to alter the predominant fee-for-service (FFS) economic incentives in the current system. To inform such policy changes, this paper identifies areas in which little is known about the effects of specific incentives (FFS, salary, etc.) on the two components of value: resource use and quality. Specific suggestions are offered regarding research that would be informative for policy makers, focusing on fundamental "building block" studies rather than overall evaluations of complex interventions, such as accountable care organizations. This research would better identify critical aspects of the FFS model and salary-based payments that are particularly problematic, as well as situations in which FFS or salary may be less problematic. The research would also explore when alternatives, such as episode-based payment might be feasible, or simply be hypothetical solutions. The availability of electronic health record-based data in various delivery systems would allow many of these studies to be accomplished in 3-5 years with budgets manageable by public and private funding sources.

The siren song of physician incentives: avoiding the rocks.

As the United States attempts to reform its health care system, various incentive programs are playing an increasingly important role. In this review, the primary dynamics that drive the rise of incentives in health care management are discussed. Increasingly well-designed studies on the impact of incentives on outcomes continue to yield variable and, at times, unexpected results. The incorporation of incentives into the overall process of organizational cultural change is an important tool but one with significant limitations.

Report from the Committee for Improving the Work Environment of Japanese Surgeons: survey on effects of the fee revision for medical services provided by surgeons.

PURPOSE: The aim of this study was to achieve improvements in the work environment of Japanese surgeons and shortage of surgeons. METHODS: Questionnaires were distributed to selected Japanese surgical Society (JSS) members. Retrospective analysis was conducted comparing the current 2011 survey with previous 2007 survey. To examine the influence of 2010 revision of the fee for medical services performed by surgeons, we distributed a second questionnaire to directors of hospitals and administrators of clerks belonging to official institutes in JSS. Collective data were analyzed retrospectively. RESULTS: The main potential causes for the shortage of surgeons in Japan were long hours (72.8 %), excessive emergency surgeries (69.4 %), and high risk of lawsuit (67.7 %). Mean weekly working hours of surgeons in national or public university hospitals and private university hospitals were 96.2 and 85.6, respectively. Approximately 70 % of surgeons were forced to do hardworking tasks, possibly leading to death from overwork. Of note, approximately 25 % of surgeons had over time of more than 100 h a week, coinciding to the number of hours that might lead to death from fatigue, described in the Japanese labor law. Although the total medical service fee in hospitals, especially in large-scale hospitals with more than 500 beds, increased markedly after 2010 revision of the fee for medical services performed by surgeons, few hospitals gave perquisites and/or incentives to surgeons. CONCLUSION: To prevent and avoid collapse of the surgical specialty in Japan, an improvement in the work environment of surgeons by initiation of the JSS would be required as soon as possible.

Rural implications of the Primary Care incentive Payment Program.

Key Findings. (1) Both the number and proportion of providers eligible to receive Primary Care Incentive Payments in 2011, 2012, and 2013 increased during the years used to determine eligibility (2009, 2010, and 2011). (2) For most practice types, rural providers were more likely to be eligible for Primary Care Incentive Payments. However, rates of eligibility varied between provider types. (3) Rural Family Practice physicians were less likely to be eligible for Primary Care Incentive Payments than their urban counterparts.