From the Department of Family Medicine, Oregon Health & Science University, Portland, OR (BP); Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine, Denver, CO (SBG); Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, D.C. (AB, WL).
J Am Board Fam Med. 2018 Jul-Aug;31(4):588-604. doi: 10.3122/jabfm.2018.04.170388.
Prior research has demonstrated the associations between a strong primary care foundation with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the United States reinforces the volume of services over value-based care, thereby devaluing primary care, and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from volume-based to value-based payment models, the Medicare Access and Children's Health Insurance Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a taxonomy of the major health care payment models, reviewing their ability to uphold the functions of primary care, and their impacts across the Quadruple Aim.
An Ovid MEDLINE search and expert opinion from members of the Family Medicine for America's Health payment and research tactic teams were used. Titles and abstracts were reviewed for relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and relevant articles.
No payment model demonstrates consistent benefits across the Quadruple Aim across a limited evidence base. Several cross-cutting lessons from available payment models several recommendations for primary care payment models, including the following: implementing per member per month-based models, validating risk-adjustment tools, increasing investments in integrated behavioral health and social services, and connecting payments to patient-oriented and primary care-oriented metrics. Along with ongoing research in emerging payment models, data systems integrated across health care and social services settings using metrics that can capture the ideal functions of primary care will be critical to the development of future payment models that most optimally enhance the role of primary care in the United States.
Although the ideal payment model for primary care remains to be determined, lessons learned from existing payment models can help guide the shift from volume-based to value-based care. To most effectively pay for primary care, future payment models should invest in a primary care infrastructure, one that supports team-based, community-oriented care, and measures the delivery of the functions of primary care.
先前的研究表明，拥有坚实的基层医疗基础与改善四重目标结果之间存在关联。美国现行的按服务项目付费的支付体系强化了服务数量而不是基于价值的护理，从而贬低了基层医疗的价值，并阻碍了医疗保健系统实现四重目标。通过支持从基于数量的支付模式向基于价值的支付模式转变，《平价医疗法案》和《儿童健康保险计划再授权法案》可能有助于加强基层医疗的作用。本叙述性评论提出了主要医疗保健支付模式的分类法，审查了它们维持基层医疗功能的能力，以及它们对四重目标的影响。
使用 Ovid MEDLINE 搜索和来自美国家庭医学支付和研究策略团队的专家意见。审查标题和摘要与主题的相关性，并根据专家意见进一步缩小文献范围，纳入及时和相关的文章。
在有限的证据基础上，没有任何支付模式在四重目标方面都表现出一致的优势。从现有的支付模式中吸取了一些交叉教训，并为基层医疗支付模式提出了一些建议，包括以下几点：实施按人按月计费的模式、验证风险调整工具、增加对综合行为健康和社会服务的投资，以及将支付与以患者为中心和以基层医疗为中心的指标联系起来。随着新兴支付模式的持续研究，使用可以捕捉基层医疗理想功能的指标，将医疗保健和社会服务环境中的数据系统集成在一起，对于开发最能增强美国基层医疗作用的未来支付模式将至关重要。
尽管基层医疗的理想支付模式仍有待确定，但从现有支付模式中吸取的经验教训可以帮助指导从基于数量的护理向基于价值的护理转变。为了最有效地支付基层医疗费用，未来的支付模式应投资于基层医疗基础设施，该基础设施支持团队为基础、面向社区的护理，并衡量基层医疗功能的提供情况。
