Husaini Mustafa, Joynt Maddox Karen E
WASHINGTON UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS, MISSOURI.
INSTITUTE FOR PUBLIC HEALTH AT WASHINGTON UNIVERSITY, ST. LOUIS, MISSOURI.
Methodist Debakey Cardiovasc J. 2020 Jul-Sep;16(3):225-231. doi: 10.14797/mdcj-16-3-225.
Over the past two decades, Medicare and other payers have been looking at ways to base payment for cardiovascular care on the quality and outcomes of care delivered. Public reporting of hospital performance on a series of quality measures began in 2004 with basic processes of care such as aspirin use and influenza vaccination, and it expanded in later years to include outcomes such as mortality and readmission rates. Following the passage of the Affordable Care Act in March 2010, Medicare and other payers moved forward with pay-for-performance programs, more commonly referred to as value-based purchasing (VBP) programs. These programs are largely based on an underlying fee-for-service payment infrastructure and give hospitals and clinicians bonuses or penalties based on their performance. Another new payment mechanism, called alternative payment models (APMs), aims to move towards episode-based or global payments to improve quality and efficiency. The two most relevant APMs for cardiovascular care include Accountable Care Organizations and bundled payments. Both VBP programs and APMs have challenges related to program efficacy, accuracy, and equity. In fact, despite over a decade of progress in measuring and incentivizing high-quality care delivery within cardiology, major limitations remain. Many of the programs have had little benefit in terms of clinical outcomes yet have led to marked administrative burden for participants. However, there are several encouraging prospects to aid the successful implementation of value-based high-quality cardiovascular care, such as more sophisticated data science to improve risk adjustment and flexible electronic health records to decrease administrative burden. Furthermore, payment models designed specifically for cardiovascular care could incentivize innovative care delivery models that could improve quality and outcomes for patients. This review provides an overview of current efforts, largely at the federal level, to pay for high-quality cardiovascular care and discusses the challenges and prospects related to doing so.
在过去二十年中，医疗保险和其他支付方一直在探寻如何根据所提供心血管护理的质量和结果来确定支付金额。2004年开始对医院在一系列质量指标上的表现进行公开报告，最初涉及阿司匹林使用和流感疫苗接种等基本护理流程，随后几年范围扩大到包括死亡率和再入院率等结果指标。2010年3月《平价医疗法案》通过后，医疗保险和其他支付方推进了按绩效付费项目，更普遍地称为基于价值的采购（VBP）项目。这些项目主要基于潜在的按服务收费支付基础设施，并根据医院和临床医生的表现给予奖金或惩罚。另一种新的支付机制，称为替代支付模式（APM），旨在转向基于诊疗过程或整体的支付方式，以提高质量和效率。与心血管护理最相关的两种APM包括 accountable Care Organizations（可问责医疗组织）和捆绑支付。VBP项目和APM都面临与项目有效性、准确性和公平性相关的挑战。事实上，尽管在衡量和激励心脏病学领域高质量护理提供方面已经取得了十多年的进展，但主要限制仍然存在。许多项目在临床结果方面益处不大，却给参与者带来了显著的行政负担。然而，有几个令人鼓舞的前景有助于成功实施基于价值的高质量心血管护理，比如采用更复杂的数据科学来改进风险调整，以及使用灵活的电子健康记录来减轻行政负担。此外，专门为心血管护理设计的支付模式可以激励创新的护理提供模式，从而改善患者的质量和结局。本综述概述了目前主要在联邦层面为高质量心血管护理付费的努力，并讨论了这样做所涉及的挑战和前景。
