Berenson Robert A, Shartzer Adele, Pham Hoangmai H
Urban Institute Health Policy Center, Washington, DC 20034, United States.
Institute for Exceptional Care, Washington, DC 20006, United States.
Health Aff Sch. 2023 Jul 3;1(2):qxad024. doi: 10.1093/haschl/qxad024. eCollection 2023 Aug.
The National Academies of Sciences, Engineering, and Medicine's (NASEM's) 2021 report on primary care called for a hybrid payment approach-a mix of fee-for-service and population-based payment-with performance accountability to strike the proper balance for desired practice transformation and to support primary care's important and expanding role. The NASEM report also proposed substantial increases to primary care payment and reforms to the Medicare Physician Fee Schedule. This paper addresses pragmatic ways to implement these recommendations, describing and proposing solutions to the main implementation challenges. The urgent need for primary care payment reform calls for adopting a hybrid model within the Medicare fee schedule rather than engaging in another round of demonstrations, despite legal and practical obstacles to adoption. The paper explores reasons for adopting a roughly 50:50 blend of fee-for-service and population-based payment and addresses other design features, presenting reasons why spending accountability should rely on utilization measures under primary care control rather than performance on total cost of care, and proposes a fresh approach to quality, emphasizing that quality measures should be parsimonious, focused on important outcomes with demonstrated quality improvement.
美国国家科学院、工程院和医学院（NASEM）2021年关于初级保健的报告呼吁采用混合支付方式——即按服务收费和基于人群的支付相结合——并对绩效负责，以在期望的实践转型中实现适当平衡，并支持初级保健日益重要且不断扩大的作用。NASEM报告还提议大幅提高初级保健支付水平，并对医疗保险医师费率表进行改革。本文探讨了实施这些建议的务实方法，描述并提出了应对主要实施挑战的解决方案。尽管采用这种模式存在法律和实际障碍，但鉴于初级保健支付改革的迫切需求，仍需在医疗保险费率表中采用混合模式，而非再进行一轮示范项目。本文探讨了采用约50:50的按服务收费与基于人群支付混合方式的原因，并讨论了其他设计特点，阐述了为何支出问责应依赖于初级保健可控的利用措施，而非护理总成本绩效，并提出了一种全新的质量方法，强调质量措施应简洁明了，专注于具有质量改善证明的重要结果。
