Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Abstract

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Impact of reimbursement systems on patient care – a systematic review of systematic reviews

“…When salary and FFS payments are combined, a decrease in clinical services per year and in hospital readmissions is noted [ 27 , 30 ]. Within models of bundled payments, heterogeneous results are found: While one source describes a decline in all-cause hospitalizations and readmissions [ 30 ], other sources find both improvements and deterioration in hospital facility use and the number of acute admissions [ 27 , 31 ]. Deteriorations are described in the following categories: use of patient care resources, number of services provided per patient, shorter lengths of stay, discharges to post-hospital facilities [ 16 , 18 , 24 , 30 , 32 ].…”

“…One review finds a decrease in transfer rates out of hospitals for a salary-based payment [ 30 ]. The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ].…”

“…The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ]. Some reviews notice an improvement in the quality and number of screenings [ 30 , 42 ] or a decrease in the case complexity [ 16 ].…”

“…Evidence of the impact on quality of care and health outcomes associated with P4P is also examined in reviews. One review reports improvement in terms of an increase in immunization rates among children for FFS payments [ 35 ], whereas other sources find increases, decreases and no changes in number of treatment cases, treatment outcomes, mortality, and hospitalization rates [ 18 , 27 , 31 ]. The most influences on health outcomes or quality of care are found in models of value-based payment.…”

“…Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].…”

Impact of reimbursement systems on patient care – a systematic review of systematic reviews

“…When salary and FFS payments are combined, a decrease in clinical services per year and in hospital readmissions is noted [ 27 , 30 ]. Within models of bundled payments, heterogeneous results are found: While one source describes a decline in all-cause hospitalizations and readmissions [ 30 ], other sources find both improvements and deterioration in hospital facility use and the number of acute admissions [ 27 , 31 ]. Deteriorations are described in the following categories: use of patient care resources, number of services provided per patient, shorter lengths of stay, discharges to post-hospital facilities [ 16 , 18 , 24 , 30 , 32 ].…”

“…One review finds a decrease in transfer rates out of hospitals for a salary-based payment [ 30 ]. The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ].…”

“…The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ]. Some reviews notice an improvement in the quality and number of screenings [ 30 , 42 ] or a decrease in the case complexity [ 16 ].…”

“…Evidence of the impact on quality of care and health outcomes associated with P4P is also examined in reviews. One review reports improvement in terms of an increase in immunization rates among children for FFS payments [ 35 ], whereas other sources find increases, decreases and no changes in number of treatment cases, treatment outcomes, mortality, and hospitalization rates [ 18 , 27 , 31 ]. The most influences on health outcomes or quality of care are found in models of value-based payment.…”

“…Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].…”

Impact of reimbursement systems on patient care – a systematic review of systematic reviews

“…When salary and FFS payments are combined, a decrease in clinical services per year and in hospital readmissions is noted [ 27 , 30 ]. Within models of bundled payments, heterogeneous results are found: While one source describes a decline in all-cause hospitalizations and readmissions [ 30 ], other sources find both improvements and deterioration in hospital facility use and the number of acute admissions [ 27 , 31 ]. Deteriorations are described in the following categories: use of patient care resources, number of services provided per patient, shorter lengths of stay, discharges to post-hospital facilities [ 16 , 18 , 24 , 30 , 32 ].…”

“…One review finds a decrease in transfer rates out of hospitals for a salary-based payment [ 30 ]. The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ].…”

“…The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ]. Some reviews notice an improvement in the quality and number of screenings [ 30 , 42 ] or a decrease in the case complexity [ 16 ].…”

“…Evidence of the impact on quality of care and health outcomes associated with P4P is also examined in reviews. One review reports improvement in terms of an increase in immunization rates among children for FFS payments [ 35 ], whereas other sources find increases, decreases and no changes in number of treatment cases, treatment outcomes, mortality, and hospitalization rates [ 18 , 27 , 31 ]. The most influences on health outcomes or quality of care are found in models of value-based payment.…”

“…Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].…”

Impact of reimbursement systems on patient care – a systematic review of systematic reviews

“…When salary and FFS payments are combined, a decrease in clinical services per year and in hospital readmissions is noted [ 27 , 30 ]. Within models of bundled payments, heterogeneous results are found: While one source describes a decline in all-cause hospitalizations and readmissions [ 30 ], other sources find both improvements and deterioration in hospital facility use and the number of acute admissions [ 27 , 31 ]. Deteriorations are described in the following categories: use of patient care resources, number of services provided per patient, shorter lengths of stay, discharges to post-hospital facilities [ 16 , 18 , 24 , 30 , 32 ].…”

“…One review finds a decrease in transfer rates out of hospitals for a salary-based payment [ 30 ]. The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ].…”

“…The results for bundled payments are heterogeneous [ 18 , 27 , 30 , 31 ]. Heterogeneous results, which means improvements as well as decreases and no changes are found within the primary studies in the reviews for mortality, rehospitalization rates, quality of care and numbers of treatment cases [ 16 , 27 , 30 , 31 , 42 ]. Some reviews notice an improvement in the quality and number of screenings [ 30 , 42 ] or a decrease in the case complexity [ 16 ].…”

“…Evidence of the impact on quality of care and health outcomes associated with P4P is also examined in reviews. One review reports improvement in terms of an increase in immunization rates among children for FFS payments [ 35 ], whereas other sources find increases, decreases and no changes in number of treatment cases, treatment outcomes, mortality, and hospitalization rates [ 18 , 27 , 31 ]. The most influences on health outcomes or quality of care are found in models of value-based payment.…”

“…Other sources report heterogeneous effects in patient satisfaction, short-term health outcomes and mortality [ 20 , 22 , 40 , 47 ]. No effects on mortality, quality of care, health outcomes, rehospitalization or patient satisfaction after an implementation of value-based reimbursement are described in six reviews [ 11 , 20 , 31 , 37 , 38 , 46 ].…”