Health affairs
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In January 2009 Blue Cross Blue Shield of Massachusetts launched a new payment arrangement called the Alternative Quality Contract. The contract stipulates a modified global payment (fixed payments for the care of a patient during a specified time period) arrangement. ⋯ This arrangement exemplifies the type of experimentation encouraged by the Affordable Care Act. We describe this unique contract and show how it surmounts hurdles previously encountered with other global-payment models.
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Under the Affordable Care Act, the new Center for Medicare and Medicaid Innovation will guide a number of experimental programs in health care payment and delivery. Among the most ambitious of the reform models is the accountable care organization (ACO), which will offer providers economic rewards if they can reduce Medicare's cost growth in their communities. However, the dismal history of provider-led attempts to manage costs suggests that this program is unlikely to accomplish its objectives. ⋯ This paper proposes a more flexible payment model for providers and private insurers that would divide health care services into three categories: long-term, low-intensity primary care; unscheduled care, including unscheduled emergency services; and major clinical interventions that usually involve hospitalization or organized outpatient care. Each category of care would be paid for differently, with each containing different elements of financial risk for the providers. Health plans would then be encouraged to provide logistical and analytic support to providers in managing health costs in these categories.
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When a physician who isn't a radiologist holds an ownership interest in an advanced imaging machine and refers patients for diagnostic procedures on that machine, this act of self-referral presents a conflict of interest. Numerous studies demonstrate greater use of high-tech imaging when physicians can financially benefit from such referrals. ⋯ However, the rewards for imaging self-referral remain strong. Policy makers continue to search for the right mechanisms for containing the practice and for assuring that Medicare beneficiaries receive only medically necessary imaging studies, regardless of who owns or operates the equipment.