Journal of general internal medicine
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A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings. ⋯ Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.
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Some Medicare Part D enrollees whose drug expenditures exceed a threshold enter a coverage gap with full cost-sharing, increasing their risk for reduced adherence and adverse outcomes. ⋯ Certain chronically ill MAPD enrollees are at high risk of gap entry and exposure to unsubsidized medication costs. Clinically vulnerable populations should be counseled on how to best manage costs through drug substitution or discontinuation of specific, non-essential medications.
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The Patient-Centered Medical Home (PCMH) is a widely endorsed model of delivery system reform that emphasizes primary care. Pilot demonstration projects are underway in many states, sponsored by Medicare, Medicaid, major health plans and multi-payer coalitions. ⋯ Multi-stakeholder involvement will be essential in developing a long-term policy-relevant research agenda for outcomes of the PCMH.
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In this paper, we describe a range of payment options to support the PCMH, identifying their conceptual strengths and weaknesses. These include enhanced FFS payment for office visits to the PCMH; paying additional FFS for "new" PCMH services; variations of traditional FFS combined with new PCMH-oriented per patient per month capitation; and combined capitation payments for traditional primary care medical services as well as new medical home services. In discussing options for PCMH payment reform we consider issues in patient severity adjustment, performance payment, and the role of payments to community service organizations to collaborate with the PCMH. ⋯ We conclude that the conceptual strengths and weaknesses of available payment models for medical home functions invoke a complex array of options with varying levels of real-world feasibility. The different needs of patients and communities, and varying characteristics of practices must also be factors guiding PCMH payment reform. Indeed, it may be that different circumstances will require different payment approaches in various combinations.
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The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. ⋯ Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.