Category Archives: Health Care Payment Reform

Oct 16 2014

RWJF Scholars in the News: Ebola safeguards, pay-for-performance, brain development and more.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni and grantees. Some recent examples:

PBS NewsHour interviews Howard Markel, MD, PhD, FAAP, on whether hospitals, doctors and nurses are sufficiently prepared to handle Ebola cases in the United States, and what measures should be taken to increase safety. “As someone who studies epidemics, there’s always lots of fear, scapegoating and blame,” Markel, an RWJF Investigator Award in Health Policy Research recipient, said. “American tolerance for anything less than perfection has only shortened. The incredible thing to focus on is that so little has happened, so few cases have spread here.” The video is available here and an accompanying article is available here. Markel is also quoted in an Ebola story in the New Republic and wrote a blog for the Huffington Post.

In an article for Forbes magazine, RWJF Investigator Award in Health Policy Research recipient Peter Ubel, MD, discusses whether pay-for-performance health care models can lead to overdiagnosis and overuse of antibiotics. He cites recent journal articles suggesting that sepsis may be over diagnosed in hospitals because the institutions receive higher reimbursements for sepsis patients than for those with milder infections. “In other words, it pays not to miss sepsis diagnoses,” Ubel writes. “Because of the inherent subjectivity of medical diagnoses, those groups that assess health care quality need to remain on the alert for the unintended consequences of their measures. And those insurers and regulators eager to establish clinical care mandates? They need to slow down and make sure their administrative fixes do not create undue side effects.” Ubel also wrote a separate Forbes article on health insurance turnover.

Recent research on children who began life in overcrowded Romanian orphanages shows that early childhood neglect is associated with changes in brain structure, Science Times reports. A study co-authored by RWJF Health & Society Scholars program alumna Margaret Sheridan, PhD, finds that children who spent their early years in Romanian orphanages have thinner brain tissue in cortical areas that correspond to impulse control and attention, providing support for a link between the early environment and Attention Deficit Hyperactivity Disorder (ADHD). Researchers compared brain scans from 58 children who spent at least some time in institutions with scans of 22 non-institutionalized children from nearby communities, all between the ages of 8 and 10. The article notes that the study is among the first to document how social deprivation in early life affects the thickness of the cortex.

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Jun 19 2014

RWJF Clinical Scholars Video Podcast: Joshua Sharfstein on Hospital Incentives

One of the challenges of health care reform is to realign financial incentives so that providers and hospitals have economic inducements to keep patients healthy, rather than just treating them when they’re ill.

In the latest Robert Wood Johnson Foundation (RWJF) Clinical Scholars Health Policy Podcast, Maryland Secretary of Health & Mental Hygiene Joshua Sharfstein, MD, discusses a hospital in Hagerstown, Md., that took charge of the local public school health program, hiring school nurses and more “because it’d be an economic winner for them.” The hospital’s economic incentives were such that, “If they did it well, and helped kids with asthma control their asthma so they didn’t need to go to the emergency room, [the hospital] would save money on ER visits,” Sharfstein explains.

Sharfstein is interviewed by Clinical Scholar Loren Robinson, MD. The video podcast is part of a series of RWJF Clinical Scholars Health Policy Podcasts, co-produced with Penn’s Leonard Davis Institute of Health Economics.

The video is republished with permission from the Leonard Davis Institute.

Feb 25 2014

Physician Compensation Patterns Pose Challenges to Efforts to Incentivize Changes in How Care Is Delivered

Salary is the most common type of compensation for physicians in non-solo practice settings, many of whom are paid through a blend of methods, according to a new American Medical Association (AMA) Policy Research Perspectives report that says it provides a “rare glimpse” into how non-solo physicians are paid.

Just over 53 percent of non-solo physicians reported that all or most of their compensation came from salary, while nearly 32 percent said all or most of their compensation was based on personal productivity. The report points out that this breakdown “suggests that it may be difficult to align practice-level incentives that encourage judicious use of resources with physician-level incentives that do not.”

Ideally, the report says, financial and other incentives would encourage physicians to make the best care decisions possible for patients, providing them “the right care, in the right place, and at the right time,” but current incentives often do not encourage that approach.

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Jan 27 2014

A Year of Dramatic Increase in Insurance Coverage

Michael Geruso, PhD, is a Robert Wood Johnson Foundation Scholar in Health Policy Research at Harvard University and an assistant professor of economics at the University of Texas at Austin. This post is part of the “Health Care in 2014” series.


2014 marks the start of coverage for those who are newly insured via the health insurance exchanges. In general, healthy behaviors and lifestyle are probably the most important inputs to health, especially for those of us free of serious chronic conditions. But for those of us who are sick, quality health care and access to drugs is crucial for health and happiness. We will soon know to what extent the health insurance exchanges have overcome their implementation problems and have connected previously uninsured Americans to health care.
When markets for health insurance work efficiently, they can deliver access to crucial health services to those who need and want them most. Unfortunately, free, unregulated markets for health insurance rarely function efficiently. The market failures in health care have long been noted by economists, most famously by Nobel Prize winner Kenneth Arrow, MA, PhD. In my view, one the most important changes that the Affordable Care Act (ACA) brings with it is an attempt to address and correct market failures via the exchanges.

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Dec 12 2013

Human Capital News Roundup: TV coverage of terrorism, alcohol laws, electronic health records, and more.

Around the country, print, broadcast, and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows, alumni, and grantees. Some recent examples:

MedPage Today reports that Medicare could save up to $560 million per year if the program reimbursed ambulances for transporting patients to places other than hospital emergency departments. Roughly 35 percent of Medicare patients taken to a hospital could be treated at other places, according to an analysis by Gregg Margolis, PhD, director of health care systems and health policy at the U.S. Department of Health and Human Services. Margolis is an alumnus of the RWJF Health Policy Fellows program.

Six or more daily hours of exposure to media coverage of the Boston Marathon bombings in the week following the tragedy was linked to more acute stress than having been at, or near, the marathon, reports KMBZ, an ABC affiliate in Boston. “We were very surprised at the degree to which repeated media exposure was so strongly associated with acute stress symptoms,” said E. Alison Holman, PhD, FNP, the study’s lead author and an RWJF Nurse Faculty Scholar. The study was also covered in Medical Xpress.

The herpes virus that produces cold sores has been linked to cognitive impairment throughout life, BioScience Tech reports. A study led by RWJF Health & Society Scholars alumna Allison Aiello, PhD, MS, documents that the virus’ effects on children ages 12 to 16 include lower reading and spatial reasoning test scores. The study is also covered in Medical Xpress.

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Apr 30 2013

RWJF Scholar Alum Discusses Accountable Care Organizations

Elliott Fisher, MD, MPH, a health policy researcher and alumnus of the Robert Wood Johnson Foundation Clinical Scholars program (1983-1985), was recently named director of the Dartmouth Institute for Health Policy & Clinical Practice. Fisher coined the term “Accountable Care Organization” (ACO). In this Clinical Scholar Health Policy podcast, he discusses the origins of ACOs and the effort to develop them in the nation’s health care system. Watch his interview with RWJF Clinical Scholar Chileshe Nkonde-Price, MD, (2012-2014). The video is republished with permission from the Leonard Davis Institute.

Mar 22 2013

A ‘Goldilocks’ Theorem of Shared Savings and ACOs

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation (RWJF) Health & Society Scholar in residence at the University of Pennsylvania and a senior fellow at the Leonard Davis Institute of Health Economics. This is the first in a series of essays, reprinted from the Leonard Davis Institute of Health Economics’ eMagazine, in which scholars who attended the recent AcademyHealth National Health Policy Conference reflect on the experience.


Like Goldilocks wandering through the house of the Three Bears, policy-makers in search of a health care payment model have found it difficult to settle on an option that is "just right."

Fee-for-service—paying doctors separately for each service they provide—leads to too much unnecessary and duplicative care (too hot!). Capitation—paying doctors a fixed fee for caring for patients—leads doctors to skimp on care and avoid costly populations (too cold!). A "just right" payment model should give providers incentives to provide all the clinically necessary care to patients while keeping costs low.

Shared savings models—allowing providers to keep a portion of the money they save caring for patients—have been touted as one method for aligning the incentives of providers and payers. Most prominently, shared savings is a central element of the Affordable Care Act's Accountable Care Organizations (ACOs).

An ACO is a network of providers that have agreed to accept a bundled payment for treating patient populations, and in return stand to gain incentive payments for meeting performance targets (or to lose money for missing targets). In the "happily ever after" version of ACOs, groups of providers will finally have a business case for coordinating patient medical records, reducing costly visits to the emergency room, and improving patient compliance with chronic disease therapies without leading to excessive procedures or gaps in care. Healthy patients, healthy profits.

But will it work?

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Jan 4 2013

Health Care Costs are Killing Us

Arthur Kellermann, MD, MPH, FACEP, holds the Paul O’Neill-Alcoa Chair in Policy Analysis at the nonprofit, nonpartisan RAND Corporation. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program and the RWJF Health Policy Fellows program. This post is part of the "Health Care in 2013" series.


For the first month of my medicine internship at the University of Washington, I was assigned to Seattle’s VA Hospital.  I was stunned to learn that my attending physician would be Paul Beeson, widely regarded at the time as one of the giants of American medicine. [i]  At an age when most doctors are enjoying their retirement, Dr. Beeson was still doing what he loved best—caring for patients and teaching.

I have forgotten most of the clinical pearls Dr. Beeson taught that month. But one that still stands out is the way he questioned the need for every lab test, x-ray and treatment my team ordered. “Why do you want that?” he’d ask.  “What will you do with the result?” Throughout the month, he urged us to forego interventions that offered little benefit to our patients, but exposed them to potential side effects or complications. His message was clear.  Do only what’s needed, not more. 

Today, we need Dr. Beeson’s message more than ever before.  In the three decades since I trained under him, America’s health care system has grown so large, it claims a bigger share of the gross domestic product than American manufacturing or wholesale and retail trade. [ii]  As a result, the federal government spends more on health care than national defense and international security assistance.  In several states, health care is crowding out spending for education. In the past decade, health care cost growth has wiped out the hard-won earnings of middle-class families. [iii]

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Jan 3 2013

Let’s Get Serious about Substance Abuse Treatment – Starting with Payment Reform

Brendan Saloner, PhD, is a Robert Wood Johnson Foundation Health & Society Scholar at the University of Pennsylvania. This post is part of the "Health Care in 2013" series.


New Year’s resolutions are about fresh starts and new beginnings, and for many Americans that includes the decision to finally give up heavy drug and alcohol use. Unfortunately, when it comes to encouraging individuals to enter treatment, providing counseling, and supporting long-term recovery, our health care system is showing up late to the party.

There are 21 million adults and adolescents with a diagnosable substance abuse problem in the United States, but fewer than one in five receive treatment in a given year. The reasons why people do not get treated are complicated. Many are not ready to give up using substances or don’t recognize they have a problem, but many others are discouraged from seeking treatment because of the cost or the perceived lack of treatment options. Opportunities to raise awareness about treatment are often missed, as primary care doctors infrequently screen for substance abuse during routine visits, and are often unaware of where to refer patients for specialized addiction treatment.

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Oct 8 2012

Improving Medical Education to Focus on Delivering Value to Patients

The Robert Wood Johnson Foundation Human Capital Blog is asking diverse experts: What is and isn’t working in health professions education today, and what changes are needed to prepare a high-functioning health and health care workforce that can meet the country’s current and emerging needs? Today’s post is by Mitesh Patel, MD, MBA, a Robert Wood Johnson Foundation Clinical Scholar and senior fellow at the Leonard Davis Institute for Health Economics at the University of Pennsylvania, a member of the AAIM-ACP High-Value, Cost-Conscious Care Curriculum Development Committee, and a practicing physician at the Philadelphia Veteran Affairs Medical Center.  He is also the author of Clinical Wards Secrets, a guide for medical students transitioning from the classroom to hospital wards.


Health care costs continue to escalate.  Concurrently, the amount of published medical research has increased 10-fold over the last decade.  Each of these changes combined with recent health care reform has led to a rapidly evolving health care system.  Unfortunately, medical education has been unable to keep pace with these changes. 

Health care professionals find themselves searching for ways to deliver better value for their patients.  They are looking for an opportunity to become a part of the solution to stemming the rising costs while still providing high-quality, evidence-based care.

The American College of Physicians (ACP), the Accreditation Council for Graduate Medical Education (ACGME), and the Medicare Payment Advisory Commission (MedPAC) have each recognized these deficits among the health care workforce.  They’ve called for a restructuring of medical education to address these issues.  However, teaching hospitals and medical educators lack a common strategy to accomplish this daunting task.  To address these issues, my research team and I studied approaches to transforming medical education to help prepare providers to assess and deliver value-based care for their patients.

To better prepare a high-functioning health and health care workforce, we must start by gaining a better understanding of the problem.  In 2009, we published the first study that shed light on this issue on a national scale.  We found that among U.S. medical students, less than half felt they were appropriately trained in topics relating to the practice of medicine such as medical economics.  In addition, we found that a higher intensity curriculum in health care systems resulted in a payoff, not a tradeoff.

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