By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx

By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care
workforce in
the United States needs to be reconfigured to meet the needs of
a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical
homes, for
instance, will greatly alter the mix of caregivers needed and
create new
roles for existing health care workers. The focus of health
system
innovation, however, has largely been on reorganizing care
delivery
processes, reengineering workflows, and adopting electronic
technology
to improve outcomes. Little attention has been paid to training
workers
to adapt to these systems and deliver patient care in ever more
coordinated systems, such as integrated health care networks
that
harmonize primary care with acute inpatient and postacute long-
term
care. This article highlights how neither regulatory policies nor
market
forces are keeping up with a rapidly changing delivery system

and argues
that training and education should be connected more closely to
the
actual delivery of care.
H
ealth care professionals are be-
ing challenged to find new ways
to organize care and develop
systems that hold providers ac-
countable for the quality, cost,
and patient experience of care.1 The once in-
cremental pace of change is accelerating, and
there is evidence that long-standing paradigms
are dramatically shifting.2 For example, the rela-
tively slow acceptance of prepaid and managed
care systems is being replaced by the rapid adop-
tion of bundled and risk-based payment mod-
els.3,4 Early adopters of accountable care organi-
zations (ACOs) are finding that their workforce
is shifting from acute care to community- and
home-based settings with increasing roles for
physicians, nurses, social workers, patient navi-
gators and outreach coordinators, and other
clinicians in providing enhanced care coordina-
tion, better medication management, and im-
proved care transitions.5
The training of health professionals, however,
lags behind these reforms because it remains
largely insulated from change behind the walls
of schools of medicine, dentistry, pharmacy, and
nursing. Medical training is done primarily in
hospitals, while the greatest challenges are
found in coordinating care in multiple out-

patient settings. This article describes how
health workforce policy was done in the past.
It illustrates some of the specific changes under
way and how they are changing the health care
workforce. Further, it suggests that closer links
should be built between the day-to-day caring for
patients and the training of the people who de-
liver that care.
Workforce Policy Center Stage Again
Health workforce policy took center stage in an
earlier Health Affairs thematic issue in 2002.6
Articles in that issue described future efforts to
doi: 10.1377/hlthaff.2013.0531
HEALTH AFFAIRS 32,
NO. 11 (2013): 1874–1880
©2013 Project HOPE—
The People-to-People Health
Foundation, Inc.
Thomas C. Ricketts (tom_
[email protected]) is the
deputy director of the Cecil G.
Sheps Center for Health
Services Research and a
professor in the Departments
of Health Policy and
Management and Social
Medicine at the University of
North Carolina at Chapel Hill.
Erin P. Fraher is an assistant
professor in the Departments
of Family Medicine and

Surgery, University of North
Carolina at Chapel Hill.
1874 Health Affairs November 2013 32:11
Overview
Downloaded from HealthAffairs.org on February 23, 2020.
Copyright Project HOPE—The People-to-People Health
Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at
HealthAffairs.org.
shape the clinical workforce as a “dream”7 or
subject to “hand-to-hand” combat.8 The “hands”
in thiscase weredescribedby KevinGrumbach as
the “heavy hand” of government regulation and
the “invisible hand” of market forces that con-
stantly pushed the United States into a rolling
series of surpluses followed by shortages.8 The
“dream,” as Uwe Reinhardt saw it, was that reg-
ulation and control could actually work. He of-
fered in its place a change in policy to expose
physicians to the actual costs of their training
while pushing them to the right places and spe-
cialties with judiciously targeted tax-financed
loan repayment.7
In much of the rest of the world, coordinated
workforce planning that develops national and
regional goals has long been accepted as a legiti-
mate policy exercise. This work is achieved by
pairing technical workforce experts and policy

makers with clinicians and patients to guide the
structure of the health workforce—in both num-
bers and skill mix—to meet the needs of delivery
systems and thepopulation.9 IntheUnited States
a mix of government policies and professional
guidelines combine with strong market forces to
shape the health care workforce; the latter al-
most invariably dominates but with a recogni-
tion among most stakeholders that regulation is
necessary.10
As a result, the United States has forgone any
substantial investment in workforce planning
except for the veterans’ health system.11 The
United States has left it up to states, professional
associations, employers, payers, and other
stakeholders to negotiate their interests via the
market and the political process. The result is a
complex and uncoordinated web of training in-
stitutions efforts, licensing board rules, place-
ment programs such as the National Health
Service Corps, and payment regimes. These are
not compared or evaluated to determine if they
are producing the right people for the right work
to meet patients’ needs.
With many observers asking if there will be
enough providers to meet the needs of rapidly
innovating systems, this laissez-faire system is
now in flux. The Centers for Medicare and
Medicaid Services has funded numerous pilots
to identify new models for workforce develop-
ment and payment to support health system in-
novation. These pilots, however, are relatively
isolated and have not been linked in any system-
atic way to broader systems or structures that

govern the way we train, regulate, or deploy
the health workforce.
The earlier Health Affairs thematic issue raised
many familiar, unanswered questions, including
a fundamental one: How many of what kinds of
professionals with what competencies are need-
ed to care for our population? This issue asks the
same questions but adds another: What has
changed over the past ten years?
The Affordable Care Act has created a new
vocabulary to describe networks of providers
tied together to offer enhanced care coordina-
tion. The ACO and the patient-centered medical
home have become seemingly ubiquitous mod-
els for holding systems accountable for the care
provided to patients across community, ambula-
tory, and acute care settings. These emerging
models of integrated care have been abetted by
increasing market concentration in health care
delivery systems.
ACOs, which take on risk by having a portion
of their reimbursements tied to the outcomes of
care for a predetermined Medicare population,
are seeking to reduce costs and improve care by
ramping up screening and preventive care and
the coordination of services. This restructuring
will have far-reaching implications for how clin-
ical work is organized and compensated, with
more work shifting to lower-paid and allied
health workers who provide care in less costly
community- and home-based settings.

Teams And Workforce
Almost all of the new arrangements include
plans or structures that call for more “team-
based care” and make use of “enhanced” roles
for various professions, despite a lack of consen-
sus on what those two terms really mean. Teams
have been described as groups of people whose
roles continuously shift in response to internal
and external forces, including patient expecta-
tions; policy and payment changes; organiza-
tional factors; geographic proximity of other
providers; and professional regulation, training,
and attitudes.12,13 Broadly conceptualized, roles
within teams fall into two categories: lower-cost
health professionals acting as substitutes for
higher-cost ones (for example, nurse practi-
tioners for physicians), or lower-cost health
professionals functioning as supplements who
extend and enhance the work of others (for
example, navigators to coordinate care or dis-
charge planners to help patients make the tran-
sition from acute to postacute care). Despite the
numerous calls for more team-based models of
care, relatively little attention has been given to
how to prepare physicians, nurses, therapists,
technicians, and others already in the workforce
to practice in accountable or reformed teams.
Health care professionals have been seen more
as parts of a puzzle that need to be carefully fit
together into a transformed system of care than
as fungible resources that can be crafted or re-
made to help build a truly reformed and more
November 2013 32:11 Health Affairs 1875

Foundation, Inc.
HealthAffairs.org.
effective health care delivery system. For exam-
ple, although the use of electronic health records
(EHRs) has burgeoned with the implementation
of the federal program to certify and reward the
meaningful use of health information technolo-
gy, there is limited understanding of how health
professionals can work with EHRs to change the
flow of work or how work should be reconfigured
and reallocated among team members. EHRs are
shaping the work of clinicians as much as they
are being adopted for and adapted to current
practices. To be optimally effective, EHRs re-
quire broad and rapid adoption, practitioners
must pay constant attention to data entry, and
care patterns have to be reengineered to accom-
modate EHRs’ use.14,15
Projecting Supply, Demand, Need,
And Requirements
That workforce projections are controversial
should come as no surprise; any projection will
inevitably be ambushed by unknown or un-
expected factors and events that affect future
workforce supply and demand. The surprising
thing is that projections, whether based on em-
pirical models or “expert” opinion, are criticized
for not correctly predicting the future when their
purpose is almost always to change policies and

practices. Projections, when accepted as roughly
correct, are often followed by policy shifts that,
in turn, change the future supply or pipeline of
workforce production.
Projections turn out to be wrong either be-
cause it is not known how many physicians there
are16 or because there is a lack of understanding
of the true relationship between physician
supply and health outcomes.17 They are, in one
sense, “projectiles” shot across the bows of
policy makers to stimulate action; they paint a
picture of what is likely to happen if some desir-
able policy is not implemented. If a policy is
changed, then the projection is likely to turn
out wrong because it helped cause changes in
the factors that drove the model.
For example, the Graduate Medical Education
National Advisory Committee’s 1980 projection
of a physician surplus was used to justify cut-
backs in federal support to medical education,
thus changing medical school growth trends.
That policy shift reduced production and even-
tually led to a perceived shortage.18 The more
recent Association of American Medical Colleges
forecasts of shortages of physicians have similar-
ly prompted the expansion of existing and the
opening of new medical schools and have put
strong pressure on the debate over how to sup-
port graduate medical education to provide the
additional training necessary to produce practic-
ing physicians.19
Recent work has focused on developing dy-

namic projection models that are amenable to
changes in the assumptions on which they are
based and that allow policy makers to simulate
the effects of potential policy scenarios20 on
workforce supply and demand. This type of work
is supported by the National Center for Health
Workforce Analysis in the Department of Health
and Human Services, but the center struggles
with a lack of both up-to-date inventories of ex-
isting health professionals and a common data
set to measure practitioner capacity or simply
identify the location of practice.21,22
The modeling field in the United States and
other countries23 is moving toward using projec-
tions not as a method for generating one “right”
answer but as a way to educate health profession-
als and their associations, policy makers, and
other workforce stakeholders about the com-
plexity of projecting future workforce needs
and the effects of the policy options they have
at hand. Engaging stakeholders—particularly
clinicians—in themodeling process cangenerate
numerous desirable results, including a better
understanding of how rapid health system
change affects workforce deployment and im-
proved communication between the professions
and policy makers. Having clinicians involved in
modeling can also serve as a check on the “face
validity” of model outputs and can generate clin-
ical input in areas where data inputs are weak.
Stakeholders engaged in modeling can also help
identify ways to redesign care processes to ad-
dress workforce shortfalls or surpluses.
Models and projection thus cannot provide a

single “right” answer in a system that is rapidly
changing. The important thing is to have a model
that can be used to simulate the effect of policy
change and educate stakeholders about the
effects of policy options. For example, a model
might show that increasing graduate medical
education slots will likely have a relatively small
effect on the overall match of supply to need
compared to increasing productivity and delay-
ing retirement.
Efforts to model the nursing workforce have
been complicated by nursing’s persistent sine-
wave pattern of shortages prompting policy ac-
tions that, in turn, stimulate rapid growth lead-
ing to surpluses.24 Analyses of nurse supply and
demand remain doggedly unconnected to physi-
cian workforce projections. There are no exam-
ples of national models that simultaneously
project the supply of both professions despite
their substantial overlap in providing care.
Combining the two in projections is now an im-
perative given nurses’ complementary and sup-
plementary roles in delivering or supporting
Overview
Foundation, Inc.
HealthAffairs.org.

many of the new services required by ACOs and
patient-centered medical homes, such as care
coordination, patient navigation, transition
care, and population health management.
An obvious link would be in the production
and deployment of nurse practitioners and their
impact on the “effective supply” of primary care
practitioners,25,26 but including “nonphysicians”
in physician supply-demand calculations has
proved difficult. For example, in the develop-
ment of an index to identify shortage areas for
federal support, an intense battle was fought in a
special “negotiated rulemaking” committee
mandated by the Affordable Care Act over how
to count nurse practitioners and physician assis-
tants in a formula for proposed new Health
Professional Shortage Areas and Medically
Underserved Populations.27 Advocates from the
nurse practitioner and physician assistant pro-
fessions felt strongly that they should be as-
signed a weight of at least 0.75 full-time-equiva-
lent of a primary care physician to account for
their contribution to community-based primary
care. Counting them would often increase the
local supply above a shortage threshold, making
the community or population lose its designa-
tion and thus its eligibility for federal support.
Productivity In The Health Care
Workforce
The promise of technology as the way to improve
the quality of care and lower costs, especially via
the EHR, has been promoted on the basis of its
potential to improve productivity in the system

by making care more efficient and effective.28
This is essentially an economic calculus: Can
more be done and done better and at lower cost?
That question remains to be answered.
What the United States has done is rapidly
increase the number of people and types of work-
ers who are delivering care. Employment in the
health care sector grew rapidly between 2000
and 2010—at a rate of greater than 3 percent
annually—and even faster growth has been
projected for the following decade, but there
are signs of a slowdown in that growth.29 This
is in contrast to overall employment, which
shrank by 0.2 percent per year in the first decade
of this century and is projected to grow by only
1.3 percent during 2010–20.
Employment growth in ambulatory health
services has been strong at 3.3 percent per year,
with an anticipated increase to 3.7 percent.
These labor inputs may be growing faster than
patient care needs, thus making the overall
workforce less productive and efficient. On the
other hand, that same expanding workforce may
be generating greater value by improving out-
comes through better coordination and greater
intensityof care.Whetherthesystem isbecoming
more or less efficient in terms of value for money
because of the addition of new specialties or new
professions has seldom been asked30 and even
less often answered.31
Professions Unto Themselves

The United States accepts in policy and practice
the idea of “sovereign” and self-regulating pro-
fessions that have substantial control over their
place in the health care system. This approach
has meant that workforce policy has been largely
shaped around the demands of the professions
and not around the needs of the patients. The
question of whether the professions should con-
trol entry into their respective realms through
self-regulation remains largely out of the main-
stream of debate but is raised from time to time
by libertarian thinkers.32 There are very intense
battles over scope-of-practice rules, with ad-
vanced-practice nurses making strong claims
on primary care, nurse anesthetists being chal-
lenged over their contributions by anesthesiolo-
gists, and the development of dental therapists’
work being challenged by dentists. These con-
flicts are becoming sharper despite a body of
evidence that shows that most of these work
and professional roles are effective in saving
money and maintaining or improving quality.33
New and different types of health profession-
als—community health workers, patient navi-
gators, health coaches, care coordinators, and
more—are attempting to create their own space
in the health care delivery system as their con-
tributions to the new payment and organiza-
tional models become more apparent. The
emergence of new professions runs counter to
theories of how health care workers should func-
tion in teams adapting and “upskilling” existing
professional or paraprofessional roles to meet
patients’ needs.34

The progressive division of labor and the crea-
tion of specialized labor categories that are able
to do one focused job more efficiently than a
range of work has been the pathway to greater
productivity in manufacturing and other sectors
but to a lesser extent in health services. In the
health care realm, increasing specialization is
reflected in the growing complexity of how a
hospital is staffed to care for patients—a process
that has given us hospitalists, intensivists, noc-
turnalists, and other types of practitioners who
are defined by their functional role as much as by
their disciplinary specialization.35 The prolifera-
tion of new professions and professional roles
does not necessarily lead to greater efficiency
because, as David Meltzer and Jeanette Chung
◀
3%
Employment growth
Employment in the health
care sector grew more
than 3 percent a year
during 2000–10, compared
to a 0.2 percent annual
shrinkage in overall
employment growth in the
same decade.
November 2013 32:11 Health Affairs 1877
Foundation, Inc.

HealthAffairs.org.
point out, there are real costs associated with
coordination.35 Those costs have not been calcu-
lated or even anticipated in most of the calls for
reorganization using teams.
The rise of additional specialists and profes-
sions within the health care “team” in new mod-
els of care have made Irving Zola and Stephen
Miller’s description of long-term care common-
place:“In thecourse of…long term disorders, the
doctor recedes further and further into the back-
ground, eventually assuming the role of occa-
sional medical consultant.With this, the physio-
therapist, visiting nurse, dietician, prosthetist
becomes essentially ‘the doctor’ not only in
terms of primary day-to-day management, but
in terms of the transference relationship as
well.”36
The career paths for physicians, nurses, and
even dentists are multiplying. They involve serial
training in fellowships to acquire new techni-
ques and skills; adapt to shifts in practice focus;
and, more often, prepare them for a return or
to introduce them to a type of practice that is
more flexible—essentially a return to a generalist
role.37 At the simplest level of care, the nature of
laborfordirect careworkerswho feed,move,and
clean patients has become dominated by part-
time jobs with fewer and fewer benefits.38 To
achieve true integration, teams must accommo-
date the multiple needs of the people working

around the patient, including highly trained
physicians who seek professional satisfaction
andhigh rewards aswell as unlicensed personnel
whose formal connection to the system is tenu-
ous but whose practical training and skills are
often crucial in generating quality care and pa-
tient satisfaction.
The pressure to coordinate, or perhaps simply
serve as a traffic cop controlling, the flow of
practitioners around the patient, has emerged
as a true challenge. Atul Gawande’s description
of hismother’s careduring her knee replacement
gives a sense of what a contemporary hospital-
based team is like: It is large, potentially irratio-
nal, and likely to grow.39 We know far less about
what makes for an effective team of ambulatory
caregivers when it comes to managing transi-
tions for patients with complex chronic illnesses
from community to acute care settings and back.
If the workforce needs of the future are to be
adequately assessed, it is necessary to first get
a better handle on who will make up the work-
force in each setting in the future.
Training And Education As Field Of
Reform
Training professionals for the future of team-
based care has been recognized as a real chal-
lenge. The Institute of Medicine is currently
supporting a committee, the Global Forum on
Innovation in Health Professional Education, to
explore how best to promote “transdisciplinary
professionalism.” The group recognizes the
challenges of integrating the diverse cultures

and skill sets of the various professions, the
problem of teaching “followership” and leader-
ship, and the practical problem of measuring
how well a team works.
The National Center for Interprofessional
Practice and Education has been funded by the
Health Resources and Services Administration
to do similar work. These efforts follow on a
series of precursor programs in interdisciplinary
training that never quite found traction in for-
mal policy or in health professions training.40
Thecentraltask for reformedhealth care delivery
may indeed be to create and sustain teams of
different professional pedigrees. The question
is whether teams can be constructed around a
template or whether it must happen in practice
with ad hoc teams forming around the patient
and their needs.
Innovations In Training And
Education
The ways in which health care professionals are
taught are changing rapidly. Additionally, there
is pressure to streamline pathways into profes-
sions.41 Online courses, clinical simulators, and
learning teams have made education more flexi-
ble. Still, little is known about what constitutes
efficient and effective clinical training.42 The true
costs of preparing health professions are being
revealed by the rapid growth in the number of
private, including for-profit, health professions
institutions that have sprung up to meet demand
from prospective students.43 These include oste-
opathic medical schools and physician assistant

programs and umbrella “Health Science”
schools that provide training for nurses, thera-
pists, and technicians. Public community col-
leges in some states fill this niche, but the market
Training professionals
for the future of
team-based care has
been recognized as a
real challenge.
Overview
Foundation, Inc.
HealthAffairs.org.
has also responded vigorously to train workers,
especially allied health workers, for reformed, if
not fully coordinated, systems.44
The “safety net” of public clinics, hospitals,
and private charity caregivers is one place where
innovation in role assignment and integration of
multiple professions has been welcomed,45 but
the benefits are difficult to calculate. Community
health centers (also known as federally qualified
health centers) have become testing grounds for
a new approach to graduate medical education
through the Teaching Health Centers Program.46

Through this program, the new centers are
funded as temporary demonstrations whose
long-term outlook depends on future appropria-
tions.47 They do offer a new approach to meeting
the growing need for locations to provide grad-
uate medical education given the recent rapid
rise in the number of US medical school gradu-
ates and the apparent “bottleneck” that has
slowed growth in residency training and thus
physicians’ progression into the workforce.
Revolutionary changes in the nature and form
of health care delivery are reverberating back-
ward into medical education as leaders of the
new practice organizations demand that the ed-
ucational mission be responsive to their needs
for practitioners who can work with teams in
more flexible and changing organizations. In
the face of this pressure, the traditional response
of health educators—that they should have au-
tonomy in defining the educational mission—is
no longer viable. Instead, more explicit, formal,
and systemic linkages between practice and ed-
ucational institutions that are coordinated with
maintenance of certification and licensing are
inevitable.48 There are proposals to base certifi-
cation and licensure on actual performance and
patient care outcomes instead of on simply meet-
ing additional education and training require-
ments. 49 This new pressure to make medical
education at all levels more accountable to public
and patient needs means that we must measure
how medical education affects medical care out-
comes, not just the outputs of the programs and

institutions.
Conclusion
We often hear how the United States has a non-
system of health care—a faircharacterization of a
very adaptable sector of the economy that com-
bines rigid professional norms, rapid shifts in
staffing and deployment of workers to capture
funding streams, and the constant creation of
new work roles and employment opportunities.
It is largely these characteristics of the workforce
that have both constrained the coordination of
health care and allowed the system to grow very
rapidly. To blunt rising costs, it seems necessary
to find ways to temper this professional and oc-
cupational exuberance to achieve both greater
efficiency and effectiveness.
To anticipate these changes and prepare the
workforce for new roles, it will be necessary to
invest in workforce planning but not solely at the
macro level of overall supply. Investments are
needed in research and implementation studies
to help foster greater understanding about the
actual content of care that is required in the new
systems. Investments in research are also needed
to identify how best to allocate new caring roles
among a set of professions and disciplines that
are trained and deployed in a coordinated fash-
ion. Workforce planning needs to be more “bot-
tom up” as it seeks to identify the “right kind”
and the “right number” of workers. ▪
This work was supported in part by
contracts with the American College of
Surgeons and the Physicians Foundation.

The authors thank Laura Trude and Kelly
Quigley of the Health Workforce
Information Center at the University of
North Dakota for their assistance.
NOTES
1 Berwick DM, Hackbarth AD.
Eliminating waste in US health care.
JAMA. 2012;307(14):1513–6.
2 Berwick D. Escape fire: designs for
the future of health care. San
Francisco (CA): Jossey-Bass; 2004.
3 Marmor T, Oberlander J. …
RESEARCH Open Access
Workforce planning and development in
times of delivery system transformation
Patricia Pittman1* and Ellen Scully-Russ2
Abstract
Background: As implementation of the US Affordable Care Act
(ACA) advances, many domestic health systems are
considering major changes in how the healthcare workforce is
organized. The purpose of this study is to explore
the dynamic processes and interactions by which workforce
planning and development (WFPD) is evolving in this
new environment.

Methods: Informed by the theory of loosely coupled systems
(LCS), we use a case study design to examine how
workforce changes are being managed in Kaiser Permanente and
Montefiore Health System. We conducted site
visits with in-depth interviews with 8 to 10 stakeholders in each
organization.
Results: Both systems demonstrate a concern for the impact of
change on their workforce and have made
commitments to avoid outsourcing and layoffs. Central
workforce planning mechanisms have been replaced
with strategies to integrate various stakeholders and units in
alignment with strategic growth plans. Features
of this new approach include early and continuous engagement
of labor in innovation; the development of
intermediary sense-making structures to garner resources,
facilitate plans, and build consensus; and a whole system
perspective, rather than a focus on single professions. We also
identify seven principles underlying the WFPD processes
in these two cases that can aid in development of a new and
more adaptive workforce strategy in healthcare.
Conclusions: Since passage of the ACA, healthcare systems are
becoming larger and more complex. Insights from
these case studies suggest that while organizational history and
structure determined different areas of emphasis, our
results indicate that large-scale system transformations in
healthcare can be managed in ways that enhance the skills
and capacities of the workforce. Our findings merit attention,
not just by healthcare administrators and union leaders,
but by policymakers and scholars interested in making WFPD
policies at a state and national level more responsive.
Keywords: Workforce planning and development, Human
resources in health, Healthcare delivery reform, System
change, Loosely coupled systems, Labor-management

partnerships, US Affordable Care Act
Background
As the implementation of the 2010 Affordable Care Act
(ACA) advances in the United States, many healthcare
organizations are taking bold measures to reorganize
their delivery systems and finding that in order to do so,
changes must be made to the healthcare workforce [1].
While different healthcare organizations in the United
States, be they public or private, are at very different
points in this process, commonly popular concepts in-
clude moving staff to new ambulatory and home care
settings [2]; creating new jobs relating to care coordin-
ation and outreach to the sickest patients [3]; designing
new modes of delivering care in response to consumer-
ism [4]; adopting team-based care and task shifting
based on the principal of practicing at the top of license
and education [5]; requiring new roles and skills as part
of the adoption of health information technologies
(HIT); and the use of data for decision-making [6].
Understanding what workforce changes are occur-
ring and how they are being managed is key not just
for healthcare leaders but for policymakers as well.
Traditional methods of projecting provider shortages
and justifying the allocation of public funding to
expand various professional pipelines are giving way
* Correspondence: [email protected]
1Milken Institute School of Public Health, The George
Washington University,
2175 K Street, NW, Suite 500, Washington, DC 20037, United
States of
America
Full list of author information is available at the end of the

article
© 2016 The Author(s). Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the data made available in this article, unless otherwise stated.
Pittman and Scully-Russ Human Resources for Health (2016)
14:56
DOI 10.1186/s12960-016-0154-3
http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-016-
0154-3&domain=pdf
mailto:[email protected]
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
to the notion that there are many models of care delivery
and that they have vastly different staffing configurations.
For example, several studies have demonstrated that
including advanced practitioners in primary care medical
homes allows practices to expand panel sizes [7, 8].
Choices about staffing, therefore, can have enormous im-
plications for productivity, making assumption about the
demand for certain health professions a moving target.
The policy question then becomes not just how will
these changes alter the national demand for certain

types of health workers at an aggregate level but how
are organizations making choices about ways to recon-
figure their workforce and, ultimately, what kinds of
local, state, and federal policies are most supportive of
workforce transformations that advance both workers’
well-being and the value of their services.
We know from the literature reviewing the hospital re-
structuring of the 1990s that workforce change manage-
ment faces many challenges. The critiques of this era
were many, but chief among them, according to Walston
and colleagues, were the following: goals for change
were not clear, too many changes were implemented too
quickly, there was a lack of communication with em-
ployees, a lack of engagement with physicians and
unions, there was a poor understanding of the local
site differences by management leading to a one-size-
fits-all approach, and, lastly, that training needs were
not anticipated [9].
In a review of the international literature on workforce
planning and development (WFPD), Curson and col-
leagues suggest that the problem goes deeper. They
argue that workforce policies lack the capacity to re-
spond to new demands for system change [10]. The
reason, they point out, is that most workforce planning
do not take account of political dynamics among the
range of stakeholders outside the control of human re-
source administrators, be they at the organizational or
the policy level.
It is with these critiques in mind that we are interested
in understanding how two leading health systems in the
United States, with a historic commitment to developing
and retaining their workforce and to managing change
through labor-management partnerships, are responding

to the demands of the post-ACA environment. The aim
is to explore how they are determining what changes are
needed and how they are implementing those changes in
practice. Their experiences may provide insights for
other organizations, as well as for policymakers charged
with ensuring that the healthcare workforce is able to
meet population needs.
Our first case focuses on Kaiser Permanente (KP), an
integrated system that has historically served the em-
ployer market on the West Coast. It has been at the
forefront of systems that emphasize value over volume
and among the organizations most advanced in the use
of HIT to improve the patient care process. In addition,
KP has one of the most successful models of labor-
management partnerships (LMP) in the nation.
The second system is the Montefiore Health System,
headquartered in the Bronx, NY, an organization with al-
most 20 years of experience with shared risk contracts
with payers. Like KP, they have extensive experience with
care coordination, they are in the process of expanding
to new markets, and they have a LMP. They differ from
KP in that their patient population is predominantly
poor and Spanish speaking, and an extraordinary 80 %
of their revenue is coming from Medicaid and Medicare.
Conceptual framework
The objective of this study is to go beyond descriptive
groupings of health workforce changes to explore the dy-
namic processes and interactions by which staffing models
emerge. To frame our inquiry, we draw on the literature
on health workforce planning and development and the
theory of loosely coupled systems (LCS) [11].
For the purposes of this paper, we define WFPD as the

macro level processes and practices that enable the sys-
tem to change and adopt new staffing arrangements and
respond with timely and appropriate education, training,
and certification programs. Schrock has suggested that
WFPD policies span the continuum of skill formation,
employment networks, and career advancement [12].
This means not simply examining the supply and distribu-
tion of personnel in different categories but also under-
standing educational and training pathways, management
of performance, and the regulation of working conditions.
Dussault and Dubois argue that the traditional ap-
proach to WFPD is a linear, sequential, and protracted
skill formation process through which healthcare pro-
viders hand off demand projections to education institu-
tions and certifying bodies that in turn, supply the
requisite workforce [13]. Weick reasons that this form of
sequential task interdependence induces rule-based
action and cognitive processes that are not equipped to
tackle ambiguous problems like providing a skilled
workforce for care models that are in a constant state of
flux [14]. This and other complex, non-routine problems
require controlled cognition or slow, deliberative, and
explicit thinking that is more often associated with
reciprocal interdependence coordinated by an iterative
process of negotiation and mutual adjustment among
relatively autonomous units and subsystems. [14]
Dussault and Dubois describe an alternative approach
that is emerging in healthcare that coordinates the
efforts of a diverse range of institutional actors through
adaptive processes that respond to specific, local polit-
ical, economic, cultural, and social contexts where
healthcare is delivered [13]. This approach is understood

14:56 Page 2 of 15
as a political exercise in which values and differences are
made explicit, compromises are made, and actions are
justified. Orton and Weick further suggest that there is a
need to move beyond the traditional focus on static
organizational elements, like structure, resource alloca-
tion, and technology, and turn instead to a focus on the
dynamic relationship among them [15].
Organizational scholars developed the concept of
“loose and tight coupling” as one way to examine com-
plex organizational structures and relationships [16–19].
The focus of this approach is on hierarchy and inter-
dependence among elements within and between organi-
zations and how variability in these features enables
different operational strategies and responses to shifts in
the external environment [17]. In tightly coupled sys-
tems, individual units and organizations are linked to-
gether through formal structures and procedures and
they respond to change through centralized control
mechanisms that reduce variation and close the system
off from the effects of external forces. In loosely coupled
systems, on the other hand, the links among the compo-
nents are weak and a high level of autonomy exists
among the interdependent parts of the system [20].
While the variation in the way similar functions are or-
ganized and managed may make it difficult to integrate
activities, theorists argue that it enables flexibility and
openness to change in the environment [15].
According to the theory of LCS, all systems are both
tightly and loosely coupled because there is variation in

how subunits are linked and rely on each other (couple-
d)—as well as in the number and strength of their con-
nections (lose or tight) [15, 17, 21]. Therefore, any
subsystem may be closed to outside forces to ensure for
stability (tight), while another subsystem may remain
open to outside forces to enable flexibility (loose) [15].
This paradoxical nature of LCS makes it difficult for
researchers to conceptualize and study [16], yet we
would suggest that its application to the US healthcare
system during this period of intense transformation
holds explanatory potential. Healthcare systems are sim-
ultaneously being asked to expand coverage and access,
while being financially incentivized to extend the con-
tinuum of care to address the social determinants and
provide ongoing care management. As a result, there
are significant pressures on traditional care models and
staffing arrangements, leading in turn to the emer-
gences of new patterns of “coupling,” both within and
across healthcare organizations. Further, we submit that
the effectiveness of the transformation occurring in
healthcare today may hinge on new, more adaptive
methods to prepare the healthcare workforce to
perform in a more complex system of care, where job
tasks, team interactions, and work locations are con-
tinuously changing.
To analyze changes in WFPD, we borrow from Weick’s
typology of strategies for changing LCS [11] and from the
descriptions on a new approach to WFPD in healthcare
put forth by Curson et al. [10] and Dussault and Dubois
[13] to identify a set of principles that together, may serve
as a new adaptive WFPD framework aligned with the
needs of a rapidly changing deliver system.
Methods

We use a case study design to explore how two major
health systems undergoing significant system transform-
ation are managing the process of workforce change. We
selected Kaiser Permanente (KP) and Montefiore because
they are well known for their innovative approaches to in-
tegrating healthcare yet they are significantly different
from each other with regard to their organizational histor-
ies, structures, and patient populations.
We conducted site visits to both organizations in the
spring and summer of 2015, conducting interviews with
8–10 people at each site including executives, human re-
source managers, the heads of innovation and care coord-
ination programs, and union and LMP representatives.
Some interviews were held in group settings, while others
were individual. We also conducted planning and follow-
up phone calls with some of the participants. Interviews
were taped and transcribed. We also reviewed current
organizational documents, including training plans, re-
ports, and collective bargaining agreements, as well as
prior studies on each system [9, 22, 23].
Data analysis proceeded through several steps. First,
the research team conducted a review of each case,
including the historic development of the system and
significant drivers of change, as well as the strategies,
structures, and resources informants reported as being
central to the competiveness of the system and the
sustainability of the workforce in the post-ACA environ-
ment. To support this analysis, the research team devel-
oped a series of inductive and deductive codes, which
we used to extract relevant data from the case docu-
ments and interview transcripts. Next, the researchers
jointly analyzed the coded data to developed individual
case profiles. These profiles were validated by key infor-
mants from each case. Finally, we conducted a constant

comparative method to identify cross-cutting themes
and principles to explain the workforce planning and de-
velopment strategy emerging within the two systems.
Results
Case study 1: Kaiser Permanente
Kaiser Permanente (KP) was established in 1938 as a
comprehensive medical system for the workers and their
families at Kaiser steel mills and shipbuilding facilities
across California and in Portland, OR. In 1945, after
WWII ended and many shipyards closed, KP opened
14:56 Page 3 of 15
membership to the general public. The KP unions played
an instrumental role in this expansion by helping KP
market to unionized employers in areas where the com-
pany had a presence. Today, it operates as a Health
Maintenance Organization (HMO) with 8.3 million
health plan members in seven regions: Northern and
Southern California, Colorado, Georgia, Hawaii, Mid-
Atlantic, and the Northwest. Each region is made up of
two separate entities, the Kaiser Foundation Health Plans
and the Permanente Medical Group (PMG), a physician-
owned corporation that owns and operates KP’s medical
facilities. The PMG contracts with the Foundation to
serve KP health plan members. A key feature in this
model is that physicians are employed by KP. The na-
tional program office includes a variety of support func-
tions, including human resources, labor relations,
information technologies (IT), finance, and patient care
services (nursing).
The KP Labor-Management Partnership (LMP) was

formed in 1997. At the time, KP faced competitive
pressures leading executives to demand deep union
concessions. In response, many of the KP unions of-
fered the company a choice: continued harsh labor-
saving tactics and escalating labor strife, including a
strike, or a partnership to address the fiscal crisis and
improve the quality of care at KP. The company
agreed to the partnership [24]. The governance struc-
ture consists of the LMP Strategy Group, with one
representative from each of three sectors: Physicians,
Management and Labor, and each region maintains
its own tripartite LMP council.
By 2015, the LMP included 12 international and 28
local unions representing 105 000 KP employees or
about half of the total KP workforce, across six of the
seven regions. Hawaii is not part of the partnership, and
not all KP unions are involved in the partnership, most
notably absent is the California Nurses Association.
KP also has a network of functional units to support
the design and management of change and WFPD
strategies. The LMP staff is integrated into these units,
and labor representatives are highly engaged in their
activities. These units include the following:
� National Workforce Planning and Development
(housed in national human resources (HR))
provides opportunities to the KP workforce to
optimize skills and competencies and manages two
LMP education trusts: the Ben Hudnall Memorial
Trust and SEIU/UHW Joint Employer Education
Fund.
� National Innovations Network including patient care

services, workforce planning, and IT functions as a
loosely coupled “future-sensing” group that
examines technology trends, creates proof of
concepts and proof of technology, and develops
pilots.
� Unit-based teams (UBT) are natural work groups of
frontline workers, physicians, and managers who
solve problems and enhance quality.
Drivers of change
KP’s history of pre-paid, member-based service is critical
to understanding the company’s current competitive
situation. KP is well positioned to grow in a post-ACA
era in which policies to advance integration has prolifer-
ated. Growth has been especially dramatic in the South-
ern California Region, where new individuals that joined
via the Health Exchange grew by 4 % per year (from 2 to
6 %). This rapid influx of new members has been most
pronounced among younger and healthier individuals as
compared to members in KP’s traditional employer-
based plans.
KP leadership knew that they needed to understand
the implications of this shift in demand and have held
focus groups with their newest members. Results have
led the company to reorient business strategy around
three priorities, as follows:
1. Convenience. Millennials are demanding “care
anywhere and how we want it.” Increased access,
convenience, and enhanced experience of healthcare
are therefore major priorities for the organizations.
2. Affordability. Because the individual market is more

price sensitive than the group market, there is a
heightened awareness that they must reduce the
cost of care in order to continue to expand in this
market.
3. Value. At the same time, new healthcare consumers
expect more value or increased and enhanced
services, and this is driving a number of efforts
focused on the care experience.
Change strategies
Three strategic initiatives have emerged in response to
these drivers. The LMP and the national innovation
units are integrated into all three, as are KP members’
views, as represented through surveys, focus groups, and
ethnographic studies.
� Perform, Grow, Lead is KP’s strategic plan. It
emphasizes affordability targets, meeting rising
customer expectations, and transforming care.
Guiding principles include the following: One KP,
which calls for a common care experience across all
regions, and the KP people strategy, which
articulates the desired characteristics of the KP
workforce as “innovative, engaged, change ready,
healthy, and accountable.”
14:56 Page 4 of 15
� Vision 2025 is an ongoing initiative to understand
what healthcare consumers will look like and how
KP can position itself to meet needs in a rapidly
changing healthcare market. It develops care models

and offers strategic road maps to guide planning and
change. Health information technologies are central
to this strategy, including the use of social media to
keep its members informed and healthy and new
mobile technologies to enhance staff communication
and reporting. Remote diagnostic tools will also be
more available to patients for common ailments like
strep throat, to allow self-testing and more rapid
recoveries. In the next 5 to 7 years, they see
increased use of remote monitoring technology,
sensors, and virtual care, as well as health analytics
to enhance the nurse role in triage and care
management [23]. As one interviewee put it, “…if it
can be automated, it will be.”
� Reimagining Ambulatory Design (RAD) is an
initiative of the Southern California Region that may
spread across KP. Its goal is to design a new
ambulatory care delivery model aligned to the
principles of consumerism. In extensive research
with members, the leads of this effort discovered
that “…people wanted access to care in a much
more radically different way… It has to do with
much more embedding of services into the
community, into the home, into work…and much
more local access for simple things.” This “life-
integration vision” has sparked several experiments
to redesign and relocate KP clinical operations in
Southern California.
Workforce planning and development strategies
Human resource (HR) leaders and the Coalition of
Kaiser Permanente Unions (CKPU) staff report that early
on the focus of WFPD was on creating consistent work-
force metrics and analytics to help the regions forecast
future staff and skill needs. They now view these tools

as necessary but insufficient. A regional HR leader
described the change:
So, at first…we forecasted membership growth,
utilization, supply, turnover, retirement, we looked at
the local labor markets, we connected with a
university for economic analysis of the projected
nursing workforce, and the fluctuations around the
economy. And then we realized that most forecasting
is based on the previous year, or the previous three, or
the previous five years, projecting forward. But if
you’re in the midst of complete transformation of
how you’re providing care, how accurate are those
numbers? …We need to understand what kinds of
jobs (are coming); we need to understand how work is
transforming. So, it really started in 2012 to 2013, (we
have been) trying to get a movement towards a kind
of qualitative approach to understanding change.
Key to this new approach is that it is integrated with
KP’s strategic growth initiatives. As one HR leader ex-
plained, “workforce development is being driven by the
business need.” Part of this emanates from the “affordabil-
ity” imperative, which both HR and labor representatives
agree has given finance a larger role in the company. At
the same time, HR leaders describe the emerging WFPD
approach as “maturing,” by which they mean that finance
is one important player but that they also take into ac-
count other interests. Indeed, HR leaders view themselves
as “intermediaries” who help senior leaders understand
the strategic value of the workforce in the context of the
drive toward labor-cost-saving solutions.
The LMP, which was further strengthened in the 2015
National Agreement, has several mechanisms that inte-

grate labor and innovative WFPD strategies into the
strategic change processes. First, for collective bargain-
ing, they use an “interest-based approach,” rather than
traditional, positional bargaining. Both sides emphasize
that there is full transparency in this process—manage-
ment shares information on the company’s financial situ-
ation, competitive standing, and other data related to
the subjects of bargaining and labor provides insight into
the affect of change on the workforce. This open ex-
change results in accommodation, as illustrated by the
Employment and Income Security Agreement (EISA),
which stipulates that any innovation or change at KP
must include a plan for retaining the effected employees.
A second LMP mechanism consists of the negotiated
programs to support innovation and the implication of
change for the workforce. The national agreement delin-
eates the mission and values of joint programs, sets aside
funds, and directs LMP staff and company to consist-
ently integrate the programs across all KP regions.
Examples of these national efforts include Total Health,
which advances wellness, health, and safety in the work-
place; unit-based teams, which identify quality improve-
ment and cost containment solutions at the ground
level; and the National Taft-Hartley Education and
Training Trusts, described above.
Lastly, an important characteristic of the LMP govern-
ance and planning structures is that it is holistic and aims
to permeate every level of the system. In theory, every
manager has a designated labor partner with whom they
are encouraged to engage in strategic and operational de-
cisions that affect the workforce. Both sides report that
this works better in some regions than others, but where
it does work, they say that the engagement is ongoing and
includes strategic decisions that affect not only the work-

force but also the future direction of the company.
14:56 Page 5 of 15
Jobs for the Future, an initiative in the Southern
California region, illustrates how these mechanisms
work together to integrate labor and WFPD strategies
into the strategic change processes at KP. The project
grew from the HR leader’s intermediary strategy of
showing up and intently listening at meetings related to
the RAD project, a strategic change initiative aimed at
redesigning ambulatory care. According to this leader,
he quickly convinced the VP overseeing the project of
the value of labors’ early involvement, and soon after, a
LM committee was formed to explore the proposed
innovation and its impact on the jobs and workers.
Rather than focus on the contentious questions of
workforce impacts, the committee first set out to de-
velop a holistic view of the redesign (new care models,
technologies, facilities, etc.) in order to target the oper-
ational initiatives that would have significant impact on
jobs. Though the HR lead reported that some labor and
management participants fell into traditional roles and
knee-jerk reactions, he observed that these positions
quickly gave way as the committee became more en-
gaged in the processes to redesign the care models and
workflows.
Next, the committee developed a rigorous method-
ology to assess the impact on jobs and formed LM sub-
committees to apply the method to the redesign of
specific work areas. In the end, the committee proposed

three new jobs: a roving receptionist of the future that
would take on multiple roles of patient greeter/way
finder/educator, a multifunctional healthcare worker that
would staff new small walk in clinics and perform patent
care and diagnostic functions, and a patient navigator
who would facilitate the extension of care into the arena
of social determinants by helping to coordinate commu-
nity resources. Each of these new roles transgresses
existing occupational, as well union boundaries and
jurisdictions.
The difference between the new with the old approach
to labor relations managing change at KP are explained
by the HR leader as he reflected on this project:
The traditional way of doing it is you’re assigning
labor relations people who don’t understand the
operations and all the technology and innovations.
They’re not included in those conversations. So they
go to the bargaining table, and the labor person has
only been told that there is either going to be a layoff,
or a change in jobs, and we are doing this because of
the need for affordability, or because we need to cater
to the customer. They are like, what!!??? So it is just
kind of set up for an antagonistic type of
relationship…because there hasn’t been this pre-work,
conversations and joint learnings about why this
change is really happening, how it will improve care.
There is a big disconnect between …
SPECIAL COMMUNICATION
How Evolving United States Payment Models

Influence Primary Care and Its Impact on the
Quadruple Aim
Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew
Bazemore, MD, MPH,
and Winston Liaw, MD, MPH
Introduction: Prior research has demonstrated the associations
between a strong primary care founda-
tion with improved Quadruple Aim outcomes. The prevailing
fee-for-service payment system in the
United States reinforces the volume of services over value-
based care, thereby devaluing primary care,
and obstructing the health care system from attaining the
Quadruple Aim. By supporting a shift from
volume-based to value-based payment models, the Medicare
Access and Children’s Health Insurance
Program Reauthorization Act may help fortify the role of
primary care. This narrative review proposes a
taxonomy of the major health care payment models, reviewing
their ability to uphold the functions of
primary care, and their impacts across the Quadruple Aim.
Methods: An Ovid MEDLINE search and expert opinion from
members of the Family Medicine for
America’s Health payment and research tactic teams were used.
Titles and abstracts were reviewed for
relevance to the topic, and expert opinion further narrowed the
literature for inclusion to timely and
relevant articles.
Findings: No payment model demonstrates consistent benefits
across the Quadruple Aim across a
limited evidence base. Several cross-cutting lessons from
available payment models several recommen-
dations for primary care payment models, including the
following: implementing per member per

month– based models, validating risk-adjustment tools,
increasing investments in integrated behavioral
health and social services, and connecting payments to patient-
oriented and primary care-oriented met-
rics. Along with ongoing research in emerging payment models,
data systems integrated across health
care and social services settings using metrics that can capture
the ideal functions of primary care will
be critical to the development of future payment models that
most optimally enhance the role of pri-
mary care in the United States.
Conclusions: Although the ideal payment model for primary
care remains to be determined, lessons
learned from existing payment models can help guide the shift
from volume-based to value-based care.
To most effectively pay for primary care, future payment
models should invest in a primary care infra-
structure, one that supports team-based, community-oriented
care, and measures the delivery of the
functions of primary care. ( J Am Board Fam Med 2018;31:588
– 604.)
Keywords: Delivery of Health Care, Family Medicine, Health
Expenditures, Primary Health Care
Forty years ago, in the milestone “Declaration of
Alma Ata,” all member nations of the World
Health Organization declared that achieving health
for all was dependent on a foundation of primary
care.1 A quarter century later, Dr. Barbara Starfield
added to the evidence base, demonstrating that
primary care produces higher quality of care, im-
This article was externally peer reviewed.

Submitted 26 September 2017; revised 11 March 2018;
accepted 13 March 2018.
From the Department of Family Medicine, Oregon
Health & Science University, Portland, OR (BP); Eugene S.
Farley, Jr. Health Policy Center, University of Colorado
School of Medicine, Denver, CO (SBG); Robert Graham
Center for Policy Studies in Family Medicine and Primary
Care, Washington, D.C. (AB, WL).
Funding: none.
Conflict of interest: none declared.
Corresponding author: Brian Park, MD MPH, Department
of Family Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Pk Rd, Mailcode FM, Portland, OR
97239 �E-mail: [email protected]).
588 JABFM July–August 2018 Vol. 31 No. 4
http://www.jabfm.org
o
n
2
3
F
e
b
ru
a

ry 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w
w
.ja

b
fm
.o
rg
/
J A
m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a

s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9
Ju

ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
http://www.jabfm.org/
proves health outcomes, increases access, lowers
costs, and attenuates disparities.2,3,4 She attributed
the positive impact of primary care on health sys-
tems to the “4 Cs,” which define its function: first
contact, continuity, comprehensiveness, and coor-
dination (Figure 1).4 Subsequent research has dem-
onstrated that supporting these 4 Cs are the ele-
ments of primary care that help health systems
achieve the Quadruple Aim of improving patients’
experience of care, population health, and physi-
cian satisfaction, while reducing costs.5,6,7,8

Starfield’s work and the healthcare system’s
longstanding inattention to primary care may ex-
plain the ongoing failure of the United States to
achieve its Quadruple Aims, given the inadequate
system level support for primary care.9,10,11,12,13,14
Its predominant fee-for-service (FFS) payment
model has long been thought to undermine or
insufficiently support the 4 Cs that explain primary
care’s positive effects.15,16,17 Under pure FFS pay-
ment models, clinicians are reimbursed retroac-
tively for services, incentivizing higher volume,
treatment rather than prevention, and fragmenta-
tion of care without regard for quality or cost. Such
models reward greater numbers of services ren-
dered (ie, volume) rather than the quality and cost
of care provided to patients (ie, value).18,19
Payers, public and private, are experimenting
with shifting from paying for volume to paying for
value. The Affordable Care Act included provisions
that advance primary care and value-based pay-
ment, including the creation of the Center for
Medicare and Medicaid Innovation (CMMI), which
has tested innovative payment and delivery system
models aimed at improving value.20,21,22 Five years
after the Affordable Care Act, the Medicare Access
and Children’s Health Insurance Program CHIP Re-
authorization Act (MACRA) passed. Under MACRA,
providers1 will select 1 of 2 incentive tracks: the al-
ternative payment model (APM; see Table 1) or the
Merit-Based Incentive Payment System (see Table
2).23 Both programs provide incentives for improving
quality and reducing costs.

As value-based payment spreads, better under-
standing of existing models can guide which ap-
proaches deserve ongoing implementation and re-
search efforts. This narrative review of the literature
proposes a taxonomy of the major health care pay-
ment models, highlights their distinguishing charac-
teristics (Table 3), and reviews their impacts across
the Quadruple Aim (Table 4). We also discuss the
impact of each payment model in supporting the 4
Cs of primary care; given the lack of widespread use
and standardized metrics in measuring these pri-
1Eligible clinicians provide care for at least 100 Medicare
patients and bill for greater than $30,000 of Medicare Part B
services.
Table 1. Scheduled Adjustments in APM Eligibility Criteria
under Medicare Access and Children’s Health
Insurance Program Reauthorization Act
Year Eligibility
2019 and 2020 �25% of total Medicare revenue is from a
qualified, eligible APM
2021 and 2022 �50% of total Medicare revenue OR
�25% of total Medicare revenue and 50% of all-payer revenue
(eg, Medicaid, private insurers)
is from a qualified, eligible APM
2023 and beyond �75% of total Medicare revenue OR
�25% of total Medicare revenue and 75% of all-payer revenue
is from a qualified, eligible APM
APM, alternative payment model; OR, odd ratio.

Figure 1. The 4 Cs of Primary Care.
• Contact: Accessibility as the first contact with the health care
system
• Comprehensiveness: Accountability for addressing a vast
majority of personal health
care needs,
• Coordination: Coordination of care across settings, and
integration of care for acute
and (often comorbid) chronic illnesses, mental health, and
prevention, guiding access
to more narrowly focused care when needed,
• Continuity: Sustained partnership and personal relationships
over time with patients
known in the context of family and community.
doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’
Impact on the Quadruple Aim 589
o
n
2
3
F
e
b
ru
a

ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
mary care attributes24, when relevant, we consider
the hypothetical impacts of each model when for-
mal metrics were not used. Based on these findings,
we provide policy and research recommendations
for payment reform to best advance primary care.
Methods
Starfield Summit I: Advancing Primary Care
Research, Policy, and Patient Care
The first iteration of this narrative review was con-
ducted before the inaugural Starfield Summit

(http://www.starfieldsummit.com) on April 24 to
26, 2016, in Washington, D.C. It was intended to
inform and capture informant input from the Sum-
mit’s nearly 150 invited primary care leaders
(PCPs), researchers, and health care leaders to dis-
cuss and enable research and policy agenda-setting
around primary care payment, measurement, and
teams.25
Literature Review
We first conducted a literature search26 on primary
care payment, enriched through expert consulta-
tion before, during, and after the Summit. In
March 2016, an Ovid MEDLINE search was con-
ducted using the search terms “payment” and “pri-
mary care.” The search was limited to articles pub-
lished in English since 2010, yielding a total of 391
results2, with 97 articles ultimately included in the
review. Exclusion criteria included the following:
inclusion in a subsequent systematic review, up-
dated evidence available (ie, more recent article
from the same demonstration), not focused on pay-
ment models, not focused on Quadruple Aim
and/or the 4 Cs, and non-US evaluations that were
subnational. Additional articles and gray literature
were identified from the expert opinions of mem-
bers of the Family Medicine for America’s Health
payment and research tactic teams and a “snowball”
method of reviewing the references of the search
results. The literature was summarized for each
model, and key demonstrations or projects were
selected, with agreement from at least 2 authors
from the writing group, to highlight examples.
Results

Fee-For-Service
Under FFS, a provider is retrospectively paid a
predefined amount for each service. Consequently,
providers are incentivized to increase volume with-
out bearing financial risk for quality or costs; in-
surers bear high financial risk in this arrangement.
In 1992, the Centers for Medicare and Medicaid
Services (CMS) began using the Resource-Based
Relative Value Scale to set a fee schedule for dif-
ferent services, which has been criticized for dis-
proportionately weighing specialist care and proce-
dures over primary care.27,28 Despite concerns over
the limitations of FFS, its inclusion in a payment
model may enhance the use of services that are
low-cost and underutilized29, such as vaccines in
low immunization areas, where increased volume is
desirable for population health.
Traditional (Or Full-Risk) Capitation
In response to rising costs from FFS, health main-
tenance organizations (HMOs)3 emerged in the
1980s to coordinate care and reduce use30 by capi-
tating payments.26 In traditional capitation, provid-
ers are paid a prospective amount to cover all ser-
vices within a specific period of time, most often as
a per member per month (PMPM) fee. Payments
vary by age-group and sex and are determined
based on prior average costs of care under FFS.31,32
A capitated fee can cover all primary care services,
all outpatient services, or all health care services,
2In the case that a more recent report on a demonstration
project was published between the time of the initial litera-
ture search and submission of this manuscript, we replaced
the prior report with the most up-to-date evidence.

3HMOs and other managed care models also include
other mechanisms for cost control (e.g., narrow provider
networks and pre-authorization of services). For the pur-
poses of this paper, we have examined this model as a
surrogate for capitated payment, though we acknowledge
other mechanisms were in place to contribute to outcomes.
Table 2. Scheduled Payment Adjustments in Merit-Based
Incentive Payment System
Adjustment 2019 2020 2021 2022 and beyond
Baseline payment adjustment �4% �5% �7% �9%
Maximum payment adjustment for high performers �12% �15%
�21% �27%
o
n
2
3
F
e
b
ru
a
ry 2
0

2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w
w
.ja
b
fm

.o
rg
/
J A
m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0

.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9
Ju
ly 2
0

1
8
. D
o
w
n
lo
a
d
e
d
fro
m
http://www.starfieldsummit.com
Ta
bl
e
3.
O
ve
rv
ie
w

of
Pr
im
ar
y
Ca
re
Pa
ym
en
t
M
od
el
s
D
es
cr
ip
ti
on
P
ro
sp

ec
ti
ve
vs
re
tr
os
pe
ct
iv
e
F
in
an
ci
al
ly
di
sc
ou
ra
ge
s
vo

lu
m
e
of
se
rv
ic
es
?
F
in
an
ci
al
ly
en
co
ur
ag
es
hi
gh
qu
al

it
y
of
ca
re
?
P
ar
ty
th
at
pr
im
ar
ily
be
ar
s
th
e
fi
na
nc
ia

l
ri
sk
?
R
is
k
ad
ju
st
s
fo
r
pa
ti
en
t
co
m
pl
ex
it
y?
K

ey
E
xa
m
pl
e
F
ee
-f
or
-s
er
vi
ce
(F
F
S)
P
ai
d
fo
r
ea
ch

in
di
vi
du
al
se
rv
ic
e
re
nd
er
ed
R
et
ro
sp
ec
ti
ve
N
o
N
o

In
su
re
rs
N
o
M
ed
ic
ar
e
P
at
ie
nt
s
(v
ia
co
st
-s
ha
ri
ng

:
co
-
pa
ys
,
de
du
ct
ib
le
s)
T
ra
di
ti
on
al
ca
pi
ta
ti
on
(f

ul
l-
ri
sk
ca
pi
ta
ti
on
,
gl
ob
al
pa
ym
en
t)
P
ai
d
to
co
ve

r
al
l
se
rv
ic
es
w
it
hi
n
a
sp
ec
ifi
c
pe
ri
od
of
ti
m
e
P

ro
sp
ec
ti
ve
Y
es
N
o,
ex
ce
pt
fo
r
ou
tc
om
es
re
la
te
d
to
us

e
P
ri
m
ar
y
ca
re
pr
ac
ti
ce
s
N
o
M
ed
ic
ar
e
A
dv
an
ta

ge
H
M
O
s
P
ay
-f
or
-p
er
fo
rm
an
ce
(P
4P
)
ex
is
ts
in
ad
di

ti
on
to
un
de
rl
yi
ng
m
od
el
(g
en
er
al
ly
F
F
S
or
ca
pi
ta
ti

on
)
P
ai
d
fo
r
ac
hi
ev
em
en
t
of
(o
r
im
pr
ov
em
en
t
in
)

a
qu
al
it
y
m
ea
su
re
B
ot
h
ex
is
t
(m
os
t
m
od
el
s
re

tr
os
pe
ct
iv
el
y;
ho
w
ev
er
,
ca
n
be
pa
id
pr
os
pe
ct
iv
el
y

an
d
su
bs
eq
ue
nt
ly
re
co
nc
ile
d)
P
ot
en
ti
al
ly
(d
ep
en
ds
on

qu
al
it
y
m
et
ri
cs
)
Y
es
,
fo
r
se
rv
ic
es
be
in
g
m
ea
su

re
d
vi
a
qu
al
it
y
m
et
ri
c
D
ep
en
ds
on
un
de
rl
yi
ng
pa
ym

en
t
m
od
el
P
ot
en
ti
al
ly
M
ed
ic
ar
e
P
hy
si
ci
an
G
ro

up
P
ra
ct
ic
e
D
em
on
st
ra
ti
on
P
ro
je
ct
P
ri
m
ar
y
ca
re

pr
ac
ti
ce
s,
if
ta
rg
et
s
no
t
m
et
B
un
dl
ed
pa
ym
en
t
(e
pi

so
de
-
of
-c
ar
e)
P
ai
d
fo
r
al
l
se
rv
ic
es
re
nd
er
ed
fo
r

a
gi
ve
n
ep
is
od
e
of
ca
re
M
ix
ed
(g
en
er
al
ly
re
tr
os
pe
ct

iv
el
y
tr
ig
ge
re
d
an
d
pr
os
pe
ct
iv
el
y
pa
id
)
Y
es
(b
ut

do
es
no
t
di
sc
ou
ra
ge
vo
lu
m
e
of
ep
is
od
es
)
N
o,
ex
ce

pt
fo
r
ou
tc
om
es
re
la
te
d
to
ut
ili
za
ti
on
P
ri
m
ar
y
ca
re

pr
ac
ti
ce
s,
or
ga
ni
za
ti
on
s
N
o
C
M
M
I’
s
B
un
dl
ed
P

ay
m
en
ts
fo
r
C
ar
e
Im
pr
ov
em
en
t
Sh
ar
ed
sa
vi
ng
s
P

ai
d
ba
se
d
on
sp
en
di
ng
be
lo
w
a
pr
ed
et
er
m
in
ed
be
nc
hm

ar
k
ov
er
a
pe
ri
od
of
ti
m
e
(c
on
ti
ng
en
t
on
m
ee
ti
ng
ce

rt
ai
n
qu
al
it
y
ta
rg
et
s)
M
ix
ed
(p
ro
sp
ec
ti
ve
at
le
ve
l

of
th
e
A
C
O
,
bu
t
pr
ov
id
er
s
of
te
n
st
ill
pa
id
vi
a
F

F
S)
Y
es
Y
es
A
C
O
s
P
ot
en
ti
al
ly
M
ed
ic
ar
e
Sh
ar
ed

Sa
vi
ng
s
P
ro
gr
am
A
C
O
s
B
le
nd
ed
F
F
S
an
d
ca
pi
ta

ti
on
P
ai
d
a
pr
ed
et
er
m
in
ed
am
ou
nt
in
te
nd
ed
to
co
ve
r

m
ed
ic
al
ho
m
e
se
rv
ic
es
fo
r
a
sp
ec
ifi
c
pe
ri
od
of
ti
m

e
in
ad
di
ti
on
to
F
F
S
M
ix
ed
N
o
(t
o
th
e
ex
te
nt
th
at

F
F
S
is
th
e
pr
ed
om
in
an
t
pa
ym
en
t
m
ec
ha
ni
sm
)
N
o

D
ep
en
ds
on
un
de
rl
yi
ng
pa
ym
en
t
m
od
el
P
ot
en
ti
al
ly

M
ed
ic
ar
e
C
om
pr
eh
en
si
ve
P
ri
m
ar
y
C
ar
e
In
it
ia
ti

ve
C
om
pr
eh
en
si
ve
(p
ri
m
ar
y)
ca
re
pa
ym
en
t
P
ai
d
a
ri

sk
-a
dj
us
te
d
am
ou
nt
to
co
ve
r
al
l
pr
im
ar
y
ca
re
se
rv
ic

es
fo
r
a
sp
ec
ifi
c
pe
ri
od
of
ti
m
e;
in
cl
ud
es
co
m
po
ne
nt

of
P
4P
P
ro
sp
ec
ti
ve
Y
es
Y
es
P
ri
m
ar
y
ca
re
pr
ac
ti
ce

s
Y
es
Io
ra
H
ea
lt
h
C
on
ti
nu
ed
o
n
2
3
F
e
b
ru

a
ry 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w

w
.ja
b
fm
.o
rg
/
J A
m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e

d
a
s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9

Ju
ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
including inpatient and outpatient. In contrast to
FFS, capitation incentivizes cost control. Capita-
tion may also exist as part of blended models with
mixed PMPM payments and FFS, or in a further
risk-adjusted form mixed with pay-for-perfor-
mance in comprehensive primary care payment;
these models are discussed in a later section. In
contrast to FFS, capitation shifts financial risk to
the provider, while the payer has lower risk.

One study examined the impact of capitation on
one of the 4 Cs and finding capitated models was
associated with decreased first contact (access).33
This may reflect the incentive for providers to
avoid sicker patients (termed adverse selection or
“cherry-picking”) to reduce costs. Another possible
negative impact on the 4 Cs is a financial incentive
to inappropriately underdeliver services, leading to
decreased comprehensiveness.34 The prospective
element of capitation could benefit primary care by
enabling upfront investments in practice compo-
nents that enhance the 4 Cs (eg, care coordination)
and providing flexibility for practices to determine
how finances are spent.
Traditional capitation has demonstrated mixed
effects on cost and quality35,36,37, although most
evidence suggests a decreased use of hospitals and
other expensive resources and worse patient satis-
faction, consistent with the backlash toward HMOs
in the 1990s.38
Pay-For-Performance (P4P)
P4P supplements an underlying payment model,
most often as a bonus on top of FFS. P4P refers to
payment based on the achievement of a quality
target (eg, hemoglobin A1c [HbA1c] level �8 for
diabetic patients or delivery of cancer screening) or
improvement in performance (eg, change from
baseline for HbA1c); the latter approach may at-
tenuate variation in quality across providers, and
provide incentives for both high-performing and
low-performing practices.39

Limited evidence exists for the impact of P4P on
the 4 Cs. The United Kingdom’s Quality and Out-
comes Framework (QOF) found decreased conti-
nuity rates and no differences in patient-reported
perception of coordination, when compared with
preintervention periods.40 Incentivized metrics
tended to improve, whereas nonincentivized met-
rics demonstrated unchanged or worsened rates of
improvement; a limited set of targeted metrics
could thus inhibit the comprehensive function ofTa
bl
e
3.
Co
nt
in
ue
d
D
es
cr
ip
ti
on
P
ro
sp

ey
E
xa
m
pl
e
D
ir
ec
t
pr
im
ar
y
ca
re
P
ai
d
ou
ts
id
e
of

th
ir
d-
pa
rt
y
in
su
re
rs
(o
ft
en
di
re
ct
ly
fr
om
pa
ti
en
ts
)

a
pr
ed
et
er
m
in
ed
am
ou
nt
to
co
ve
r
al
l
pr
im
ar
y
ca
re
se

rv
ic
es
fo
r
a
sp
ec
ifi
c
pe
ri
od
of
ti
m
e
P
ro
sp
ec
ti
ve

Y
es
N
o
P
ri
m
ar
y
ca
re
pr
ac
ti
ce
s
fo
r
pr
im
ar
y
ca
re

ex
pe
ns
es
N
o
Q
lia
nc
e
P
at
ie
nt
s
fo
r
ot
he
r
as
pe
ct
s

of
ca
re
(a
nd
in
su
re
rs
if
pa
ti
en
ts
ha
ve
th
ir
d
pa
rt
y
in
su

ra
nc
e)
A
C
O
,
ac
co
un
ta
bl
e
ca
re
or
ga
ni
za
ti
on
;
H
M

O
,
he
al
th
m
ai
nt
en
an
ce
or
ga
ni
za
ti
on
;
C
M
M
I,
C
en

te
r
fo
r
M
ed
ic
ar
e
an
d
M
ed
ic
ai
d
In
no
va
ti
on
.

o
n
2
3
F
e
b
ru
a
ry 2
0
2
0
b
y g
u
e
st. P
ro
te
cte
d
b
y co

p
yrig
h
t.
h
ttp
://w
w
w
.ja
b
fm
.o
rg
/
J A
m
B
o
a
rd
F
a
m

M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
1
2
2
/ja
b
fm
.2
0
1
8
.0

4
.1
7
0
3
8
8
o
n
9
Ju
ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m

Ta
bl
e
4.
Im
pa
ct
of
Pr
im
ar
y
Ca
re
Pa
ym
en
t
M
od
el
s

on
th
e
Q
ua
dr
up
le
Ai
m
an
d
Te
ne
ts
of
Pr
im
ar
y
Ca
re
P
ay

m
en
t
M
od
el
Q
ua
dr
up
le
A
im
A
llo
w
s
P
ro
ac
ti
ve
In
ve

st
m
en
t
in
P
ri
m
ar
y
C
ar
e
T
he
4
C
s
of
P
ri
m
ar
y

C
ar
e
E
le
m
en
ts
A
ss
oc
ia
te
d
w
it
h
Su
cc
es
sf
ul
P
ro

gr
am
s
H
ea
lt
h
O
ut
co
m
es
E
xp
er
ie
nc
e
of
C
ar
e
C
os

t
C
on
tr
ol
P
ro
vi
de
r
Sa
ti
sf
ac
ti
on
C
on
ta
ct
(A
cc
es
s)

C
on
ti
nu
it
y
C
oo
rd
in
at
io
n
C
om
pr
eh
en
si
ve
ne
ss
F
ee

-f
or
-s
er
vi
ce
(F
F
S)
2
2
2
2
✕
2
4
3
2
1
2
*
B
ill
in

g
m
ec
ha
ni
sm
s
av
ai
la
bl
e
th
at
re
co
gn
iz
e
pr
im
ar
y
ca

re
te
ne
ts
an
d
no
n-
fa
ce
-t
o-
fa
ce
se
rv
ic
es
T
ra
di
ti
on
al

(f
ul
l-
ri
sk
)
ca
pi
ta
ti
on
4
3
M
os
tl
y
2
M
os
tl
y
1
2

✔
2
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce
1
2
R
is
k
lim

it
ed
to
pr
im
ar
y
ca
re
se
rv
ic
es
P
M
P
M
de
te
rm
in
at
io
n

ba
se
d
on
an
ti
ci
pa
te
d
ne
ed
ra
th
er
th
an
F
F
S*
P
ay
-f
or

-
pe
rf
or
m
an
ce
(P
4P
)
2
1
2
1
2
1
2
✕
2
1
2
4
3
2
A

pp
ro
pr
ia
te
,
al
ig
ne
d
m
ea
su
re
s
fo
r
us
e
in
pr
im
ar
y

ca
re
*
B
un
dl
ed
pa
ym
en
t
(e
pi
so
de
-o
f-
ca
re
)
4
3
(w
ea

k)
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en

ce
✔
/✕ (r
et
ro
ac
ti
ve
ly
tr
ig
ge
re
d)
In
su
ff
.
ev
id
en
ce
In
su

ff
.
ev
id
en
ce
1
(w
ea
k)
In
su
ff
.
ev
id
en
ce
N
/A
,
m
ay
no

t
ap
pl
y
to
pr
im
ar
y
ca
re
gi
ve
n
di
ffi
cu
lt
y
de
fi
ni
ng
an

d
as
si
gn
in
g
bu
nd
le
s
Sh
ar
ed
sa
vi
ng
s
1
1
2
1
In
su
ff

.
ev
id
en
ce
✔
/✕
(p
ro
vi
de
rs
of
te
n
pa
id
F
F
S)
In
su
ff
.

ev
id
en
ce
In
su
ff
.
ev
id
en
ce
1
*
In
su
ff
.
ev
id
en
ce
T
ar

ge
t
hi
gh
-n
ee
ds
pa
ti
en
ts
A
dd
re
ss
ps
yc
ho
so
ci
al
ne
ed
s

A
pp
ro
pr
ia
te
ri
sk
-
ad
ju
st
m
en
t
N
on
-F
F
S
in
ce
nt
iv

es
at
pr
ov
id
er
le
ve
l*
P
hy
si
ci
an
-l
ed
or
in
te
gr
at
ed
A
C

O
C
on
ti
nu
ed
o
n
2
3
F
e
b
ru
a
ry 2
0
2
0
b
y g

u
e
st. P
ro
te
cte
d
b
y co
p
yrig
h
t.
h
ttp
://w
w
w
.ja
b
fm
.o
rg
/
J A

m
B
o
a
rd
F
a
m
M
e
d
: first p
u
b
lish
e
d
a
s 1
0
.3
1
2
2

/ja
b
fm
.2
0
1
8
.0
4
.1
7
0
3
8
8
o
n
9
Ju
ly 2
0
1
8
. D
o
w

n
lo
a
d
e
d
fro
m
Ta
bl
e
4.
Co
nt
in
ue
d
P
ay
m
en

t
M
od
el
Q
ua
dr
up
le
A
im
A
llo
w
s
P
ro
ac
ti
ve
In
ve
st
m

en
t
in
P
ri
m
ar
y
C
ar
e
T
he
4
C
s
of
P
ri
m
ar
y
C
ar

e
E
le
m
en
ts
A
ss
oc
ia
te
d
w
it
h
Su
cc
es
sf
ul
P
ro
gr
am

s
H
ea
lt
h
O
ut
co
m
es
E
xp
er
ie
nc
e
of
C
ar
e
C
os
t
C

on
tr
ol
P
ro
vi
de
r
Sa
ti
sf
ac
ti
on
C
on
ta
ct
(A
cc
es
s)
C
on

ti
nu
it
y
C
oo
rd
in
at
io
n
C
om
pr
eh
en
si
ve
ne
ss
B
le
nd
ed

F
F
S
an
d
ca
pi
ta
ti
on
2
1
2
1
2
1
In
su
ff
.
ev
id
en
ce

✔
/✕
1
1
1
In
su
ff
.
ev
id
en
ce
T
ar
ge
t
hi
gh
-n
ee
ds
pa
ti

en
ts
A
pp
ro
pr
ia
te
ri
sk
-
ad
ju
st
m
en
t
M
ul
ti
pa
ye
r
al

ig
nm
en
t
R
ea
l-
ti
m
e
da
ta
sh
ar
in
g
O
pt
im
al
F
F
S/
ca

pi
ta
ti
on
bl
en
d
(m
or
e
re
se
ar
ch
ne
ed
ed
)
C
om
pr
eh
en
-

si
ve
pr
im
ar
y
ca
re
pa
ym
en
t
1
(w
ea
k)
1
(w
ea
k)
1
(w
ea
k)

1
(w
ea
k)
✔
1
(w
ea
k)
In
su
ff
.
E
vi
de
nc
e
In
su
ff
.
ev
id

en
ce
1
(w
ea
k)
A
pp
ro
pr
ia
te
ri
sk
ad
ju
st
m
en
t
P
ay
m
en

ts
ba
se
d
on
10
%
to
ta
l
co
st
of
ca
re
ra
th
er
th
an
pr
io
r
F

F
S
D
ir
ec
t
pr
im
ar
y
ca
re
In
su
ff
.
ev
id
en
ce
1
(w
ea
k)

1
(w
ea
k)
1
(w
ea
k)
✔
2
1
*
(b
et
te
r
in
di
v.
ac
ce
ss
,
bu

t
af
fo
rd
ab
ili
ty
an
d
w
or
kf
or
ce
co
nc
er
ns
)
In
su
ff
.
ev

id
en
ce
In
su
ff
.
ev
id
en
ce
In
su
ff
.
ev
id
en
ce
C
ou
pl
in
g

w
it
h
ap
pr
op
ri
at
e
w
ra
pa
ro
un
d
in
su
ra
nc
e
to
av
oi
d

hi
gh
pa
ti
en
t
co
st
s
fo
r
no
n-
pr
im
ar
y
ca
re
se
rv
ic
es
*

1
,
ev
id
en
ce
of
po
si
ti
ve
ou
tc
om
es
.
2
,
ev
id
en
ce
of
ne

ga
ti
ve
ou
tc
om
es
.
2
1
,
ev
id
en
ce
of
m
ix
ed
ef
fe
ct
s.
4

3
,
no
si
gn
ifi
ca
nt
ef
fe
ct
or
ch
an
ge
.
✔
,
al
lo
w
s
pr
oa

ct
iv
e
in
ve
st
m
en
t
in
pr
im
ar
y
ca
re
.
✕
,
do
es
no
t
al

lo
w
pr
oa
ct
iv
e
in
ve
st
m
en
t
in
pr
im
ar
y
ca
re
.
✔
/✕
,

so
m
e
co
m
po
ne
nt
s
al
lo
w
pr
oa
ct
iv
e
in
ve
st
m
en
t
in

pr
im
ar
y
ca
re
,
w
hi
le
ot
he
rs
do
no
t.
In
su
ff
.
ev
id
en
ce

,
no
av
ai
la
bl
e
ev
id
en
ce
;
(w
ea
k)
,
lim
it
ed
or
po
or
qu
al

it
y
ev
id
en
ce
(i
e,
�
1
st
ud
y
ex
am
in
ed
an
d/
or
no
t
a
co

m
pa
ri
so
n
st
ud
y)
.
*N
o
or
lim
it
ed
ev
id
en
ce
,
bu
t
a
st

ro
ng
th
eo
re
ti
ca
l
lik
el
ih
oo
d
of
ef
fe
ct
.
P
ro
ac
ti
ve
in

ve
st
m
en
t
in
pr
im
ar
y
ca
re
ca
n
su
pp
or
t
al
l
of
th
e
4

C
s.
A
C
O
,
ac
co
un
ta
bl
e
ca
re
or
ga
ni
za
ti
on
;
P
M
P

M
,
pe
r
m
em
be
r
pe
r
m
on
th
.
o
n
2
3
F
e
b
ru

Ju
ly 2
0
1
8
. D
o
w
n
lo
a
d
e
d
fro
m
primary care.41,42 P4P targeted to the 4 Cs could
hypothetically support primary care; however, cur-
rent metrics focus predominantly on disease-fo-
cused and process-oriented outcomes (eg, HbA1c)
outcomes, rather than patient-centered outcomes
(eg, quality of life) or primary care attributes (eg,
continuity).41,43 Metrics for the latter remain un-
derdeveloped and under used,42 despite growing
recognition of the importance of measuring the 4

Cs.45 As P4P is a bonus payment, the shortcomings
of the underlying payment model often prevail.
Overall, the evidence supporting P4P has been
mixed, with inconsistent impacts across the Qua-
druple Aim.41,45,46,47,48,49,50 In 2 large systematic
reviews, 1 from QOF and 1 from the United States,
some modest yet positive impacts on rate of im-
provement for targeted quality and patient out-
comes were observed initially, but these benefits
stagnated over time, if not regressed to preinter-
vention rates.41,51 Providers reported decreased pa-
tient-centered care and continuity41, which are im-
portant predictors of provider satisfaction.52 The
return on investment of P4P may be low, given
significant time and financial costs of implementa-
tion.53
Bundled Payment/Episode-of-Care Payment
Under bundled payment, providers receive a pre-
determined payment for all services rendered for an
episode-of-care; this payment may be provided
prospectively or retrospectively. This model has
been used in hospitals (ie, Diagnosis Related
Groups), which receive a set fee for services (ie,
labor and delivery). As with capitation, providers
are at financial risk if their costs exceed the fee but
profit from cost savings. Bundled payments may be
optimal for high-cost, low-frequency conditions or
episodes (eg, hip fractures), as there is incentive to
limit the costs for the given episode, but not to
limit future episodes.30
Limited evidence exists of the impact of bundled
payment on the 4 Cs. As reimbursements for an
episode of care are bundled for multiple providers,

coordination across specialties is encouraged54,
with improvements demonstrated in a Netherlands
bundled-payment initiative.55 Like capitation,
global payment could support the 4 Cs by enabling
investment in a strong primary care infrastructure.
Unfortunately, bundled payments can be difficult
to implement in primary care due to issues around
defining episodes of care. Although acute condi-
tions like fractures and pregnancy have clearer be-
ginning and end points, defining what constitutes a
chronic condition episode is more challenging, a
problem …
Journal of Professional Nursing 33 (2017) 400–404
Contents lists available at ScienceDirect
Journal of Professional Nursing
Original Articles
Is health care payment reform impacting nurses' work settings,
roles, and
education preparation?
Mary Val Palumbo a,⁎, Betty Rambur b, Vicki Hart c
a University of Vermont, College of Nursing and Health
Sciences, 106 Carrigan Drive, Rowell 216, Burlington, VT
05405, United States
b University of Rhode Island, Routhier Endowed Chair for
Practice, College of Nursing, 39 Butterfield Road, Kingston, RI,
02881, United States
c University of Vermont, Office of Health Promotion Research,
1 South Prospect Street, Rm 4428, Burlington, VT 05401,
United States
⁎ Corresponding author.

E-mail addresses: [email protected] (M.V. Palumb
(B. Rambur), [email protected] (V. Hart).
http://dx.doi.org/10.1016/j.profnurs.2016.11.005
8755-7223/© 2016 Elsevier Inc. All rights reserved.
a b s t r a c t
a r t i c l e i n f o
Article history:
Received 11 August 2016
Accepted 28 November 2016
This study explores nurses' work settings and educational
preparation in the five years before passage of the Af-
fordable Care Act (ACA) and five years after ACA passage,
with the aim of identifying areas for nurse educators'
attention. The study setting was one small state undergoing
rapid transition away from fee-for-service service
and thus provided the ideal laboratory to assess the impact of
health reform on the nursing workforce. A second-
ary analysis of data gathered during relicensure compared the
nursing workforce at an interval of one decade,
with surveys in 2005 (n = 4075; 65% response rate) and in 2015
(n = 6723; 97% response rate). Findings dem-
onstrated an increase in the proportion of nurses who reported
working in ambulatory care and community set-
tings (p = 0.001). However, there was no associated decrease in
the proportion of nurses who reported working
in hospitals. Among respondents who reported employment in
the ambulatory care/community settings in 2005,
34.3% had a BSN or higher, a proportion that increased to
41.2% in 2015 (p = 0.010); nevertheless, the greatest
proportional increase was among AD prepared nurses (34% to
48%). Although new nursing roles emerging as a
result of health reform offer baccalaureate nurses the
opportunity use the full complement of their knowledge

and skills, these data suggest that BS prepared nurses are not
fully accessing these opportunities. Implications
for nursing education and further research are detailed.
© 2016 Elsevier Inc. All rights reserved.
Keywords:
Ambulatory care
Nursing education
Payment reform
Introduction
Health care reform and the growing momentum in the volume-
to-
value transition creates a new environment for nursing practice.
Health
reform rooted in “The Triple Aim” of 1) improved patient
experiences,
2) improved population health, and 3) cost containment has
seeded
the development of new payment models and redesigned care
delivery.
Responsibility for population health and overall cost of care
broadens
the accountability horizon for organizations. Instead of
responsibility
for an episodic encounter that is billed and reimbursed, payment
reform
creates incentives to understand the value of care, the longer
term im-
pact of clinical decision making on cost of care and patient
overall health
and well-being, and population-level costs. Thus, payment
reform is an
element of health reform that potentially creates particular
opportuni-
ties for new or renewed roles for nurses. In traditional fee-for-

service re-
imbursement schemas, for example, many nursing skills (such
as care
management and patient education) equate to a “labor cost,”
while
medical services are perceived as a “revenue generator.”
Payment re-
form dramatically shifts this equation, suggesting the potential
for
o), [email protected]
more nursing employment in non-acute care settings. Yet have
nurses'
work settings and roles evolved as well? This preliminary study
ex-
plores nurses' work settings in the time of reform, five years
pre-Afford-
able Care Act passage and five years post ACA passage, with
the aim of
clarifying potentially fruitful areas for curricular reform and
empirical-
ly-based nurse continuing education.
Background and Context
One element of health reform, the Affordable Care Act of 2010
(ACA),
creates a path toward universal health insurance that builds on
the
existing U.S. hybrid financing model of governmental payers
(Medicare,
Medicaid, Children's Health Insurance Program, or CHIPS, and
TriCare)
and commercial insurance. It requires that all individuals are
covered
by one of these means, either via one of the governmental
insurances

or commercial insurance. Commercial insurance may be
employer-
based or individually purchased. The law also requires each
state to ei-
ther create a “Health Insurance Exchange” or to participate in
the federal
exchange. The purpose of the exchanges are to enable
individuals and
small businesses to compare different health insurance plans in
an “ap-
ples to apples” manner because all plans must include the
“essential
benefit package”, i.e., services that much be covered. What
differs
among the plans is the “actuarial value” of the plans, the
amount of
http://crossmark.crossref.org/dialog/?doi=10.1016/j.profnurs.20
16.11.005&domain=pdf
http://www.sciencedirect.com/science/journal/
Table 1
Key provisions of U.S. Department of Health and Human
Services January 26, 2015
announcement
Timeline of Medicare Value Based Initiative Date
30% of traditional fee-for-service to value based payments By
end of 2016

50% of traditional fee-for-service to value based payments By
end of 2018
85% of all tradition medicare payment to quality or value By
end of 2016
90% of all traditional medicare payment linked to quality or
value By end of 2018
401M.V. Palumbo et al. / Journal of Professional Nursing 33
(2017) 400–404
cost sharing in the form of copayment, deductible, and
coinsurance.
These are also standardized by what is termed metal levels. For
exam-
ple, in a plan with a 60% actuarial value (AV)—a bronze plan—
the in-
sured would pay roughly 40% of health costs but have a lower
monthly premium than, for example, a platinum plan, which has
an ac-
tuarial value of roughly 90%. The law subsidizes those who
meet eligibil-
ity requirements, provided they select a silver plan (AV value of
70%)
In addition to providing such onramps to health insurance, the
ACA
creates incentives for testing alternative payment models
(APMs) to ad-
dress the limitations created by traditional fee-for-service (FFS)
reim-
bursement, a payment model that fragments care by creating
payment silos rather than seamless care across the care
continuum.
Fee-for-service also fuels accelerating health care cost,
overtreatment
and overutilization while simultaneously leaving others
underserved

By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx

By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx

Recommended

Recommended

More Related Content

Similar to By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx

Similar to By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx (20)

More from clairbycraft

More from clairbycraft (20)

Recently uploaded

Recently uploaded (20)

By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx