Commonwealth Fund Task Force on Payment and Delivery System Reform

Meaningful improvements to how health care is organized, paid for, and delivered are not only needed but possible. The Commonwealth Fund’s 18-member Task Force on Payment and Delivery System Reform harnessed their real-world experience and the best available evidence to recommend ways to improve quality, advance equity, and increase affordability of health care in the U.S. 

These recommendations are directed at delivery system reform, not insurance coverage, and the federal government, rather than states, because this is where the Task Force sees optimal opportunity for bipartisan collaboration to transform health care for all. 

Task Force Recommendations

1. Increase delivery system preparedness for health disasters. 

The COVID-19 pandemic has exposed numerous deficiencies and inequities in the U.S. health care system and its capacity to prepare for, or respond to, any national health-related crisis — not just a novel virus.

The Task Force identified three areas for federal policy action: improve digital systems for communication and data collection; update workforce policies that allow for flexibility; and develop a refined national crisis response strategy. Two examples of Task Force recommendations on preparedness include:

• Congress should strengthen surveillance systems to better track epidemic and nonepidemic illnesses and the health impacts of public health crises, and to ensure the availability of vital supplies for managing outbreaks.
• Congress should empower the U.S. Department of Health and Human Services (HHS) to develop and implement an interoperable and secure public health information system that enables rapid and secure exchange of standardized electronic health information. This system should include data from public health departments, laboratories, providers of clinical care, and manufacturers.

2. Increase health system accountability for health care quality, equity, and costs.

The federal government has invested in several payment and delivery experiments that have yielded insights into what works, what shows promise, and what should be discontinued. Based on a review of the evidence, the Task Force offers guidance to accelerate adoption of value-based payment in Medicare and Medicaid and lays out criteria for the Center for Medicare and Medicaid Innovation (CMMI) to maximize adoption over the next five years. Two sample recommendations include:

• The Centers for Medicare and Medicaid Services (CMS) should require all Medicare providers to participate meaningfully in promising value-based payment arrangements. The agency should offer financial and technical assistance when needed and permit limited exceptions.
• In Medicaid and the Children’s Health Insurance Program, Congress should allow a higher federal match rate for promising value-based payment approaches.

3. Strengthen primary health care.

Evidence shows that a strong foundation of primary care yields better health outcomes, greater equity, and lower per capita costs. Yet the primary care system in the U.S. often falls short, especially for people of color, women, people with low incomes, and rural residents. The Task Force envisions a team-based primary care system for the 21st century that is untethered to a clinician’s office, tech-enabled, and fully capable of addressing behavioral health and social needs.

Recommendations for federal policymakers focus on reforming payment for primary care services, increasing the supply and retention of primary care clinicians, and leveraging telemedicine. Two examples of Task Force recommendations include:

• CMS should significantly increase reliance on capitated and hybrid prepayment models in primary care.
• CMS should establish a new process for determining the value of primary care services and compensation for clinicians who provide them. The new approach should promote a career in primary care and be adapted to keep the pipeline robust.

4. Support the empowerment and engagement of people, families, and communities.

Partnerships between providers, patients, and their communities are essential for a health system to offer high-quality care, achieve value, and reverse long-standing racial and ethnic disparities. Patients, family caregivers, and communities should be engaged in codesigning new delivery models and policies, confronting and combatting racism in health care, promoting digital tools and telehealth services, and strengthening policies to protect the privacy and security of patients’ personal information. Two sample recommendations are:  

• HHS and national health care accreditation organizations should require all provider organizations and insurers, in partnership with patients and communities, to develop, implement, and maintain plans and programs for eliminating health disparities and combatting structural racism in their organization and to publicly report progress.
• Congress should fund, through the Federal Communications Commission, broadband internet service in communities that lack it.

5. Reduce administrative burden.

To reduce administrative burden and costs, the Task Force calls for changes in billing and payment; streamlined, standardized performance measures; and removal of unnecessary administrative obstacles at the point of care. Two examples of recommendations include:

• Congress should direct the Office of the National Coordinator for Health Information Technology (ONC) and CMS to create a uniform, national, standardized billing system for all payers.
• Congress should direct HHS to establish a parsimonious set of core quality and equity metrics that can be used by all payers and clinicians.

6. Encourage a balance of regulatory and competitive approaches to promote a high-performing health system.

All Task Force recommendations will be effective only if they are accompanied by efforts to make health care markets work for consumers. The Task Force recommends a range of regulatory and competition-promoting policies, including antitrust enforcement, to produce more efficient health care markets that deliver greater benefits to everyone. Two examples of recommendations are:

• Congress should require the federal government to correct market distortions and control costs when health care competition is absent and states have failed to step in.  
• HHS should fully implement current authorities, and Congress should pass new legislation as necessary, to provide payers and purchasers in local markets with transparent information on price, quality, and utilization (stratified by demographic identifiers including race, ethnicity, age, gender, and zip code) for each individual service and episode of care.

Advancing Racial Health Equity

The U.S. health care system is not immune from the structural and interpersonal racism that plagues American society.  Our health care is characterized by long-standing inequities in access, quality, and outcomes for people of color, which has been further pronounced during the COVID-19 pandemic, adding greater urgency to the need for widespread change.

To advance racial health equity, the Task Force has issued a number of policy imperatives:

• Require data by race and ethnicity be collected, publicly reported, and used.
• Develop, test, and scale payment and delivery models to reduce disparities.
• Encourage health systems to confront and combat racism in their policies and programs, as well as to meaningfully engage and empower the communities they serve.
• Expand, diversify, and train the health care workforce
• Assess and develop protections against racial bias in health care technology

Read the full Task Force report.

Task Force Members