Managed Care - January 2008 - (Page 22) your beta-blocker, aspirin, and statin?” “I generally don’t like using the term ‘consumer’ for patients, but in this case it seems appropriate,” says Douglas Kamerow, MD, a columnist in the British Medical Journal. In his Annals of Surgery article, Casale states, “We considered but rejected as overly draconian at this time doing things like measuring nicotine levels during follow-up or canceling the ‘deal,’ essen- tially ‘voiding the warranty’ if patients missed appointments, did not participate in rehab, etc.” What perhaps gives Geisinger officials confidence that any lapse in patient follow-through might be spotted is the hospital system’s much touted electronic records system. “A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, Experts weigh in on Geisinger’s experiment mong some top experts in health care there is certainly excitement about Geisinger’s program for coronary artery bypass graft (CABG) surgery, but some wariness as well. For instance, the health plan is reluctant to use the word “warranty” when talking about its effort, and it should be, says Mark V. Pauly, PhD, professor of health care systems at the University of Pennsylvania. “The five-year warranty on my BMW covers all costs needed to return it to full driving and operating condition, whatever mechanical malady may strike,” he says. The Geisinger CABG program, however, does not guarantee any special outcome or consumer satisfaction, he says. “The patient who expires on the OR table, and therefore incurs no future cost, is a financial win for the program, whatever regret I am sure the surgical team will have,” says Pauly. A Bundling services As Paul sees it, the Geisinger program is actually an exercise in bundling payments — bundling more services together than is usually done for surgery, but fewer than would be included under full capitation. “The old problem with greater bundling was partly political, but the analytic problem was how to adjust risk,” says Pauly. “Without risk adjustment, there were incentives for cream skimming in selection of patients, a possible incentive to let a person developing a whole cascade of complications die rather than try to rescue — I am assuming that this incentive will be resisted but it could matter at the margin where things are not black and white — and an incentive to patch up the patient well enough but not as well as the best that could be done.” Different providers should be free to propose whatever bundling they would like, and different insurers should offer different bundles for bidding and experimentation, says Pauly. However, despite his reservations, Pauly thinks that the Geisinger program, which he describes as “subcapitation,” should work pretty well in an integrated system that is used to total capitation. Thomas Bodenheimer, MD, MPH, an adjunct professor in the department of family and community medicine at the University of California–San Francisco and a leading authority on the management of chronic disease, asks what seems to be on everybody’s mind. “Is it scalable to the disorganized majority of the health care system? I think it is, but it really depends on health plans or Medicare making an actuarial estimate of whether the 50 percent — or whatever percent — increased case rate cost will save or lose the health plan money.” Negotiations needed Bodenheimer contends that in a high quality system, with few complications, the 50 percent would probably be more than the health plan would be willing to pay. “So a lot depends on whether health plans can negotiate a price for the CABG-plus-guarantee that the hospitals and surgeons will accept. The hospitals and surgeons would need to negotiate who gets what percent of that case rate payment. If the hospitals and surgeons don’t feel that they are getting enough upfront payment to justify taking the risk, they won’t go for it. So it’s all about estimating risk and negotiating price.” All of which would take some doing, adds Pauly. “The problem for a less integrated system is: Who is in charge? Who makes money if we succeed and loses money if we fail? However, given consumers’ apparent preferences for less tightly coupled systems, the PPO that can figure out a way to do this, even if imperfectly, might have a very valuable resource.” 22 MANAGED CARE / JANUARY 2008
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