Managed Care - January 2010 - (Page 42)
Episode-of-Care Payment Creates Clinical Advantages It is customary to think of this payment method as a cost-control mechanism, and it is, but it can raise quality of care too on episodes of care. The Centers for Medicare and Medicaid Services, for example, announced more demonstration projects for bundled physician and hospital payments, and recently published a proposed rule for including quality incentives in a new prospective bundled payment program for endstage renal disease. There should be no illusions: Bundled payment strategies can be very complex to develop, implement, and maintain. A bundle-oriented system that encompasses even a third of the medical care provided in the United States will require extensive consensus building, constant testing, and significant enhancements to the payment infrastructure. By Douglas J. Moeller, MD, and James Evans McKesson Corp. hy don’t we make more payments for entire episodes of care instead of paying for each step? Shouldn’t we pay for results, not for process? The concept of a bundled payment is hardly new: Diagnosisrelated groups (DRGs) for inpatient care, comprehensive obstetrical care, and most surgical fees are well-known examples of bundled payment. The question is whether this approach can be applied to medical care (asthma, congestive heart failure, James Evans, left, is vice president for claims diabetes) or other situations in performance at McKesson, and Douglas J. which a single payment is tied to Moeller, MD, is a medical director there. What we know a predefined episode of care. Let’s start with what we know: Several proposals that include Case rates (DRG-based inpatient episodes of care have been floated by policymakers, facility payments) and other global service payand though the details vary, the goal of each is to ments (e.g., pregnancy/delivery) have been emreward integrated care by multiple caregivers and ployed effectively for decades. From that facilities over an extended period of time. experience, we have well-defined coding and payMost of us understand that an unforeseen dement mechanisms in place, we know where key velopment of fee-for-service payment has been to challenges lie, and we know what tools are needed. create incentives to perform more services withRisk adjustment models and contract manageout requiring attention to the overall quality and ment tools have been translated into groupers cost. As a result, “cost-effective” and “improved (tools used to measure resource use), pricers (tools outcomes” are paired in today’s discussions about to help determine the payment amount for a payment reform and are driving innovation in uticlaim), and the documentation needed to support lization and cost management. bundled payment. Episode-of-care contracting has been most effective when a single entity such as a hospital controls all aspects of the bundled servBundled payment ices package. Splitting a single payment between Many forward-looking organizations, whether two or more entities is much more challenging. anticipating a mandate or seizing a strategic opMany configurations of providers and services portunity, are looking at bundled payment based W MANAGED CARE / JANUARY 2010
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