Most healthcare providers let “innovations around reimbursement” come and go.
The majority of us — whether we’re aides, nurses, specialists, or generalists — try to provide the best care possible, in as reasonable a way as possible. And we let the reimbursement and payment fall however it does, after the fact.
That said, there are certainly big shifts that affect how we care for patients — and certainly how we’re paid to do so. And “bundled payments” are one of those shifts that are big enough to pay attention to.
A New York Times article did a thoughtful review recently of Medicare’s bundled payments programs. Currently, these programs are effectively pilots, with hospitals able to opt into the program, rather than making them mandatory.
As I’m sure you’re aware, bundled payment programs create a single payment for every health care service associated with an event. (Rather than paying for the healthcare services individually.) The idea, of course, is that this approach would decrease costs: “In theory, if doctors and hospitals get one payment encompassing all this, they will better coordinate their efforts to limit waste and keep costs down.”
Of course, anyone who has ever gotten a “meal deal” because it was a better value — even though they weren’t originally planing on buying chips or a drink — understands why this may not be the best idea.
That said, some data shows that at least for hip and knee replacements, overall costs are slightly lower than with fee-for-service models. But different types of healthcare are different. And data on hip and knee replacements may not relate at all to other areas of healthcare — especially when the data is coming entirely from hospitals who have opted into the program (rather than taking part in it mandatorily.
But we have some broader concerns about programs like bundled payments.
5 Reasons Bundled Payment Programs May Not Be a Silver Bullet:
- Most waste isn’t coming from doctors pursuing profit over smart care.
One core concept in the formulation of this type of program is that providers are seeking profit first and safe, considerate care second. My honest take? This happens, but not very often. And so it's possible that one of the framing ideas is false.
- Savings from bundled payments necessitate collaboration — and collaboration needs tools.
Bundled payments benefit greatly from collaboration that can be empowered by healthcare collaboration tools like iClickCare. But simply changing how things are paid for may not provide the tools necessary to make that collaboration -- and thus the savings -- possible.
- Savings from bundled payments necessitate care coordination — and care coordination demands support.
This type of integrated payment depends on the interdependency of the providers. As with healthcare collaboration, however, providers are often attempting to coordinate care against all odds. And so it may make more sense to make care coordination more effortless than simply to change payment structures.
- The “bundle” might not be the right combination of services.
The bundling structure assumes that it is known what’s needed for a given healthcare event. The reality? Healthcare “events” can be unpredictable and complex -- every patient is different.
- Savings are good but rationing usually isn’t.
The author of the Times article makes a point about steering patient access. While it certainly makes sense to guide patients towards the most appropriate treatments, I worry that this structure can raise the spectre of rationing -- which usually means that people with the least resources end up getting the worst care. Plus, in these programs, quality is generally not taken into account, at least not in very sophisticated ways — especially tracking quality across different groups.
All of the above isn’t to say that an overall shift to value-based care isn’t desirable (plus, it’s likely inevitable.) But we do think that it’s important to advocate for supports for shifts in care and reimbursement — not just change how doctors are paid.
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