Because bundled payments are relatively new and require a different type of collaboration among payers, providers, and other actors, their design and implementation process is complex. By sorting the 53 key elements that contribute to this complexity into specific pre‐ and postcontractual phases as well as the actors involved in the health system, this framework provides a comprehensive overview of this complexity from a payer's perspective. Strategically, the design and implementation of bundled payments should not be approached by payers as merely the introduction of a new contracting model, but as part of a broader transformation into a more sustainable, value‐based health care system. Context Traditional fee‐for‐service (FFS) payment models in health care stimulate volume‐driven care rather than value‐driven care. To address this issue, increasing numbers of payers are adopting contracts based on bundled payments. Because their design and implementation are complex, understanding the elements that contribute to this complexity from a payer's perspective might facilitate their adoption. Consequently, the objective of our study was to identify and structure the key elements in the design and implementation of bundled payment contracts. Methods Two of us independently and systematically examined the literature to identify all the elements considered relevant to our objective. We then developed a framework in which these elements were arranged according to the specific phases of a care procurement process and actors’ interactions at various levels of the health system. Findings The final study sample consisted of 147 articles in which we identified the 53 elements included in the framework. These elements were found in all phases of the pre‐ and postcontractual procurement process and involved actors at different levels of the health care system. Examples of elements that were cited frequently and are typical of bundled payment procurement, as opposed to FFS procurement, are (1) specification of care services, patients’ characteristics, and corresponding costs, (2) small and heterogeneous patient populations, (3) allocation of payment and savings/losses among providers, (4) identification of patients in the bundle, (5) alignment of the existing care delivery model with the new payment model, and (6) limited effects on quality and costs in the first pilots and demonstrations. Conclusions Compared with traditional FFS payment models, bundled payment contracts tend to introduce an alternative set of (financial) incentives, touch on almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. Accordingly, payers should not strategically approach their design and implementation as merely the adoption of a new contracting model, but rather as part of a broader transformation toward a more sustainable value‐based health care system, based less on short‐term transactional negotiations and more on long‐term collaborative relationships between payers and provide...
Zorgverzekeraars en zorgaanbieders maken meestal contractafspraken op basis van een vergoeding per verrichting. Dat stimuleert echter volume van zorg in plaats van uitkomsten. Daarom passen zorgverzekeraars en zorgaanbieders steeds vaker ‘bundelinkoop’ als bekostiging toe. Dan wordt een bedrag per patiënt afgesproken. We beschrijven wat bundelinkoop is en introduceren de contractelementen. De impact van zorgbundels is dat ze door een andere verdeling van (financiële) verantwoordelijkheden uitkomsten centraal stellen, schotten doorbreken en innovatie stimuleren. Opschalen van deze methode van zorginkoop vraagt om standaardisatie van de contractelementen en uniformiteit van de bundeldefinitie per aandoening anders nemen de administratieve lasten voor zorgaanbieders toe.
Background One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.Methods This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015-2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.Results The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β=7.46, SE=0.498, p-value<0.001; THA: β=5.72, SE=0.515, p-value<0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.Conclusions This study shows that enabling factors such as the presence of supplementary insurance can cause historic claims-based pricing methods to potentially overestimate clinically appropriate post-discharge PT use, which would result in a bundle price that is too high. Clinical guidelines and best practice standards should be leveraged more often in bundled payment pricing methods to target this potentially avoidable utilization of care, and to stimulate the implementation of multi-provider bundled payment contracts.
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