Introduction
Recent payment reforms promote movement from fee-for-service to
alternative payment models that shift financial risk from payers to
providers, incentivizing providers to manage patients’ utilization.
Bundled payment, an episode-based fixed payment that includes the prices of
a group of services that would typically treat an episode of care, is
expanding in the United States, including mandatory models in Medicare.
Bundled payment has not been developed specifically for substance use
disorder (SUD) treatment. Yet, bundled payment has been recommended as a way
to pay for comprehensive SUD treatment and has the potential to improve
treatment engagement after detox, which could reduce detox readmissions,
improve health outcomes, and reduce medical care costs. However, if moving
to bundled payment creates large losses for some providers, it may not be
sustainable. The objective of this study was to design a bundled payment for
detox and follow-up care and to estimate its impact on provider
revenues.
Methods
Massachusetts Medicaid beneficiaries’ behavioral health,
medical, and pharmacy claims from July 2010–April 2013 were used to
build and test a detox bundled payment for continuously enrolled adults
(N=5,521). A risk adjustment model was developed using general linear
modeling to predict beneficiaries’ episode costs. The projected
payments to each provider from the risk adjustment analysis were compared to
the observed baseline costs to determine the potential impact of a detox
bundled payment reform on organizational revenues. This was modeled in two
ways: first assuming no change in behavior and then assuming a supply-side
cost sharing behavioral response of a 10% reduction in detox
services and an increase of one individual counseling and one group
counseling session.
Results
The mean total 90-day detox episode cost was $3,743. Nearly 70
percent of the total mean cost consists of the index detox, psychiatric
inpatient care, and short-term residential care. Risk mitigation, including
risk adjustment, substantially reduced the variation of the mean episode
cost. There are opportunities for organizations to gain revenue under this
bundled payment design, but many providers will lose money under a bundled
payment designed using historic payment and costs.
Conclusions
Designing a bundled payment for detox and follow-up care is feasible,
but low case volume and the adequacy of the payment are concerns. Thus, a
detox episode-based payment will likely be more challenging for smaller,
independent SUD treatment providers. These providers are experiencing many
changes as financing shifts away from block grant funding toward Medicaid
funding. A detox bundled payment in practice would need to consider
different risk mitigation strategies, pooling providers, and an increased
reimbursement rate, but could incentivize care coordination, which is
important to reducing detox readmissions and engaging patients in care.