Opportunities and Challenges for Episode-Based Payment

Mechanic, Robert E.

doi:10.1056/nejmp1105963

Cited by 64 publications

(50 citation statements)

References 4 publications

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“…So-called value-based payment strategies, including episode-of-care or bundled payments, have been proposed as a mechanism to improve quality and reduce costs of TJA by incentivizing greater communication and coordination among providers across the continuum of care [3,7]. Episode-of-care payments set a fixed reimbursement amount to be shared among all providers, including physicians, allied health professionals, hospitals, and other facilities, for a defined episode of care that meets certain quality standards.…”

Section: Introductionmentioning

confidence: 99%

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Bozic

Ward

Vail

et al. 2014

Clinical Orthopaedics &Amp; Related Research

382

205

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Background Understanding the type and magnitude of services that patients receive postdischarge and the financial impact of readmissions is crucial to assessing the feasibility of accepting bundled payments. Questions/purposes The purposes of this study were to (1) determine the cost and service components of a 30-day total joint arthroplasty (TJA) episode of care; (2) analyze the portion of the total payment that is used for postdischarge services, including home care; and (3) to evaluate the frequency of readmissions and their impact on total episode-of-care payments. Methods All payments to Medicare providers (hospitals, postacute care facilities, physicians, and other healthcare providers) for services beginning with the index procedure and extending 30-days postdischarge were analyzed for 250 Medicare beneficiaries undergoing primary or revision TJA from a single institution over a 12 months. Payments and services were aggregated by procedure type and categorized as index procedure, postacute care, and related hospital readmissions. Results Mean episode-of-care payments ranged from USD 25,568 for primary TJA in patients with no comorbidities to USD 50,648 for revision TJA in patients with major comorbidities or complications, with wide variability within and across procedures. Postdischarge payments accounted for 36% of total payments. A total of 49% of patients were transferred to postacute care facilities, accounting for 70% of postdischarge payments. The overall 30-day unplanned readmission rate was 10%, accounting for 11% of postdischarge payments. Conclusions Episode-of-care payments for TJAs vary widely depending on the type of procedure, patient comorbidities and complications, discharge disposition, and readmission rates. Postdischarge care accounted for more than one-third of total episode payments and varied substantially across patients and procedures.

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Section: Introductionmentioning

confidence: 99%

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Bozic

Ward

Vail

et al. 2014

Clinical Orthopaedics &Amp; Related Research

382

205

View full text Add to dashboard Cite

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“…New proposals to support the launch of accountable care organizations (ACO) and medical homes are formulated on an almost monthly basis, with payment reform as a central component [1][2][3][4][5]. This evolution embodies a shift across western health systems away from traditional payment systems, such as fee for service (FFS) or salary toward wide scope prospective payment systems with risk sharing and an incorporation of clinical evidence and quality indicators in provider payment [6][7][8][9][10][11][12][13][14][15].…”

Section: Introductionmentioning

confidence: 99%

Healthcare payment reforms across western countries on three continents: Lessons from stakeholder preferences when asked to rate the supportiveness for fulfilling patients’ needs

et al. 2013

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Objective. To test the hypothesis that care typology -being complex and highly unpredictable versus being clear-cut and highly predictable -guides healthcare payment preferences of physicians, policy makers, healthcare executives, and researchers.Data Sources/Study Setting. We collected survey data from 942 stakeholders across Canada, Europe, Oceania, and the United States. Forty-eight international societies invited their members to participate in our study. Study Design.Cross-sectional analysis of stakeholder survey data linked to four scenarios of care typology: primary prevention, trial-and-error care, standard care and network care.Principal Findings. We identified two "extremes": (1) dominant preferences of physicians, who embraced fee for service (FFS), even when this precludes the advantages of other payment systems associated with a minimal risk of harm (OR 1.85 for primary prevention; OR 1.89 for standard care, compared to non-physicians); and (2) the dominant preferences of healthcare executives and researchers, who supported quality bonus or adjustment (OR 1.92) and capitation (OR 2.05), respectively, even when these could cause harm. Conclusions.Based on explorative findings, we can cautiously state that payment reform will prove to be difficult as long as physicians, healthcare executives, and researchers misalign payment systems with the nature of care. Replication studies are needed to (dis)confirm our findings within representative subsamples per area and stakeholder group.

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“…Bundled payments incentivize practitioners to reduce unnecessary tests and visits and to improve processes with the aim of reducing complications related to care. 40,41 The challenge with this payment design for pediatric patients is that, unlike acute illnesses and conditions, many chronic pediatric conditions do not have discrete dates of onset and no resolution. Global payments are fixed prepayments made to providers or a health care institution or system that cover most or all of a patient's care during a specified time period.…”

Section: Quality Measures For Paymentmentioning

confidence: 99%

A New Era in Quality Measurement: The Development and Application of Quality Measures

Mistry¹,

Franklin²,

Adirim³

et al. 2017

Pediatrics

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Quality measures are used for a variety of purposes in health care, including clinical care improvement, regulation, accreditation, public reporting, surveillance, and maintenance of certifi cation. Most quality measures are 1 of 3 types: structure, process, or outcome. Health care quality measures should address the domains of quality across the continuum of care and refl ect patient and family experience. Measure development for pediatric health care has a number of important challenges, including gaps in the evidence base; the fact that measures for most conditions must be agespecifi c; the long, resource-intensive development process; and the national focus on measure development for adult conditions. Numerous national organizations focus on the development and application of quality measures, including the Pediatric Quality Measures Program, which is focused solely on the development and implementation of pediatric-specifi c measures. Once a quality measure is developed for use in national measurement programs, the organization that develops and/or "stewards" the measure may submit the measure or set of measures for endorsement, which is recognition of the scientifi c soundness, usability, and relevance of the measure. Quality measures must then be disseminated and applied to improve care. Although pediatric health care providers and child health care institutions alike must continually balance time and resources needed to address multiple reporting requirements, quality measurement is an important tool for advancing high-quality and safe health care for children. This policy statement provides an overview of quality measurement and describes the opportunities for pediatric health care providers to apply quality measures to improve clinical quality and performance in the delivery of pediatric health care services.

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Opportunities and Challenges for Episode-Based Payment

Cited by 64 publications

References 4 publications

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Bundled Payments in Total Joint Arthroplasty: Targeting Opportunities for Quality Improvement and Cost Reduction

Healthcare payment reforms across western countries on three continents: Lessons from stakeholder preferences when asked to rate the supportiveness for fulfilling patients’ needs

A New Era in Quality Measurement: The Development and Application of Quality Measures

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