Bundled Episode Payment and Gainsharing Demonstration Project (Text Version)
On September 27, 2010, Weslie Kary made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (900 KB).
Bundled Episode Payment and Gainsharing Demonstration Project
Agency for Healthcare Research and Quality
2010 Annual Meeting
September 27, 2010
Weslie Kary, MPP, MPH
Integrated Healthcare Association
- What is bundled or "episode" payment?
- Why do it?
- IHA bundled episode and gain-sharing demonstration and evaluation plan.
What is bundled (episode) payment?
- A single prospective price for all services needed by the patient over an episode of care.
- Defined on parameters of time and services.
Image: Table showing things that might be included in a episode definition bounded by time and services, for example: pre-admission services including physician services, imaging, and drugs.
Source: Center for Healthcare Quality and Payment Reform, Transitioning to Episode-Based Payment (www.chqpr.org)
Why bundle? Problems with current payment options.
- Fee for service: rewards volume of services, not appropriateness or coordination of care.
- Global capitation: shifts too much risk to providers, creates incentive for risk selection.
- Pay-for-performance: when framed as quality bonus, does not move enough money.
Is bundled payment a workable compromise?
Some people think so.
- Expand ACE Demo, include post-acute care by 2013.
- Demonstrate in Medicaid population by 2012.
- Bundle payments in ACO.
Images: Representative organizations that believe bundled payment is a workable compromise, including: CMS ACE Demonstration (the seal of approval that participants are allowed to use in marketing); a photo of the executive team of the Geisinger ProvenCare™ Health plan; a chart of the Prometheus Payment™ (another pilot program); and a photo of Congress, which approved an expansion of episode payment pilots in PPACA.
IHA Demonstration Project
- Focus: Major procedures and acute conditions, orthopedic first → cardiac and other.
- First participants: Monarch HealthCare, Cedars-Sinai, Hoag Hospital, Saddleback Memorial, Tenet, UCLA, Aetna, Blue Shield, CIGNA, HealthNet → all California.
- First populations: Commercial PPO → HMO, Medicaid Managed Care and Medicare Advantage.
- Episode definition: Date of surgery + 90 days, includes acute and routine follow-up, complications within 90-days, related readmits.
- What happened? Was model scalable? What facilitates success, what bodes failure? (RAND: Susan Ridgely, Peter Hussey)
- Was quality of care for orthopedic patients maintained compared to control hospitals? (U.C. San Francisco: Kevin Bozic, Steve Takemoto)
- Did efficiency go up, costs of care go down compared to baseline period? (U.C. Berkeley: James Robinson, Samuel Tseng)
More info: www.iha.org