While this risk based payment is complicated, it does remove
one of the major concerns in a capitation model. With the latter,
payment is population-based but that puts the physician or group
as the bearer of financial risk. Payment without risk adjustment
assumes that there is an equal distribution of people who have
significant health needs and those who minimally use medical resources. But one doctor’s population is not likely to be the same as
that of another. So in capitation, doctors who have a “higher needs,”
less healthy population will be disadvantaged. Frank Opelka, MD,
the former medical director of the American College of Surgeons
and the Louisiana State University (LSU) Executive Vice President
for Healthcare Redesign, has long held that physicians should bear
the risk for clinical outcomes but not the insurance risk. Bundled
Payments are built around the risk of the individual patient and
not population financial risk that capitation represents. That is a
big difference.
A concern raised by hospitals and payers is that there may be
cherry-picking of patients so patients may be hurried into the bundle
prior to all conservative measures being performed. As an example
a patient may be proposed for a total knee replacement when he
has not yet been tried on injectable hyaluronic acid or an unloading brace. To reduce the incidence of that, Medicare will probably
risk-adjust the bundle so that premature surgeries will not have a
high margin. Commercial insurers will use their prior authorization
criteria to prevent what they believe are inappropriate surgeries.
Bundled payments may appear very complicated, but most offices
have to deal with a myriad set of reimbursement schemes already
with fee-for-service. Bundles should not be more complicated than
what we have now. The future direction with the Advanced Payment
Models may be the one in which the bundled payment option may
be the easiest to understand and participate in.
References
1.) Porter ME, Kaplan RS, How to pay for health care. Harvard
Business Review, July-Aug. 2016:88-100
2.) CMS.GOV, Bundled Payments for Care Improvement (BPCI)
Initiative: General Information, https://innovation.cms.gov/
initiatives/bundled-payments/ (last accessed Aug. 23, 16)
3.) O’Byrne TJ, Shah ND, Wood D, Nesse RE, Killinger PJ, Litchy
WJ, Stroebel RJ, Wagie AE, Naessens JM. Episode-based payment: evaluating the impact on chronic conditions. Medicare
Medicaid Res Rev. 2013 Sep 13;3(3).
Dr. James is the chief medical officer for Baptist Health Plan and
Baptist Health Community Care.
OCTOBER 2016
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