Bundled payments are becoming more widely adopted across the healthcare industry, and spine surgeons are especially likely to see bundled payment models from all payers. Providers who can successfully adapt will be positioned to capture the greatest market share of bundled payments.
Ellis M. "Mac" Knight, MD, the senior vice president and CMO of the Coker Group, a healthcare consulting firm, discussed how spine surgeons can succeed under a bundled payment model at the Becker's 16th Annual Future of Spine + The Spine, Orthopedic and Pain Management-Driven ASC Conference on June 14 in Chicago.
Bundled payment essentials
Dr. Knight identified the Bundled Payment Care Initiative, created in 2011, as "the project that convinced most people that the bundled payment model was the payment model most likely to bend the cost curve." The BPCI Advanced Program, announced in January 2018, has 32 bundled payment programs, including several bundles for spine surgery.
He highlighted five essential characteristics of bundled payments:
1. Payments cover the overall care required to treat the condition.
2. Payments are contingent on delivering good outcomes.
3. Payments are adjusted for risk.
4. The payments provide a fair profit for effective and efficient care.
5. Providers are not responsible for unrelated care or catastrophic cases.
"Inclusion and exclusion criteria is especially problematic for spine surgery," Dr. Knight said, "because there are so many possible procedures." If, for example, the procedures are identified by DRG, surgeons have to know whether the DRG includes complications and comorbidities. Patient selection, Dr. Knight claims, is probably one of the greatest obstacles to making bundles work in surgical specialties. Bundled payments are high risk for surgeons who take on challenging cases, who must do a better job of managing socioeconomic and behavioral aspects of patient care.
Surgical location is another key consideration for bundled payment models. As an increasing number of surgeries are migrating to the ambulatory space, the dilemma in spine surgery is figuring out how to benefit from the cost advantages afforded by that space without sacrificing quality.
Recommendations
Dr. Knight recommends using a modified Lean mapping technique to map care processes, including care process units across the care continuum. Costs for CPUs can be used to negotiate bundled budgets, determine if non-negotiable bundled budgets will produce a profit, and identify costs that may be eliminated without sacrificing the quality of patient care.
When surgeons have a say in which quality measures are used, they should try to use outcome versus process measures; consider patient-reported outcome measures and experience measures as outcome measures; and pick measures that can be tracked in real time or near-real time. Dr. Knight advises surgeons to pick measures they are already collecting, such as complications and readmissions.
Dr. Knight laid out a stepwise approach:
1. Select the bundled services.
2. Form the clinically-integrated, provider-led network. Surgeons should consider functioning as a convener rather than abdicating this role to hospitals or health systems.
3. Build the infrastructure.
4. Design the CPUs and integrated process units.
5. Refine the CPUs and IPUs to optimize value.
6. Take the services to market: potential target markets include government payers such as CMS, commercial payers and self-insured employers.
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