Comments on: Why Bundling Payments Won’t Reduce Costs — Part 3

By: WhiteCoat

WhiteCoat — Mon, 09 Jan 2012 00:25:14 +0000

Agree that non-emergent services are less subject to some of the things that I mentioned, but then some of the higher risk patients will still get vetted and refused care. For example, an obese patient with diabetes and a history of blood clots might not find someone willing to do an elective bypass operation due to the high possibility of complications. And a healthy patient with a glucose of 130 may get called “diabetic” to increase payments under risk adjustment without truly being “diabetic.”
That’s a good starting point, though.

By: Myles

Myles — Thu, 05 Jan 2012 05:55:44 +0000

I believe bundled payments should be limited to elective procedures like knee replacements or perhaps even non-emergency coronary bypass. No emergency or unscheduled services. Also, need to be risk adjusted. That might solve some of the issues you have raised (though not all). Great effort.

By: MsLaurie

MsLaurie — Tue, 03 Jan 2012 03:44:07 +0000

Hmm, not sure if its relevant, as the Australian & USA systems are quite different, but in Victoria (one of the States in Australia), we have had a ‘casemix’ system in acute care for nearly 20 years now (so have several other States in various forms). The system, while mainly government funded, operates a bit like the bundled payment model you’ve outlined – hospitals are payed $X to deliver care for patients with diagnosis Y.

The idea is that hospitals will be able to treat some patients for less than Y, some for more than Y, but that it should roughly even out.

Payments are set with a base level of $X per diagnosis, with inlier and outlier payments as well – so if a patient is in only overnight, when usually they’d be 2 days, there will be less payment. Equally, if complications occur and suddenly the patient is in ICU for a month, that is compensated. There are co-payments for certain things that are known to cost more – such as ICU treatment, or the patient having certain co-morbidities such as HIV.

Where a patient is treated at one emergency department and then transferred to another hospital, both hospitals get paid for the relevant portion of the care provided.

While the system isn’t perfect by any means, patients do not seem to be being routinely over-diagnosed or under-treated…

I should probably also mention that while the hospitals are not required to make a profit, they do have to remain financially solvent, and *generally*, they are. Regarding payment though – generally Australian doctors are employees of the hospital, so tend to recieve a salary, rather than direct per-procedure payments, so that might also be a factor in the bundling working reasonably.

Sorry to ramble & love the blog