“In existing [bundled payment] programs, surgeons are subject to identical episode length, metrics, and reimbursement. One potential unintended consequence of this one-size-fits-all approach is an uneven playing field for different surgeons and organizations—a dynamic that may explain why hospitals that bundle joint replacement differ from those that do not. Our anecdotal experiences at academic medical centers corroborate this evidence: hesitation among colleagues often stems from a belief of poor fit due to practice setting and patient case mix.
[..] One approach to attracting more surgeons could be to create options (“participation tracks”) that involve delivering different sets of services to focused patient populations. Among low-risk patients with little or no comorbidity and good preoperative functional status, few are likely to require high-intensity postacute care facility services currently encompassed in surgical episode design. Consequently, 90-day episodes targeting this population could exclude certain services (eg, care at institutional postacute care facilities) to engage surgeons around others (eg, physical therapy in an ambulatory care setting). Alternatively, surgical bundles could be structured for individuals with multiple chronic conditions who require medically complex care to emphasize preoperative optimization of surgical candidacy and postdischarge coordination to reduce care fragmentation or adverse events during care transitions.
A precedent for this approach is emerging. In forthcoming Medicare primary care payment models, clinicians can prospectively select between 2 distinct tracks for average-risk and high-risk “seriously ill” populations, which use different quality metrics and financial incentives to reflect differences in these groups’ health care needs. With attention to appropriate risk adjustment and monitoring for unintended effects, payers could similarly create targeted participation options that increase the salience of bundled payments to surgeons, particularly those with more heterogeneous patient populations. [..]
[A second approach] Rather than hold surgeons accountable for the myriad of services across episodes spanning hospitalization and 90 days of postacute care, bundles could target services that are broadly relevant to many patient groups. One example could be to redefine episodes to include more “preacute” services, thereby engaging surgeons in preoperative assessment and optimization. Excluding postdischarge services could avoid inappropriately penalizing surgeons for outcomes that occur months after surgery and are less likely to be procedure related.
Another example could be to focus episodes on hospital care while evaluating performance using hospital data, not just payer claims. This approach could enable hospitals and payers to capture changes in quality and utilization (eg, reductions in device costs, length of stay) as measured through multiple data sources—a tack used successfully to create savings in prior bundled payment programs. Some employers and commercial payers have begun to adopt such approaches, implementing bundled payments that require multistep preoperative evaluation or the option of either completely excluding or allowing abbreviated postdischarge periods within the episode.”
Full article, Liao JM, Wong SL and Chu D. JAMA Surgery 2020.9.30