POSTED September 6, 2016
Expansion of bundled care payment models to include Cardiac and Maternity Service Lines
As preliminary findings continue to support bundle payment schemes for Orthopaedic procedures such as TKA and THA, the Center for Medicare Services (CMS), alongside thought leaders, are designing plans for their own take on this value-based reimbursement model. Findings suggest that bundles improve quality of care and patient reported outcomes, while creating significant savings for the health system.
As the US healthcare system continues to visualize care as a continuum rather than disparate events, bundle payment expansion plans have been passed by CMS. Proposals for hip fracture and cardiac procedures such as bypass surgery have been published, and plans have been discussed for maternity care and mammography. The goal of expansion is to hold providers more accountable for the quality and coordination of the services they provide, improve the value of care, while decreasing costs. The inclusion of cardiac care and hip fractures in bundled payment models would be the first use of this structure in emergency surgery as opposed to the current use in elective scheduled surgery situations.
According to the Agency for Healthcare Research and Quality (AHRQ), the most common types of procedures performed during hospitalizations in 2010 were associated with maternal and newborn stays or cardiovascular and musculoskeletal procedures.Due to the large scope of these procedures, changing the model across all three will have a huge impact on national costs.
Maternal mortality rates have increased significantly over the last 20 years in the United States due to obesity-related complications such as hypertension and diabetes, the increase in the number of c-section births (1 in 3 US mothers), a lack of access to affordable, quality health care, and more women giving birth at an older age. This rate has more than doubled since 1987, reaching 17.8 deaths of mothers per 1,000,000 live births in 2011. Maternity care, when defined as an episode of care, ranging from prenatal care, labor and childbirth, to postpartum follow up appointments is a prime candidate for quality improvement through bundled payments. A recent white paper on clinical episode payment models for maternity care, argued that episode-based bundled payments could lead to a higher percentage of babies born at healthy weights, better recovery processes among mothers, and healthier infants at birth (HCP-LAN, 2016). A pay for performance reimbursement model will put the focus on quality improvements. Bundled payments for maternity care could decrease the rate of unnecessary and expensive c-section’s, reduce pre-term rates to non-elective (only medically indicated), reduce infant mortality, reduce maternal mortality, and reduce ethnic and racial disparities by streamlining care.
Although joint replacement surgeries and maternity care offer a similar episode of care model (pre-op to post-op), it will be interesting to see how this model is adapted to more trauma based procedures such as hip fracture and heart attack response. The Department of Health & Human Services proposed a new model for mandatory bundled payment for heart attack care (AMI) and cardiac bypass surgery (CABG). With this proposed ruling, the hospital in which a Medicare patient is admitted for heart attack care or bypass surgery would be accountable for the cost and quality of care provided to the beneficiary during the inpatient stay and for 90 days after discharge. This model would reward hospitals that work together with physicians and providers to avoid complications, prevent hospital readmissions, and speed recovery. With improvements in care coordination, CMS hopes to increase the number of patients who recover in cardiac rehabilitation, which has been shown to reduce readmission rates (and therefore reduce costs). Discharge processes in hospitals need to be restructured to reflect the evidence base. The adoption of bundled payments in cardiac care will allow providers to rethink processes that discharge patients to post-acute care settings. As this ruling is only proposed at the moment, look out for the final ruling in November 2016.