Pa­tients ex­pe­ri­ence care based on episodes of ill­ness. Why can’t providers de­liver and be paid on episodes too?

Modern Healthcare - - OPINIONS COMMENTARY -

stays only; hos­pi­tals of­fer a dis­count to Medi­care fee-for-ser­vice rates, share in pro­gram sav­ings and can make gain­shar­ing ar­range­ments with physi­cians. In two of the mod­els—one cov­er­ing post-acute pe­ri­ods only and one cov­er­ing both in­pa­tient stays and posta­cute pe­ri­ods—the CMS will per­form a ret­ro­spec­tive rec­on­cil­i­a­tion of ac­tual costs with a pre­de­ter­mined tar­get price. In the fourth model, providers will re­ceive a prospec­tive, sin­gle bun­dled pay­ment for all Medi­care Part A and Part B ser­vices and 30-day read­mis­sions.

Be­cause ex­am­ples from around the coun­try have demon­strated that gain­shar­ing can in­crease co­or­di­na­tion and foster best prac­tices, all four mod­els al­low par­tic­i­pat­ing hos­pi­tals to en­ter into ar­range­ments with physi­cian that would give them in­cen­tives to work col­lab­o­ra­tively with the hos­pi­tal to re­duce in­ter­nal hos­pi­tal costs through qual­ity im­prove­ment and ef­fi­ciency ini­tia­tives.

For ex­am­ple, in the in­pa­tient-only model, the episode of care would be de­fined as the in­pa­tient stay in the gen­eral acute-care hos­pi­tal. Medi­care will pay the hos­pi­tal a dis­counted amount based on the pay­ment rates es­tab­lished un­der the in­pa­tient prospec­tive pay­ment sys­tem, and will pay physi­cians sep­a­rately for their ser­vices un­der the Medi­care physi­cian fee sched­ule. How­ever, hos­pi­tals will share in any sav­ings to Medi­care re­sult­ing from their par­tic­i­pa­tion, and hos­pi­tals Valinda Rut­ledge, left, is di­rec­tor of the pa­tient­care mod­els group at the Cen­ter for Medi­care and Med­i­caid In­no­va­tion Cen­ter and former pres­i­dent and CEO of CaroMont Health, Gas­to­nia, N.C. Dr. Nancy Nielsen is an in­ternist and se­nior ad­viser to the Cen­ter for Medi­care and Med­i­caid In­no­va­tion Cen­ter and a past pres­i­dent of the Amer­i­can Med­i­cal As­so­ci­a­tion.

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