Bun­dled pay­ment predica­ment

Study looks at varied costs of post-dis­charge care

Modern Healthcare - - THE WEEK IN HEALTHCARE - Melanie Evans

Vari­a­tion in what Medi­care pays for cer­tain surg­eries raises ques­tions about how best to care for pa­tients af­ter they leave the hos­pi­tal, ac­cord­ing to a study. The re­search, pub­lished in the jour­nal Health Af­fairs, also sug­gests that fi­nan­cial in­cen­tives for many hos­pi­tals un­der bun­dled pay­ment mod­els may prove to be a “wash,” the au­thors said.

Many hos­pi­tals were high cost for one surgery, but not oth­ers, the study found. There­fore, bun­dled pay­ments— un­der which hos­pi­tals re­ceive a lump sum for mul­ti­ple med­i­cal ser­vices re­lated to a pro­ce­dure— could of­fer fi­nan­cial gains for some surg­eries but cre­ate fi­nan­cial pres­sure for oth­ers.

Re­searchers with the Univer­sity of Michi­gan and the Dart­mouth In­sti­tute for Health Pol­icy and Clin­i­cal Prac­tice an­a­lyzed Medi­care spend­ing on four surg­eries from the point at which pa­tients en­tered the hos­pi­tal through 30 days af­ter they left.

Post-dis­charge care and physi­cian ser­vices largely ac­counted for the 10% to 40% dif­fer­ence be­tween high-cost and low-cost hos­pi­tals, af­ter re­searchers ac­counted for ge­o­graphic cost dif­fer­ences—such as cost of liv­ing—and the sever­ity and com­plex­ity of pa­tients’ con­di­tions.

David Miller, an as­sis­tant pro­fes­sor at the Univer­sity of Michi­gan Med­i­cal School in Ann Ar­bor and one of the study’s au­thors, said the find­ings could lead to fur­ther re­search that would iden­tify which post-dis­charge care is “money well spent” and which may be op­por­tu­ni­ties to elim­i­nate costly waste.

Skilled nurs­ing, home health­care and re­ha­bil­i­ta­tion hos­pi­tals were the source of “a large and highly vari­able” amount of pay­ments af­ter ac­count­ing for dif­fer­ences in ge­o­graphic costs and ill­ness, the study said.

Hos­pi­tals in the high­est quin­tile re­ceived $2,500 to $7,750 more than hos­pi­tals in the low­est quin­tile based on the anal­y­sis of Medi­care fee-for-ser­vice hip re­place­ment, coro­nary artery by­pass graft, back and colec­tomy surgery pa­tients be­tween Jan­uary 2005 and Novem­ber 2007. For hip re­place­ments, post-dis­charge care ac­counted for 85% of the dif­fer­ence be­tween the high­est-cost and low­est-cost hos­pi­tals.

The numbers sug­gest, the re­searchers wrote, that “strong in­cen­tives ex­ist for the CMS to ex­pand or re­fine its bun­dled pay­ment poli­cies to in­clude spend­ing for home health, re­ha­bil­i­ta­tive and skilled-nurs­ing ser­vices pro­vided af­ter hos­pi­tal dis­charge.”

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