Wednesday, September 09, 2015

Bundling Better – How Medicare Should Pay for Joint Replacement and Many Other Types of Care

The Center for Healthcare Quality and Payment Reform has issued a detailed alternative to the problematic payment changes for hip and knee replacement surgeries that were proposed in July by the Centers for Medicare and Medicaid Services (CMS).  CHQPR’s report Bundling Better: How Medicare Should Pay for Comprehensive Care (for Hip and Knee Surgery and Other Healthcare Needs) describes in detail how a properly designed payment system for hip and knee replacement could enable physicians, hospitals, and other providers to improve care for patients and reduce costs for the Medicare program without the need for those providers to accept excessive or inappropriate financial risk, and without requiring or encouraging greater consolidation of providers.  A copy of the report can be downloaded here.
Making sure CMS implements the right kinds of changes in Medicare payment for hip and knee surgery is not just important for orthopedic surgeons and the hospitals and post-acute care providers that care for hip and knee surgery patients.  The way CMS pays for this procedure will likely be the template for the alternative payment models Medicare uses to pay for many other procedures and conditions, so getting it right should be everyone’s concern.  The same payment approach described in Bundling Better could be used to support better care for a broad range of patients and health conditions, not just hip and knee problems.  Moreover, the same payment model could also be used by private employers, state Medicaid agencies, Medicare Advantage plans, and commercial health insurance plans to enable providers to improve care and reduce costs for their employees and members.  The payment changes proposed in Bundling Better would also improve the ability of Accountable Care Organizations to successfully manage the overall costs and quality for a population of patients.
The problems with the way CMS has proposed to change payment for joint surgery were described in detail in CHQPR’s report Bundling Badly: The Problems With Medicare’s Proposal for Comprehensive Care for Joint Replacement.  For example:
  • The CMS proposal does not change any of the underlying fee for service payment structures that create the current problems.  Instead, it tries to impose an overall budget on the total cost of care after the care has already been delivered.
  • The CMS proposal would set the same budget for an episode of care regardless of differences in patient need, which could lead higher-need patients to be underserved or be denied access to surgery.
  • The CMS proposal would put hospitals at risk for all of the costs of post-acute care services, even though hospitals do not have direct control over those services today and would not be given any greater control under the proposal.  Hospitals would also be held accountable for the management of patients’ chronic conditions after discharge, regardless of whether the physicians who had been managing those conditions prior to the hospital admission were even affiliated with the hospital.
  • The CMS proposal would reduce the overall budget for services if fewer services eligible for current payments were delivered, with no consideration for the costs providers had incurred in delivering new or improved services that are not reimbursed under current payment systems.
  • Under the CMS proposal, providers who deliver better outcomes would not be rewarded for doing so unless they were able to reduce spending.  Conversely, providers who deliver poor outcomes would not be penalized as long as spending remained within target levels.
  • The CMS proposal would mandate participation by providers in randomly-selected regions while precluding participation by providers in other regions, which would limit the choices of Medicare beneficiaries in every community.
  • The CMS proposal would preclude the ability to implement better approaches to payment for joint replacements in any region for a five year period.
The revised approach to Comprehensive Care for Joint Replacement (CCJR) developed by CHQPR and described in Bundling Better would have the following significant advantages over both the current payment system and the proposal that CMS issued in July:
  • All of the care associated with hip or knee replacements would be delivered by a physician-led team of providers chosen in advance by the patient receiving surgery.
  • This CCJR Team would have the ability to deliver the most appropriate services to meet patients’ needs, and the providers on the Team would not be restricted to delivering only those services for which payments are made under current Medicare payment systems.
  • The CCJR Team would receive an episode payment designed to cover the costs of all of the services their patients need related to the hip or knee surgery, including all post-acute care services and any complications experienced for a 90-day period.  This payment would be established based on what providers agreed that evidence and experience indicated was necessary to support good care for patients.  The amount of the payment would be known long before care was delivered and it would be stable over time, so that providers could establish and sustain high-quality patient care services.
  • CCJR Teams who treat patients with greater needs would receive larger episode payments to adequately support the larger amount of care those patients need.
  • CCJR Teams who deliver better outcomes for their patients would receive higher episode payments.
  • Payments to CCJR Teams would flow through provider-owned CCJR Management Organizations, and limits on financial risk would be established to enable physician practices and provider organizations of all sizes to participate in the program.
  • Participation in the CCJR program would be voluntary and open to interested providers in all parts of the country, so that all Medicare beneficiaries would have the opportunity to benefit from better care under the program, and also so that no beneficiary would be forced to receive care paid through the program if their physicians did not believe it would enable them to deliver improved care.
  • The CCJR program would not preclude providers or CMS from implementing other payment models if better options became available.
Although there is an urgent need to reform payment systems and to control health care costs, it is simply not feasible to implement a well-designed CCJR payment model by January 1, 2016 as CMS has proposed.  Moreover, rushing to implement a problematic payment model and then requiring that it be used for five years in some communities while precluding any other changes in order to “test” that model will create a major barrier to true innovations in care and payment for joint replacement and it will likely have a chilling effect on innovations in other areas.
Instead, CHQPR has proposed that CCJR should be redesigned and implemented through a collaborative effort of CMS and the physicians, hospitals, and post-acute care providers who want to create a truly well-designed payment model.  Bundling Better includes a detailed timetable for implementation that could enable improved care for Medicare beneficiaries and savings for the Medicare program beginning in 2017.

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Tuesday, May 27, 2014

The Best Antidote to Provider Market Power is to Change the Healthcare Payment System

There is growing national concern that consolidations of healthcare providers are leading to higher prices for healthcare services. The June 2014 issue of the policy magazine Health Affairs includes four separate papers that propose a range of policy options to try and address this issue. Unfortunately, those hoping for answers will not find the Health Affairs papers very satisfying. Not only is there little agreement among the authors about what to do, most of them do not express much enthusiasm about either the feasibility or benefits of the options they do identify.

False Premises Lead to Wrong Conclusions

Most policy prescriptions about prices and market power are based on three fundamentally false premises:

  • False Premise #1: Consolidation of Providers is Necessary and Desirable (In Fact, It’s Not). Contrary to popular belief, there is little evidence that consolidation is either necessary or sufficient for either better care coordination or greater efficiency of care delivery, whereas there is evidence that appropriate competition can lead to lower prices and higher quality. Moreover, there are many examples around the country of small physician practices and small hospitals providing high quality, efficient care while remaining independent. Since consolidation isn’t necessary to achieve the better healthcare everyone is seeking, instead of promoting consolidation and trying to figure out how to control the resulting market power, it would make more sense to find ways to make improvements in care delivery without consolidation.
  • False Premise #2: The Payment System Isn’t the Problem (In Fact, It Is). A major cause of both consolidations and demands for higher prices is the way we pay for healthcare today, and many so-called “payment reforms” are actually making the problem worse, not better. We need radically different payment systems for both physicians and hospitals in order to get better quality care at lower cost. If a payment system can only be implemented by a large provider organization, the solution is to redesign the payment system, not to try and control the prices charged by the consolidated organization.
  • False Premise #3: Price and Utilization Are Independent (In Fact, They’re Not). What should matter to purchasers is how much they spend on healthcare in total not how much they pay for individual services. In some cases, the prices of individual services may need to increase in order to support lower utilization and lower overall spending. Conversely, demanding lower prices may simply result in higher utilization and higher overall spending, or it may force providers to consolidate in order to resist what they see as unreasonable pricing demands. “Narrow networks” that promise to send a provider more patients in return for discounts simply reinforce the idea that volume is more important than value. Moreover, narrow networks are short-term strategies – if a payer gets a discount by shifting business to a subset of providers this year, what will it do next year? Will it force patients to switch doctors and hospitals every year in order to get a discount from the members of the new narrow network? And if there is only one hospital in town, how can one “narrow” the network or send the hospital more volume?

We Don’t Pay Hospitals and Doctors For What We Really Want Them To Do

When we’re injured, we want a hospital close by that is ready to treat the injury quickly and effectively. When we have the symptoms of a heart attack, we want a hospital close by that is ready to quickly and accurately determine if we’re having a heart attack and if so, to treat it quickly. If a disaster strikes our community, we want a hospital close by that can respond rapidly and treat all of those who are injured.

But we don’t pay hospitals to be there when we need them. We only pay them when they actually do something for us. If you’re not injured, the hospital doesn’t get paid for having the emergency room staffed and ready for you. If you don’t have a heart attack, the hospital doesn’t get paid for having a cardiac catheterization lab organized to ensure you have a low door-to-balloon time. If your community doesn’t have a disaster, a terrorist attack, a flu epidemic, or any similar unfortunate event, the hospital doesn’t get paid for the capacity it has created and the preparations it has made to deal with such events.

The hospital maintains a certain amount of standby capacity as a form of insurance for the community so it can respond to needs when they arise, and then it adds additional capacity in response to both actual patient needs and discretionary choices that physicians and patients make. However, Medicare, Medicaid, and commercial health plans pay only for the services provided, not the “insurance” of the standby services. As a result, the hospital has to treat enough patients in order to generate the revenues needed to cover its standby capacity, and that can lead to overutilization.

Not only do we expect hospitals to be there when we need them, we expect hospitals to care for people whether they can pay or not and to care for patients on Medicaid even if the Medicaid payment is less than what it costs to deliver care. As a result, hospitals have to charge the paying patients more in order to cover the losses they incur on the under-paying and non-paying patients.

Physicians face many of the same kinds of problems with current payment systems that hospitals face. What we really want a primary care physician to do is to keep people healthy, but a PCP isn’t paid at all if a patient doesn’t need office visits or if a problem can be handled over the phone. We’d like specialists to take the time to help patients decide whether they need a risky, invasive procedure, but if fewer patients choose to have the procedure, the specialists may not have enough revenues to cover their practice expenses, even though the patients may be better off. And if you think it’s only the hospital that needs to be available 24/7, imagine how the hospital will treat anyone during the night or on a weekend if there isn’t a physician available during those same times. However, physicians aren’t paid by Medicare or health plans to be available in case patients need them in the hospital, only hospitals pay them for that.

If doctors and hospitals do a better job of keeping patients well, they may need to be paid more for the patients who do get sick in order to continue covering the fixed costs of maintaining hospital standby capacity and the operating costs of physician practices. However, even with higher payment for individual services, overall spending can still be lower if fewer patients need expensive treatment.

Current Payment Reform Proposals Make the Problem Worse, Not Better

Although there is growing recognition that changes in payment systems are needed, most of the payment reforms being discussed or implemented by Medicare and commercial payers don’t really solve the problems with the current payment system and they may actually make some aspects of the problem worse.

  • Episode Payments Based on Procedures Reward Volume. Most of the episode payments and bundled payments being implemented by Medicare and commercial payers are triggered by a particular procedure in the hospital. The episode payment disappears completely if the patient doesn’t need to be hospitalized or if the hospital uses a different procedure to treat the patient, so the physicians and hospital are still penalized for reducing avoidable admissions and procedures.
  • “Shared Savings” Penalizes Providers For Lower Volume. If a hospital and physicians can avoid the need to admit a patient to the hospital, both the hospital and the physicians will lose 100% of the revenue they would have been paid for that patient, but their costs won’t decrease proportionately. Giving the hospital and/or physicians a shared savings bonus payment a year later will likely result in too little, too late to cover the costs the hospital and physician already needed to incur.
  • Shared Savings Programs Force Hospitals to Acquire Primary Care Practices. If a hospital successfully reduces readmissions, avoidable procedures, or infections and complications, none of the resulting savings will be returned to the hospital under most shared savings programs unless the primary care physicians for those patients are employed by the hospital. So under shared savings programs, hospitals are forced to hire primary care physicians, not to promote “clinical integration,” but merely to protect their own revenues.

The Right Approach: True Payment Reform

What’s needed are true payment reforms – accountable payment systems that give physicians and hospitals the flexibility to redesign care, reward them for keeping patients healthy, pay them adequately for treating the patients who do need care, and give them accountability for ensuring that costs are lower and quality is higher. Several different approaches to accountable payment systems could be used:

  • Condition-Based Payment. Under condition-based payment, doctors and hospitals would be paid based on the types of health problems the patient has, not based on the specific procedures used to treat them.
  • Partial Capitation. Under partial capitation, a hospital or physician practice would be paid based on the number of patients whose care they are managing, with additional payments made for expensive services based on the marginal cost of those services.
  • Risk-Adjusted Global Payment. Under a risk-adjusted global payment, a physician group, physician IPA, physician-hospital organization, or health system would have an overall budget for delivering healthcare services to a population of patients. The budget would be increased if the health needs of the patients increased.

All of these payment systems would support the ability of physicians and hospitals to deliver better care at lower cost. Although in most cases, solo/small physician practices and independent hospitals would not be able to manage these types of payments on their own, there is no need for them to merge or consolidate to do so. Physicians can work together through an Independent Practice Association and physicians and hospitals can work together through a Physician-Hospital Organization to manage accountable payment systems.

What About Prices?

While better payment systems are a necessary element of a solution to controlling healthcare costs, payment reform isn’t sufficient. In addition to payment systems that reward providers for keeping patients healthy rather than giving them more expensive treatments, we also need ways to ensure they keep patients healthy at the lowest possible cost.

Rather than forcing patients into payer-defined narrow networks, patients should have the responsibility for choosing providers based on both cost and quality. However, it’s impossible for patients to compare prices on the over 7,000 CPT codes and over 700 DRGs used in today’s payment system, particularly when they don’t even know for sure which of those services they’re going to receive. The accountable payment models described above would define prices based on a patient’s health problems rather than the procedures they receive, so patients can choose the physicians and hospitals that offer the best combination of price and outcomes for the specific health problems those patients are facing.

Right-Sizing Healthcare Delivery for Choice and Competition

Of course, consumer choice can only control prices if there are choices of providers available. If we design payment systems that do not require physicians and hospitals to consolidate into large systems, and if we remove unnecessary regulatory requirements that increase costs for smaller providers or prevent them from participating in better payment models, then it will be more likely that patients will have multiple providers to choose from.

Purchaser-Provider Collaboration to Find Win-Win-Win Solutions

Physicians and hospitals will need to collaborate to determine what the right amount of care is for a patient population and how much it will cost to deliver that care. Purchasers will need to implement new payment systems and patient benefit designs that support the better care that providers want to deliver. Consequently, payment reforms have to be designed in collaboration with providers, not imposed on them by payers. In many cases, all of the stakeholders can “win” – i.e., patients can get better quality care, purchasers can spend less, and providers can be more financially viable – if they work together in a collaborative way to design “win-win-win” payment reforms. Instead of purchasers and providers treating each other as the enemy, and focusing on ways to beat the other in a war over prices, they need to recognize that each can help the other win.

Fortunately, a growing number of communities have neutral conveners ready to help find win-win-win solutions. Regional Health Improvement Collaboratives – non-profit multi-stakeholder organizations focused on improving healthcare quality and reducing costs – can facilitate discussions between purchasers and providers and provide the objective data analysis both sides can trust in designing truly higher-value healthcare delivery and the payment systems needed to support it. Purchasers and providers need to recognize the value of this kind of service and use it to move to better payment and delivery systems as quickly as possible.

A more detailed discussion of the above points can be downloaded at: .


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Tuesday, February 18, 2014

How Should Congress Pay for Repealing the Sustainable Growth Rate?

A bipartisan, bicameral bill was announced earlier this month as the result of a joint effort by the U.S. House Energy and Commerce Committee, House Ways and Means Committee, and Senate Finance Committee to repeal and replace the Sustainable Growth Rate formula in Medicare. There is no other industry in America that tells its key professionals that their compensation will be cut by 25% at the end of each year regardless of whether they are doing a good job or not, but that’s what the Sustainable Growth Rate formula requires in the Medicare program. Repeal is long overdue and the members and staff of the Committees should be commended for advancing a solution in a collaborative way.

The key challenge now is how to pay for the bill. Unless Congress can find over a hundred billion dollars to cover the projected cost of the legislation at a time when the federal deficit is one of the biggest challenges facing the country, the superb work of the three committees will go to waste.

Although Congress is looking at ways to cut fees to other healthcare providers, cut services to Medicare beneficiaries, or make cuts in non-healthcare programs in order to generate enough savings to pay for the bill, a better solution is actually contained within the bill itself in a little-discussed section that encourages the development and use of “Alternative Payment Models.”

Alternative payment models for physicians can save a lot of money for Medicare while actually paying physicians better because the vast majority of healthcare spending doesn’t go to physicians. In Medicare, physician fee schedule payments represent only 16% of total spending in Medicare Parts A, B, and D. Over the next decade, the Congressional Budget Office projects that physician fee schedule payments will represent only 12% of total Medicare spending. However, physicians prescribe, control, or influence most of the lab tests, images, drugs, hospital stays, and other services that make up the other 88%.

Study after study has shown that if healthcare services are redesigned to improve quality and efficiency, tens of billions of dollars in healthcare spending could be saved every year by avoiding unnecessary tests, procedures, emergency room visits, and hospitalizations; by reducing infections, complications, and errors in the tests and procedures which are performed; and by preventing serious conditions and providing treatment at earlier and lower-cost stages of disease. If physicians are given the ability to redesign care for patients in a way that reduces unnecessary spending on all of the other services, the physicians could be paid more and still reduce total Medicare spending.

How much would physicians have to save Medicare in order to pay for the SGR repeal?

The Congressional Budget Office projects that Medicare Part A, B, and D spending over the next decade will total more than $6 trillion.[1]  The cost of repealing the SGR is currently estimated to be about $115 billion.[2]  However, that figure is unrealistically low, because it assumes that physicians would receive no payment increases over the next decade, even though they haven’t received any payment increases over the past decade. The very modest 0.5% increase in physician fees contained in the compromise bill would add another $20-$30 billion to Medicare spending, bringing the total cost of the repeal and updates to about $140 billion.[3]

$140 billion represents only 2.3% of total Medicare spending, and only 2.6% of the non-physician fee schedule spending. If physicians can reduce enough of the unnecessary and problematic spending in Medicare so that non-physician spending decreases by a mere 3%, they will have more than paid for the SGR repeal.

Alternative payment models are the key to this approach for a very simple reason. The current fee-for-service payment system poses major barriers to physicians who want to redesign care in ways that benefit patients and save money for Medicare:

• Today, physicians are financially penalized for reducing unnecessary services and improving quality. Under the current Medicare payment system, physicians lose revenue if they perform fewer procedures or lower cost procedures, even if their patients are better off. Most fundamentally, under Medicare, physicians don’t get paid at all when their patients stay well.

• Some high-value services aren’t paid for adequately or at all. Medicare doesn’t pay physicians to respond to a patient phone call about a symptom or problem, even though those phone calls can avoid far more expensive visits to the emergency room. Medicare won’t pay primary care physicians and specialists to coordinate care by telephone or email, yet it will pay for duplicate tests and the problems caused by conflicting medications.

Unfortunately, most of the “payment reforms” being pursued today don’t fix these problems. Pay for performance programs and shared savings programs have had very little impact on costs for a simple reason: the barriers described earlier aren’t solved by adding a small bonus or penalty on top of the existing fee-for-service system. Even tying payment to quality measures will have little impact on quality if physicians are forced to lose money in order to implement better care.[4]

Truly different payment models create “win-win-win” approaches to paying physicians that can help improve quality and reduce total healthcare spending without forcing physicians to take financial losses themselves. These accountable payment models have three key characteristics:

• They give physicians the flexibility to deliver the care patients need without worrying about whether the payment for one type of service is lower than another or whether they will lose revenue by performing fewer procedures.

• They give physicians accountability for ensuring that changes in care result in spending that is lower than it would otherwise have been, but this accountability is limited to the kinds of spending the participating physicians can actually control or influence.

• They separate insurance risk and performance risk, so physicians are not penalized financially for taking care of sicker patients or patients with unusually complex conditions.[5]

In order to use accountable payment models to pay for the SGR repeal bill, two things have to happen:

1. Accountable payment models need to be available in the Medicare program for every physician in every specialty; and

2.Those accountable payment models need to be designed by physicians in ways that will benefit patients and save money for Medicare, but also be feasible for physicians to implement.

Although CMS has done a lot of good work in advancing different payment models over the past several years, there are few alternative payment options available to most physicians today, particularly specialists. The only “payment reform” that exists as a formal Medicare program (rather than a demonstration project) is the Medicare Shared Savings Program, but as noted earlier, this is not really a payment reform, because it leaves the current fee for service payment system completely unchanged.[6]

The barrier to getting more alternative payment models in place faster is the belief that these models have to be “tested” in a demonstration program before they can be made available for physicians to voluntarily choose to participate in. However, demonstration projects take years to put in place and evaluate, and they are unlikely to show the true impacts of a significantly different payment model because physician practices are unlikely to fundamentally redesign the way they deliver care in response to a payment change that may only last a few years.

Over the past 30 years, the payment systems that Medicare uses for its largest areas of expenditure have been implemented without conducting a demonstration or evaluation in advance. For example, the Inpatient Prospective Payment System (hospital DRGs) was designed and implemented for most hospitals across the country without a demonstration. The RBRVS Physician Fee Schedule was implemented for all physicians beginning in 1992 after it was mandated by Congress in 1989, with no demonstration or evaluation of the payment system before it was implemented. These payment systems were implemented in a phased approach and then monitored and regularly adjusted to correct any unanticipated problems and to adapt the payment systems to changes in science, technology, and other factors that occur over time.

Similarly, accountable payment models can be implemented and then monitored and regularly adjusted to correct any unanticipated problems. Each accountable payment model would have to be explicitly structured to assure CMS that Medicare spending would be lower than it would otherwise be. There would be no need to evaluate such an accountable payment model in order to determine whether it will save money; the physicians would be guaranteeing that it would reduce the types of Medicare spending covered by the model if the physicians were paid under the accountable payment model. If at any point, CMS identifies a situation where quality is being harmed for a particular provider’s patients, or where spending is not truly being reduced, that provider’s participation in the payment model could be terminated, similar to what CMS can do today in its standard payment systems. If physicians find they can’t successfully manage under the new payment model, they could work with CMS to improve it or return to fee for service payment.

Not all physicians will have the ability to successfully participate in alternative payment models that guarantee savings to CMS, particularly during the early years of implementation. Consequently, current payment systems should not be completely replaced by any alternative payment model, but rather, physicians and other providers who wish to participate in such models should be given the ability to do so voluntarily, the same way that the Medicare Shared Savings Program is structured today for ACOs.

Many physicians, medical societies, and multi-stakeholder Regional Health Improvement Collaboratives have been working to develop payment models that are specifically designed to improve patient care and save payers money. There needs to be a mechanism for them to bring those models to CMS on an ongoing basis, have them rapidly reviewed and refined, and then put into place quickly. This will not only ensure there are enough savings to pay for the SGR repeal bill, but it will also enable the largest number of Medicare beneficiaries to benefit from higher quality care.

1. Congressional Budget Office. May 2013 Medicare Baseline. May 14, 2013.

2. Congressional Budget Office. The Budget and Economic Outlook 2014 to 2024. February 2014.

3. Projected costs or savings from other provisions have led to cost estimates above or below that amount for the individual bills reported by the Committees.

4. Miller HD. Ten barriers to payment reform and how to overcome them. [Internet] Pittsburgh, PA: Center for Healthcare Quality and Payment Reform; 2013. Available from:

5. Miller HD. From volume to value: Better ways to pay for health care. Health Aff (Millwood). 2009 Sept-Oct; 28(5): 1418-28.

6. Section 1899(i) of the Social Security Act allows the Centers for Medicare and Medicaid Services to implement accountable payment models other than shared savings, but it has chosen not to do so.



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Sunday, November 03, 2013

Which Health Plans Have the Best Provider Networks?

It’s the time of year when many people must choose a health insurance plan. Although the national news has focused on the problems people are having in signing up for coverage through the new federal health insurance exchange, thousands of senior citizens are also facing choices about whether to get their health coverage through the traditional Medicare program or one of many different Medicare Advantage insurance plans, and many workers with employer-sponsored insurance will have new choices to make during their open enrollment period.

Many people are being forced for the first time to evaluate different health plans based on which physicians and hospitals are “in-network,” because employers and health insurance companies are increasingly offering “narrow network” health plans in an effort to reduce premiums.

The dictionary defines a “network” as a “group or system of interconnected people or things.” Traditionally, most health plan networks haven’t really been coordinated systems, but merely lists of physicians and hospitals that have agreed to give a bigger discount to the health plan. However, research shows that patients can stay healthier and get better quality care at a lower cost if the patients use a true network of high quality physicians who work together in a coordinated way to deliver better outcomes.

What does such a “high-value” network look like?

The most important elements of a good network aren’t the hospitals, because the network’s first goal should be to help you stay well so you don’t need a hospital at all. Instead, the most important component of a network is an adequate number of high-quality primary care practices. A truly high quality primary care practice does four key things for you: (1) it helps you get the preventive care you need to stay as healthy as possible; (2) it accurately diagnoses new health problems you experience and then provides or arranges for the most appropriate treatment in a timely fashion; (3) if you have a chronic disease such as asthma, diabetes, emphysema, or heart disease, it helps you manage that chronic condition successfully so you don’t have problems and end up in the hospital; and (4) if you need specialists, the practice helps you find the right specialists and makes sure all of your care is coordinated.

Unfortunately, most people don’t get truly high-quality primary care in any network today. It’s not because the primary care physicians are bad, it’s because of the way the physicians are paid by the health plan. For example:

• If you’re frustrated by how little time your primary care physician (PCP) spends with you when you have a visit, blame your health insurance, not the doctor. Medicare and most health plans pay doctors on the assumption that a typical office visit will last only 15 minutes. Moreover, doctors get paid less if they address multiple issues in the same visit than if they bring you back multiple times, even though it would save you time and money to get everything done in one visit.

• If you’re angry because your doctor spends more time during your short visit typing on the computer than listening to you, blame your health insurance, not the doctor. Medicare and many health plans now reduce physicians’ pay if they don’t enter detailed data about you in an electronic health record.

• If you have trouble getting your PCP to answer the phone or respond to an email when you have a question or health problem, don’t blame the doctor, blame your health insurance. Medicare and most health plans won’t pay doctors for phone calls or emails with patients, they only pay for office visits. The more time a doctor spends on the phone, the less time he or she has to see patients in the office, but the only way anybody in the physician practice can get paid is if the doctor (or a nurse practitioner or physician assistant) sees enough patients in the office every day.

Some health plans are beginning to change the way they pay primary care physicians so the physicians can better customize care to what their patients really need. These “patient-centered medical home” programs are a step in the right direction, but most of them have been too small to make a significant difference. That’s starting to change, but not nearly fast enough. Fewer doctors are going into primary care because of their frustrations with the way they’re paid, so it’s going to be harder and harder for people to find good primary care physicians if health plans don’t start paying PCPs in better ways.

From time to time, you’ll have a health problem that requires help from a specialist. But which of the dozens of subspecialties is the right one? If you need multiple specialists, will they all coordinate what they do so you don’t receive conflicting medications or duplicative tests?

In a true “network,” your PCP would help you find the right specialists and work with them to ensure all of your care is coordinated. But once again, the way doctors are paid gets in the way. For example, in many cases, the specialist could advise you and your PCP over the phone about what to do, rather than making you wait for weeks or months until you can get an appointment to see the specialist in person. But Medicare and most health plans don’t pay specialists for giving advice over the telephone or by email, they only pay for office visits and procedures. As a result, many specialists can’t see new patients quickly because their calendars are filled with office visits from patients they don’t really need to see in person. Specialists also don’t get paid for time they spend talking with other specialists or with PCPs to coordinate care, so it’s no wonder that patients can find themselves falling between the cracks.

Some health plans are beginning to pay differently for the specialists in the “medical neighborhood” as well as for the primary care “medical home.” In one pilot project, paying for email consultations with specialists resulted in dramatic reductions in the delays seriously ill patients experienced in getting appointments with specialists, because the specialists were able to successfully address other patients’ problems quickly through an email exchange with their PCP.

If you do need hospital care, you obviously want to make sure there are high-quality hospitals in your health plan’s network that can take care of you. Unfortunately, the hospitals in our region don’t publish information about the quality of the care they provide, so it’s impossible to know whether one network’s hospitals are better than another’s. Although you hear a lot of advertising about how certain hospitals are the “best” at one thing or another, most of those rankings aren’t based on actual outcomes for specific procedures. The limited data available suggest that for common hospital procedures, most of the hospitals in the Pittsburgh Region deliver care of similar quality, and many of the independent community hospitals do it at a much lower cost. For more complex conditions, the best hospital for you may not be in the Pittsburgh Region at all. Some national employers, such as Walmart and Lowes, are now paying not only medical costs but travel expenses so their employees can go to hospitals such as the Cleveland Clinic and Johns Hopkins that have committed to provide high quality care at an affordable cost.

So before you decide which health plan to use, first choose a primary care practice that is committed to high-quality, patient-centered care. Ask the PCP which health plans pay to support high-quality care, and ask which plans pay specialists so they can work as a team with your PCP. If you choose a health plan that supports truly coordinated, high-quality primary and specialty care, you’ll be healthier, you’ll spend less, and you may never need to worry about which hospitals are in the network.

(A version of this post appeared as the Regional Insights column in the Sunday, November 3, 2013 edition of the Pittsburgh Post-Gazette.)


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Thursday, February 28, 2013

Payment Reform Barrier #3: Physician Compensation Based on Volume, Not Value

Changing the way Medicare and health plans pay provider organizations is necessary but not sufficient to support higher-value healthcare delivery.  The compensation system for the individual physicians and other healthcare professionals who work in those organizations also has to change.  Most physician compensation systems today, even for physicians who are “on salary,” are based on fee-for-service, i.e., the physician gets paid in part or in whole based on the number of visits they have or the number of procedures they perform.  If this compensation structure continues when the provider organization begins being paid under a new payment model, the physician will be penalized for reducing unnecessary visits and procedures even though the provider organization would be rewarded, and the physician will be rewarded for higher volume even if it hurts the provider organization’s bottom line.  It is difficult to imagine that Accountable Care Organizations can be successful if all of their member providers are still being based using fee-for-service.

Clearly, if payment systems are changed to reward value rather than volume, the compensation of individual physicians and other providers will also need to be changed to align with the structure of the new payment system, rather than with fee-for-service payment.  Rather than primarily basing compensation on “productivity,” physicians will need to be compensated based on factors such as quality, teamwork, and overall cost-effectiveness that will determine the provider organization’s success under the new payment system.

However, it is difficult for a provider organization to change its physician compensation system if only a subset of its payers have implemented payment reforms.  The factors that determine financial success under fee-for-service are, by definition, different from the factors that will determine success under new payment models, but if physicians are going to change the way they practice, they will do that for all of their patients, not just those covered by a particular payer.  If the majority of patients are not covered by reformed payment systems, the provider organization will be penalized for changing its compensation system, but if it doesn’t change its compensation system, its ability to succeed financially in caring for patients covered under the new payment system will be limited.  In short, trying to manage patient care under multiple payment systems can create a serious Catch-22 for physicians and their practices.

Aligning physician compensation with new payment systems can also be challenging because of federal and state laws designed to prevent fraudulent or abusive conduct under current payment systems.  For example, the federal Civil Monetary Penalty statute imposes financial penalties on hospitals that make payments to physicians as an inducement to reduce or limit services to Medicare or Medicaid beneficiaries.  The law has been interpreted by the Office of Inspector General at the U.S. Department of Health and Human Services as prohibiting such payments even if the services being reduced are not medically necessary or appropriate.  Consequently, gain-sharing programs designed to share savings with physicians when unnecessary services are eliminated could make a hospital liable for civil money penalties, as well as putting it in violation of the federal Anti-Kickback statute and the Stark law.

Congress has recognized that changes in fraud and abuse statutes will be needed in conjunction with new payment models. The federal Affordable Care Act authorizes the Secretary of Health and Human Services to waive these statutes in conjunction with the Medicare Shared Savings Program and projects undertaken by the Center for Medicare and Medicaid Innovation.  However, providers may be reluctant to revamp their compensation systems based on these kinds of temporary waivers.  Permanent changes to the fraud and abuse statutes are needed if payment reforms are to be successful.  In states that have enacted statutes similar to the federal laws, state legislatures will also need to make comparable changes.

(For additional details on this and other barriers to payment reform, download CHQPR’s report Ten Barriers to Payment Reform and How to Overcome Them.)



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Wednesday, February 13, 2013

Payment Reform Barrier #2: Expecting Providers to Be Accountable For Costs They Cannot Control

Many providers have been reluctant to accept episode-of-care payments and global payments because of concerns about their ability to manage significant financial risk.  Patient advocates may also oppose payment reforms that create financial risk for providers because of a fear that if providers take on responsibility for controlling costs, they will stint on services that patients need or avoid patients with significant health problems.

Although this barrier has typically been framed in terms of how much risk providers can take, the real issue is what type of risk providers can and should take.  If episode payments and global payments are structured in ways that give providers accountability for costs they can successfully manage, then providers will be more willing to accept them; conversely, if a payment system demands that providers take accountability for costs they cannot control, then the providers will either be unwilling to accept the payment system or, if they do, they could risk financial problems, which is what happened to many providers under capitation contracts during the 1990s.

There are two key ways to structure payments so that they give providers only the types of financial risk they can manage:

  • Separating Insurance Risk and Performance Risk.  First, a payment system should be structured so the payer retains the “insurance risk” (i.e., the risk of whether a patient will develop an expensive health condition) and the provider accepts the “performance risk” (i.e., the risk of higher costs from delivering unnecessary services, delivering services inefficiently, or committing errors in diagnosis or treatment of a particular condition).  Many of the problems with managed care in the 1990s arose because traditional capitation payment systems transferred both insurance risk and performance risk to providers, causing bankruptcies when providers took on care of many sick patients without any increase in payment.
  • Focusing on Costs That a Provider Can Control.  Second, a payment system should give a healthcare provider accountability for the types of services and costs that the provider can control or significantly influence, but not for services and costs over which the provider has little or no influence.  For example, primary care physicians are in a much better position to determine the appropriateness of services they prescribe than health plans are, so building accountability for utilization of prescribed services into physician payment is better than trying to control utilization through prior authorization and utilization review programs operated by health plans.  On the other hand, a payment reform system that only gives primary care physicians a bonus if there are reductions in the total cost of all services their patients receive from all providers goes too far in shifting accountability, since primary care physicians do not control all of the factors that drive the total cost of care for their patients.  (For example, assume that a primary care physician is able to significantly reduce the rate at which his or her chronic disease patients are admitted to the hospital for exacerbations of their chronic condition; if the subset of patients who are still admitted to the hospital develop serious infections or complications, total costs might increase, even though the primary care physician had been successful in controlling the aspect of utilization that he or she could influence.)

There are several ways to structure payment systems to give providers accountability for the costs they can control, without putting them at risk for costs they cannot control:

Risk Adjustment

A common way to protect providers from insurance risk is to make higher payments for those patients who have more health conditions or more serious health problems, i.e., to “risk-adjust” payments.  For example, in the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract, provider organizations receive a budget based on the number of patients they care for, but the budget is increased if the patients have more health problems, so the providers are accepting only performance risk, not insurance risk.

Some payers have raised concerns about using risk adjustment as part of a payment system because a patient’s risk score tends to increase as soon as they become part of a risk-adjusted payment system, and this can cause overall spending to increase rather than decrease.  This happens because, under fee-for-service payment, the diagnosis codes used for risk adjustment are only recorded when a related claim for treatment is filed; as a result, many health conditions are not recorded in health plans’ claims data systems (particularly if patients have recently changed health plans).  However, under a risk-adjusted payment system, the provider has an incentive to do complete coding of diagnoses, not just to ensure accurate payment, but to ensure that all of the patient’s health conditions are being managed in a comprehensive and coordinated way.  Rather than eliminating risk adjustment entirely to avoid this artificial increase in risk scores (which could thereby discourage providers from taking on sicker patients), risk adjustment systems should be modified so that both the baseline risk score and current risk score are changed when a patient’s pre-existing condition is identified and documented.  Broader use of electronic health records will help to address this problem by enabling risk adjustment to be based on complete clinical data on the patient’s past and current patient health conditions, not just on data recorded to support recent claims for payment to a particular health plan.

Current risk adjustment systems also need to be improved so they do not penalize providers for keeping their patients well.  A patient’s risk score is typically based on the health problems that a patient has today, not on how those problems have changed as a result of the health provider’s care.  So, for example, if a physician helps a patient lose weight or stop smoking, the patient’s risk score would decrease, and as a result, under a risk-adjusted payment system, the physician would receive a lower payment than if the patient had remained unhealthy, thereby penalizing the physician for a successful health improvement effort.  Improved risk adjustment systems that capture such changes over time will be needed, particularly if more providers and payers sign multi-year contracts to manage healthcare cost and quality.

Risk Limits

At best, risk adjustment is only a partial solution; no formula could ever be 100% accurate in predicting legitimate variations in costs, simply because of the myriad factors that can affect patient costs and outcomes.  To adequately protect both providers and patients, risk adjustment should be supplemented with risk limits, such as:

  • Outlier payments to cover unusually high costs for specific patients.
  • “Risk corridors” that require payers to provide additional payments to providers when the total cost of treating a group of patients significantly exceeds the agreed-to payment level.  The sizes and cost-sharing parameters for these risk corridors could vary from provider to provider, since larger providers will be better able to manage variation in costs, and the parameters could also be changed over time as providers become more experienced in managing costs.

Risk Exclusions

In some cases, it is clear that certain kinds of costs cannot reasonably be controlled by a provider, and rather than using risk adjustment formulas or other complex calculations to adjust for this, these costs (or the situations that lead to them) should simply be excluded from accountability altogether.  For example, the costs associated with patients who are seriously injured in accidents could simply be excluded entirely from a global payment model for a small group of physicians, and be paid for separately on an episode-of-care basis or under traditional fee-for-service.

In other cases, as noted earlier, a provider may be able to control certain aspects of a patient’s healthcare costs but not others.  Healthcare providers are far more likely to be willing to accept responsibility for the utilization and cost of services they deliver or prescribe themselves than services chosen by other providers.  (For example, primary care providers can influence the rate at which their patients go to an emergency room, but not the number of tests that are ordered once the patient arrives; emergency room physicians can influence the number of tests ordered in the emergency room, but not how many patients come to the emergency room for conditions that could have been treated by their primary care provider.)   To address this, payment to physicians in a particular specialty can be designed to only include the costs of the services that these physicians can control or significantly influence, while excluding the costs of other services.  (The payer would continue to pay for the excluded services on either a fee-for-service basis or through separate payment reforms designed for the other specialties).  In some cases, one provider may be willing to take accountability for whether a patient uses a particular service delivered by another provider, but not for the price of that service, particularly if the provider of the service is in a position to negotiate high prices or increases in prices; this can be addressed by making the accountable provider responsible for the utilization of the services, but excluding accountability for increases in the price of the services.

Providers will also be better able to accept accountability for controlling costs if their patients are supporting their efforts.  If a provider does not know until after the fact who their patients are, or if the patients’ insurance benefits do not give them the ability and incentive to help the provider change their care in ways that will improve quality and lower cost, then the provider may be unable to control some of the key factors that are driving increases in costs.  If the patients’ benefit structure cannot be changed to support a provider’s ability to control certain aspects of cost, then all or part of those costs could be excluded from accountability under the payment model.  (For example, if some patients spend part of the year living in another part of the country, but their health insurance will pay for them to receive elective procedures while they are away, the designated provider in their home community might only be expected to control costs of care during the time the patient is actually resident in the local community, rather than all of the costs incurred by those patients during the entire year.)

Arbitrated Contract Adjustments

It is impossible for anyone to predict exactly what will happen when payers and providers move to completely different payment models.  New drugs, new medical devices, and new ways of delivering care are being developed at a rapid pace, and these can either help or hurt providers’ ability to control costs and improve quality.  It is not surprising that there are typically long delays in negotiating payment reform contracts, since both payers and providers will try to anticipate all possible contingencies and incorporate provisions covering them in the contracts.

This problem will be exacerbated with multi-year contracts.  Multi-year contracts between payers and providers provide a better opportunity for providers to make changes in care delivery that take time to implement and to reap returns on investments in preventive care and infrastructure, and they give payers greater ability to control the trend in healthcare costs (for example, the Alternative Quality Contract developed by Massachusetts Blue Cross Blue Shield is a five-year contract that was designed to slow the growth in spending rather than achieve immediate savings).  However, the longer the contract, the greater the potential for unexpected events to occur, the greater the difficulty of building appropriate protections into a contract to deal with those unexpected events, and the greater the reluctance providers and payers will have to sign.

A solution to this is simply to acknowledge that unexpected events may occur and to provide for opportunities to make adjustments in the contract to deal with them.  Of course, the party which is disadvantaged by the unexpected event will be more interested in making an adjustment than the party which benefits from it, so the contract could provide for having a neutral arbitrator resolve any disagreements.


(For additional details on this and other barriers to payment reform, download CHQPR’s report Ten Barriers to Payment Reform and How to Overcome Them.)


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Wednesday, February 13, 2013

Payment Reform Barrier #1: Continued Use of Fee for Service Payment

Even though the serious problems with fee-for-service payment have been widely acknowledged, many “payment reforms” do not change fee-for-service payment at all, but merely add new forms of pay-for-performance bonuses or penalties on top of it.  Trying to fix a broken system merely by adding a new layer of incentives can be problematic for physicians, hospitals, and other healthcare providers, so it is not surprising that to date, acceptance of these types of payment changes has been slow, and where they have been implemented, the impacts on cost and quality have often been relatively small.

The Many Problems with “Shared Savings”

The most common payment change being implemented by Medicare and many commercial health plans today is “shared savings.”  Under the shared savings approach, Medicare or the health plan pays providers using exactly the same fees as they receive today for their services, and then pays a bonus (or imposes a financial penalty) on the providers if the total cost of services for their patients is less than (or greater than) the amount that would otherwise have been expected.

The fact that shared savings programs do not actually change the underlying fee-for-service system creates significant challenges for providers.  For example:

  • Today, Medicare and most health plans pay physicians only for office visits, not for phone calls.  If a physician can respond to a patient’s health problem over the phone, thereby avoiding the need for the patient to make a visit to the office, the physician will lose revenue.  Reimbursing the physician for a portion of the lost revenue through a shared savings program still penalizes the physician’s practice (recouping only a portion of the loss still results in a loss) and also creates a cash flow problem, since shared savings payments typically aren’t made until a year or more after the losses occur.
  • If better coordination of a patient’s care can avoid an emergency room visit or hospital admission, the hospital will lose all of the revenue for that visit or admission, but it will still have to cover the costs of having the emergency room or hospital bed available.  Giving the hospital a bonus or shared savings payment for lower admission rates can still penalize the hospital, since the portion of the lost revenues offset through the shared savings payment may be less than the fixed costs the hospital must continue to cover.

Having two or more providers participating in a shared savings arrangement creates a version of the prisoner’s dilemma:  if provider #1 makes a good faith effort to reduce unnecessary services but provider #2 does not, provider #2 would “win” by maintaining its own fee revenues while also potentially receiving part of the savings generated by provider #1.  If provider #2 increases its volume of services, it would receive more revenue and also thwart the opportunity for provider #1 to receive any shared savings to offset the revenue it lost.

The shared savings model is biased against hospitals which do not employ physicians, since under the most common shared savings approach, all savings are credited to the organizations where the patients’ primary care physicians work, even if the savings are generated through improved care or reduced utilization in the hospital.  Forcing hospitals to solve that problem by acquiring physician practices may simply lead to higher prices, not lower costs.

Another serious problem with the shared savings model is that once the shared savings contract between the payer and provider ends, any shared savings bonuses will also typically end; providers will still be in the same fee-for-service system they had before, but they will now have lower revenues if they have reduced the volume of fee-based services in order to obtain shared savings payments, and they may also be receiving lower fee levels for individual services if payment cuts are being made through other policies, such as the federal Sustainable Growth Rate formula.  In order to obtain continued shared savings payments in the future, a physician or hospital would have to find new sources of savings.  Providers may be unwilling to significantly change the way they deliver care or invest in better ways of delivering care if they can only reap the benefits of savings for a few years.

Some payers have made modifications to the payment system to try and address some of these problems, but in general, the modifications have not changed the underlying fee-for-service payment system in any fundamental way.  For example:

  • Many medical home payment programs provide a small, flexible, non-visit-based payment to primary care physicians to help them cover the costs of services that are not reimbursed directly through fees.  Although these additional payments are highly desirable and address some of the problems of fee-for-service payment, in most cases, the vast majority of the physicians’ revenue continues to come from visit-based fees.  Moreover, the amount of non-visit-based payment the practice receives in these programs may depend on how many fee-generating visits its patients make to the practice, which means that fee-for-service still represents the dominant incentive.
  • The CMS Innovation Center created an Advance Payment Program that makes upfront payments to small provider organizations that want to participate as Accountable Care Organizations in the Medicare Shared Savings Program.  These payments are very helpful, but they are only temporary, and they can only be used to help pay for the costs of new infrastructure or personnel, not to cover revenue losses the provider incurs due to changes in the way they deliver services that reduce fee-for-service payments.

Implementing True Payment Reform

True payment reform cannot be achieved by adding new layers of bonuses and penalties on top of what is still fundamentally a fee-for-service payment system.  Moreover, to be successful, a new payment system needs to be more attractive for providers than fee-for-service payment, not less, while still reducing costs for payers and improving quality for patients.

For most types of patients and health conditions, fee-for-service payment must be replaced entirely with a new payment system that gives providers (a) greater flexibility to deliver the best combination of services for the patient, and (b) the accountability to ensure the combined cost of those services is less than the payment amount (along with the ability to retain any additional savings generated indefinitely).

Examples of such better payment systems include:

  • “Episode-of-care” payments for acute conditions or procedures that give a healthcare provider a payment or budget to cover the costs associated with all of the care a patient needs for that condition or procedure.  Under this type of payment system, the provider has the flexibility to decide which services should be provided.  If the patient’s condition can be managed with fewer individual services or by substituting different services than are delivered today, the payment would remain the same, even if fee-based revenues would have declined, but costs will be lower.  As a result, payers will save money, while providers can actually improve their operating margins.
  • “Global” payments or condition-specific comprehensive care payments for overall management of patients’ healthcare that give a healthcare provider a payment or budget for the costs associated with all of the care a group of patients need for all or some of their health conditions.  The provider has the flexibility to choose the combination of services which will best help the patients address their healthcare needs, but the provider also has the accountability to ensure that the costs of all of those services remain within the global payment or budget amount.

Where these approaches have been used, both providers and payers have benefited.  For example, in the Medicare Acute Care Episode (ACE) Demonstration, which “bundles” physician and hospital payments (i.e., it makes a single payment to both providers, rather than separate payments to each), Medicare has saved money, physicians have received higher payments, hospitals have been able to reduce their costs and improve their operating margins, and patients have received better care.  The positive results from this program led the CMS Innovation Center to create its Bundled Payments Initiative, which will both allow additional providers to participate in the bundling approach used in the ACE Demonstration and allow providers to accept full episode payments for a variety of conditions.  This win-win-win approach – lower spending for payers, better care for patients, and better margins for providers – is only feasible with the types of significant payment reforms described above, not with minor tweaks to the fee-for-service payment system.

Some payers have begun implementing these kinds of true payment reforms.  For example, in addition to the CMS Bundled Payments Initiative, the Integrated Healthcare Association in California has created episode payment definitions for a number of different procedures that are being implemented by several different health plans and providers, and the Health Care Incentives Improvement Institute is implementing episode payments with providers and payers in several different markets.  Blue Cross Blue Shield of Massachusetts has implemented the Alternative Quality Contract, which gives a group of providers a risk-adjusted global budget to cover all of the costs of care for a population of patients.  In Medicare’s Pioneer ACO program, providers will move from shared savings to partial or full global payments in the third year.

However, much faster progress is needed in more parts of the country.  All payers need to make episode and global payments available to providers for as many types of patients and conditions as possible, as soon as possible.  To be successful, though, these payment systems need to be structured appropriately to give providers accountability only for the costs they can control, and they need to be accompanied by appropriate benefit designs.   If payment reforms are designed properly, there will be no need to mandate them; many providers will voluntarily accept a payment system that gives them the flexibility to deliver the best care to their patients and rewards them for high-quality care at an affordable cost without putting them at risk for costs they cannot control.

(For additional details on this and other barriers to payment reform, download CHQPR’s report Ten Barriers to Payment Reform and How to Overcome Them.)



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Monday, January 07, 2013

How to Save $5 Billion in Healthcare Spending for Employers and Taxpayers

In all of the many discussions about how to control healthcare costs, there’s one topic that you almost never hear about: maternity care.

Maternal and newborn care together represent the largest single category of hospital expenditures for most commercial health plans and state Medicaid programs.  That means that if there are ways to reduce maternity care costs,  insurance premiums for employers could be reduced and  Medicaid coverage could be more affordable for taxpayers.

Nobody wants to cut spending on maternity care if it’s going to harm mothers or babies, but there is at least one aspect of maternity care that’s not only expensive but bad for both mothers and babies, and that’s the high rate of Cesarean sections.  One-third of the 4 million babies born in the U.S are delivered by C-section rather than vaginal delivery.  That’s a 50% increase in the past decade.  In some states, the C-Section rate went up by 70 or 80%.

How much do all those C-sections cost?

A lot.  If the rate of C-sections were reduced back down to 15% (the rate recommended by the World Health Organization), it would save about $5 billion, based on data in a new report released today called The Cost of Having a Baby in the United States.   For commercially insured patients, the report shows that the average cost of a birth by C-section was $27, 866 in 2010, compared to $18,329 for a vaginal delivery.  Medicaid programs paid nearly $4,000 more for C-sections than for vaginal births.

The report also shows that there is significant variation in costs for each type of delivery both within states and across states, which means there are additional opportunities for savings.  The average payment by commercial insurers for a vaginal birth (not including newborn care) was $10,318 in Louisiana and $11,692 in Illinois, but payments were nearly 50% higher in California ($15,259) and Massachusetts ($16,888).  The average payment for a c-section was $13,943 in Louisiana and $15,602 in Illinois, but $20,620 in Massachusetts and $21,307 in California. There is also significant variation in costs for births even within individual states.  For example, although the average maternal cost for vaginal birth in Massachusetts was $16,888, 25% of vaginal births cost more than $19,000 and 25% cost less than $13,000.  (Although the study was not designed to determine the causes of this variation, other studies have shown that variation is due to different prices charged by different hospitals and clinicians as well as different needs of women and babies.)

Other findings in the report include:

  • Increases in the cost of care.  The cost of maternal care (not including newborn care) increased by over 40% between 2004 and 2010 for commercially insured women.
  • High costs for newborn care.  Total commercial payments for care of newborns were $5,809 for babies delivered vaginally and $11,193 for cesarean births.  Total Medicaid payments for newborn care were $3,014 for vaginal births and $5,607 for cesarean births.  Reducing the rate of prematurity among infants could significantly reduce these costs.
  • High charges for the uninsured.  Uninsured parents could be charged over $50,000 for a baby born by c-section and over $30,000 for a baby born by vaginal birth.  Average provider charges for a c-section in 2010 were $51,125, but commercial insurance plans only paid $27,866, 55% of what an uninsured patient could be asked to pay.
  • High costs of hospital-based delivery.  The largest share of all combined maternal-newborn costs goes to pay for hospital or other facility costs regardless of the type of birth.  59% of total maternal and newborn care costs for vaginal births are used to pay facility fees, and 66% of costs for c-sections are for facility fees.  Similarly, the hospitalization phase of childbirth consumed from 70% to 86% of all maternal and newborn care costs, depending on payment source and type of birth.  (Consequently, increasing the use of birth centers for women who want to use them can greatly reduce procedure use and healthcare spending while improving quality.)

There are many examples of physicians, midwives, hospitals, and birth centers around the country that are reducing maternity care costs in ways that improve quality and outcomes for both mothers and babies, a win-win for both payers and patients.   However, a major barrier to changes in care delivery is the current healthcare payment system.  Instead of being on what achieves the best outcomes for mothers and babies, payments today are based on what specific procedures were used.  Fortunately, there are better ways to pay for maternity care, such as paying a single amount for a delivery (regardless of the method used).  More information on payment reform and delivery redesign opportunities in maternity care are available from CHQPR’s website, and comprehensive information on how to improve maternity care is available from Childbirth Connection’s Transforming Maternity Care website.

Improving maternity care should be a priority for every state and region in the country.  It will both save money and improve outcomes for hundreds of thousands of mothers and babies every year.  What bigger win-win opportunity could there be?


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Friday, June 25, 2010

Putting the Cart Before the Horse on ACOs

Unfortunately, too many discussions about Accountable Care Organizations these days are putting the cart before the horse – defining an ACO based on its ability to participate in a particular payment model, rather than defining the payment system that will best enable an organization to become accountable for the costs and quality of care it delivers.

This wrong-headed approach has been encouraged by the way the federal Patient Protection and Affordable Care Act (PPACA) was written. Contrary to popular belief, there isn’t a section of the law titled “Accountable Care Organizations.” The provisions about ACOs are in a new section of the Social Security Act entitled “Medicare Shared Savings Program”. In other words, the law defines a payment method, and then defines ACOs as entities that can accept that payment method.

What we SHOULD be doing instead is identifying what kinds of changes care delivery systems can make to get better outcomes and lower costs, and then defining the payment changes needed to support those changes in care.

For example, a clear focus for ACOs should be reducing the rate at which people with chronic diseases are admitted to the hospital. We know that can be done. Study after study has shown that things like having nurses make home visits, encouraging patients to call their doctor early, and improving access to primary care practices on evenings and weekends can dramatically reduce ER visits and hospitalizations. But current fee for service payment systems don’t pay for the nurse care managers, they don’t pay doctors to talk to patients on the phone, and the payers don’t even tell PCPs how often their patients are being admitted to the hospital. So the obvious solution is to pay for those things, in return for PCPs accepting accountability for reducing admission rates.

Another example is hospital-acquired infections. Tens of thousands of people still get infections in hospitals, and some infection rates are going up, even though we know infections can be eliminated with appropriate protocols. But under current payment systems, hospitals lose money – a lot of money – when they prevent infections. Again, the solution is obvious – pay for care that has a warranty, the same way we pay for products and services in every other industry.

Those care delivery changes should be central to an Accountable Care Organization, and the priority should be creating payment changes that support those delivery changes. But most people in Washington aren’t talking about those changes. Instead, they’re mostly talking about “shared savings.” Unfortunately, shared savings does nothing to enable the PCP to afford to hire a nurse care manager; it provides no upfront money and only the uncertain prospect of future payments long after the PCP pays the nurse’s salary. Shared savings does little to change the fact that hospitals lose money by preventing infections or readmissions – losing less money is still losing money.

In fact, shared savings does nothing to fix any of the problems with the current fee-for-service system. In other words, shared savings isn’t really fundamental payment reform. It’s just another form of pay-for-performance (P4P), and a pretty weak form at that. And we know that pay for performance has shown very modest success in overcoming the powerful negative incentives built into the underlying payment system.

Shared savings can be useful if it’s paired with appropriate changes in the underlying fee-for-service structure. However, too many people are assuming that the “right” payment reform is merely shared savings on top of the current fee for service system, and nothing else.

Indeed, too many discussions about payment reform today are based on the erroneous belief that we have to give financial incentives to doctors and nurses to provide better care. The reality is that most doctors and nurses WANT to provide better care, they don’t need a financial incentive to do that. The problem is that the current payment system penalizes them for doing the right thing. So the key thing is to start paying for the right things and stop paying for the wrong things, i.e., remove the disincentives.

If we aren’t explicit about how we think care is going to improve and how payment changes will support that, what will consumers think when they hear that ACOs are fueled by “savings?” They’re likely going to assume the worst – that rationing is going to occur. And if we don’t ensure the payment system supports genuine improvements in care, some providers are going to use rationing as the way they create those savings.  If they do that, it will taint the ACO concept for everyone, the same way that bad versions of managed care in the 1990s led to the demise of good versions.

It’s also unrealistic to expect that providers are going to suddenly be able to manage the total cost of care when they haven’t been expected to manage any costs of care for decades. So if a small physician practice or an IPA comes forward and says “we’re willing to take accountability for some things – hospital admissions, ER visits, use of high-tech imaging,” we shouldn’t say “No, you can only be an accountable care organization if you’re able to take accountability for total costs right away.” In fact, we should do exactly the opposite: we should provide payment systems that enable them to tackle the costs that they can, and not penalize them for the costs they can’t control. Shared savings doesn’t do that, because it’s based on total costs: for example, even if a provider successfully reduces ER visits or preventable readmissions, if costs go up somewhere else – in a part of the system they have no control over – they may get no shared savings payment at all to cover the upfront costs they had to incur to achieve the successes they had.  That’s just another disincentive to change.

To make matters worse, even if a provider comes forward and says “I’m willing to take accountability for the total costs of care for a subset of my patients,” they won’t be able to do that, either. Why? Because under the shared savings model, Medicare will determine which patients the provider is accountable for through retrospective statistical attribution, i.e., the provider won’t know who its patients are until after the care has already been delivered.

Think about it – is it better to have only 10% of the providers in the country taking accountability for 100% of their costs while the other 90% are accountable for nothing, or is it better to get 80% of the providers taking accountability for 50% of costs (or whatever portion of costs they can control)? Simple math shows the latter is far better, but a pure shared savings is likely to result only in the former.

Fortunately, although the new Section 1899 of the Social Security Act is titled “Shared Savings,” a separate part of PPACA (Section 10307 of the bill) added language to Section 1899 giving the Secretary of HHS the “Option to Use Other Payment Models.” PPACA says that this can include partial capitation or “any payment model that the Secretary determines will improve the quality and efficiency of … services…” This provision deserves much more attention than it has received to date, because it provides the flexibility that the Medicare program needs to support the specific kinds of care changes that ACOs should be implementing.


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Tuesday, March 30, 2010

What a Difference a Little Time and the Right Goals Can Make

In a new article in the Journal of Hospital Medicine, David Mitchell, a hospitalist at Akron General Medicine Center, presents a superb example of the impact on healthcare costs clinicians can make if they’re willing and able to spend the time to do careful diagnosis and conservative testing/treatment.

His example is “an elderly woman who presents to the emergency room with syncope occurring at church.”

Hospitalist 1 “takes time to gather history from the patient, family, eyewitnesses, and the primary care physician, and requests a medication list and outside medical records, which reveal several recent and relevant cardiac and imaging studies. He performs a careful examination, discovers orthostatic hypotension, and his final diagnosis is syncope related to volume depletion from a recently added diuretic as well as a mild gastroenteritis. The patient is rehydrated and discharged home from the emergency room in the care of her family, and asked to hold her diuretic until seen by her family physician in 1 or 2 days.”

Total Cost: $935
Level 4 emergency room visit $745
Level 4 internal medicine consultation $190

Hospitalist 2 “tells the staff to get the patient a telemetry bed. He sees the patient 2 hours later when she gets to the floor. The family has gone home and the mildly demented patient does not recall much of the event or her past medical history. The busy hospitalist constructs a broad differential diagnosis and writes some quick orders to evaluate the patient for possible stroke, seizure, pulmonary embolism, and cardiac ischemia or arrhythmia. He also asks cardiology and neurology to give an opinion. The testing is normal, and the patient is discharged with a cardiac event monitor and an outpatient tilt-table test scheduled.”

Total Cost: $18,749
Level 4 emergency room visit $745
Level 3 history and physical $190
Laboratory evaluation: CBC, CMP, cardiac panel, urinalysis, D-dimer $843
EKG $150
Head CT $1426
Chest CT angiogram $2120
Brain MRI $3388
Echocardiogram $687
Carotid ultrasound $911
Level 4 neurology consult $190
Subsequent visits day 2, day 3 $150
EEG $520
Level 4 cardiology consult $190
Nuclear stress test $1359
Specialist subsequent visits $150
Telemetry bed, 3 days $3453
Discharge, low-level $90
Cardiac event monitor $421
Tilt-table test $1766


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