Becker's Hospital Review

27 Executive Briefing: Bundled Payments For over a decade, DataGen has been an essential partner to healthcare organizations across the country, providing actionable information, insight, and analytics that enable hospitals and healthcare systems to strengthen financial and quality performance while preparing for reform. Drawing on our specialized health policy and payment expertise, as well as in-depth understanding of the power of analytics to drive change, DataGen transforms complex healthcare policy and payment data into actionable information. The first scenario would appear to be the preferred care pattern, and it is very common. However, patients experiencing symptoms of a heart attack may present at any hospital emergency room. It is not always apparent upon patient intake that the diagnosis will be an AMI and that the treatment will require a PCI — that is why the second scenario is also common. The question in those instances is whether full payment for that first inpatient stay is appropriate, given that the patient is receiving further care for the same heart attack at another hospital. The long LOS data for these cases may indicate that services and care are needed to stabilize the patient, or it might indicate the need to wait until the transfer hospital can schedule the PCI. The administrative data do not provide enough detail to fully examine the medical efficacy of a complete AMI inpatient payment when it is followed by a PCI inpatient stay; this requires further studies and interviews for more definitive commentary. The area with the most opportunity for care redesign and program savings is the third patient care scenario — hospitals that are li- censed to perform PCIs but transfer a patient to another facility for the procedure. It would appear that in these instances, either the patient is choosing to receive the intervention at another hospital, perhaps a specialty hospital, or the initial hospital does not have a full-time interventional cardiology program. This too requires further study about why these transfers occur — for example, whether they are being performed after hours or on weekends — but the potential is evident and could have significant implications for public health policy related to part-time surgical coverage. Implications and considerations for provid- ers accepting risk There are a number of important lessons to be learned from this targeted and limited data review: • Providers need to look at and use data in a new way. Care redesign and true program savings can only be accomplished when the entire episode of care is examined — not just the in- patient hospital cost — and patients are at the center of that care. Whether it is bundled payments, accountable care, medi- cal homes or any other risk-sharing arrangement, the emphasis is always on managing the whole episode. • Hospitals should be cautious about engaging in episode payments for diagnoses, such as AMI, that may require a procedure not performed on a full-time basis within the hos- pital or for which specialty hospitals are in close proximity. In the case of AMIs and PCIs, hospitals that do not perform this procedure, or do not have a full-time interventional cardiology program, are at a disadvantage when it comes to clinically and cost-effectively managing care. • It is essential that providers accepting risk through new payment models identify the most clinically appropriate and cost-effective settings for post-acute care. This requires an examination and comparison of outcomes (e.g., readmis- sions) and costs of the post-acute care options available, and then communicating those findings to physicians and other clini- cians who are accountable for managing patient care. n Providers need to look at and use data in a new way. Care redesign and true program savings can only be accom- plished when the entire episode of care is examined — not just the inpa- tient hospital cost — and patients are at the center of that care.

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