Avoid complications with bundled payment models
By Brian Eastwood
Just because an organization has a bundled payment agreement for a particular episode of care doesn't means that every patient who undergoes that procedure must be "in the bundle," as it were.
For example, high-risk patients who seek a knee or hip replacement could be moved out of the bundle and back into a provider's fee-for-service arrangement, says Thomas Aubel, director of medical payment strategy and policy for the University of Pittsburgh Medical Center (UPMC). This would allow the procedure to go forward without a provider worrying about whether it will "blow the bundle," Aubel says.
In such a scenario, providers must be careful not to use bundled payments as price controls to push out high-risk patient. It's important to consider the list of exclusions under a bundled payment model carefully, says Andréa Caballero, program director for Catalyst for Payment Reform. "When you're getting single payment, you want to minimize risk as much as possible," she says.
That's why progressive bundled payment models may choose to pursue more of a preventive approach, according to Elaine Daniels, senior strategic contract consultant with Blue Cross and Blue Shield of North Carolina.
Say a candidate for knee replacement has a body mass index (BMI) that exceeds the risk threshold for the procedure. Rather than simply say "No," a care coordinator could work with the patient to reduce his or her BMI--a positive development in and of itself--before the knee replacement occurs.
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Avoid complications with bundled payment models
