New Program Infiltrating the Medical Industry via the Affordable Care Act (ACA)
“You Now Have Entered the Bundle Zone”
A legally blind, hard of hearing woman over the age of 90 fell in her home and fractured her hip. She laid on the floor in her home for over two days before her neighbor found her and immediately phoned for an ambulance. The emergency medical team arrived and promptly transported her to the nearest hospital. After the general work-up in the emergency room, surgery on her hip was scheduled. The orthopedic surgeon who took the case, unbeknownst to the patient, was a doctor controlled by a relatively new type of value vs. volume Affordable Care Act rollout program…she has just entered the “Bundle Zone.”
The Affordable Care Act has appropriated $10 billon to push to reform the financing of healthcare. The expectations are steep as the goal is that half of the traditional Medicare payment to be directly tied to something that is called “Bundle Payments”. So what does that mean to the Medicare recipient? It means, changing modern healthcare to more of the Managed Care Model, i.e. an outside entity managing the care provided via a case management system. Here is a break down of the basics.
Bundled Payment Programs
- In October of 2015 formations began with a handful of entities, as many as 25 companies, taking on the task of developing, as they describe themselves, into an “episodes of care company”. In that same month it was announced that 1,600 participants had entered the Bundled Payment for Care Improvement (BPCI) program. It also includes 415 acute care hospitals, 305 physician groups and 723 skilled-nursing facilities. These companies took on the task of finding participants to engage in a test project to see if they could reduce the Medicare spending on certain treatments for specific diagnosis. For example, a fractured hip would be the diagnosis and the treatment for that condition would be outlined and followed on each case no matter the outlying circumstances. The month following the Center for Medicare and Medicaid Services released its final rule for a Compressive Care for Joint Replacement initiative which is a mandatory bundled payment program for total hip/knee replacement in 67 metropolitan area with the number of hospitals growing to 789 by April 1, 2016.
- Bundled Payments are fixed prices that are agreed upon between the center for Medicare and Medicaid and a particular health care provider. One of the highest costs to Medicare are joint replacements. Bundled payments sets a single spending target for applicable services, or what could be called a flat fee for service, which consists of the initial hospital stay, the physicians service, any outpatient services such as home health or post acute care in addition to the cost of readmission if the situations warrants. The payment program is set up to appear to have an option of a built in financial incentive that encourages providers to work together for a more efficient cost effective outcome. The challenge with this set up is that each case is different, especially when considering the many challenging conditions the individual has when their age is over 85. To expect a patient to recover from a joint replacement surgery within 8-9 days post surgery is potentially possible when you are 50 or 65, but not so much at 90 years old.
- The companies that manage the bundle payments make it their “job” to follow the client throughout their stay, and just to be clear, following the client translates into calling or emailing the providers of services reminding them they need to have their “treatment” over in a certain number of days. In dealing with the “episode of care companies” they don’t make it their practice to visit their clients, review their records, attend care planning sessions. Just the calling and emailing to push to keep the days down and focus on the financial incentive to meet the goal of short stay and reduced cost to the insurance company.
“A Bundle of Barriers”
The hip surgery was a success, afterward, the 90 year old patient was referred to rehabilitation where she was provided physical and occupational therapy. The start of the 9-10 day clock began to tick. Up out of bed, exercise, eat, more exercise, eat again, now mediation, doctor visits, tests, measurements and each day the countdown continues. PUSH PUSH PUSH. The patients frail aging body was healing, yet her schedule rigid and overwhelming. At one point, the patient had to be readmitted to the hospital for an exacerbation of a coexisting condition due to fatigue. The therapy, nursing and social service workers were all under pressure to “get her discharged” to make the 9-10 day goal. Changes to Medicare are necessary, understood, yet each patient should be afforded the opportunity to access treatment and services based on their need, not some number of days to recover. Before elective or unscheduled procedures, ASK your surgeon “ARE YOU PART OF A BUNDLE PROGRAM”. If so, what is the number of days YOU are given to recover? Think long and hard, maybe another surgeon not engaged in the bundle program is a better choice. Remember YOU are in charge of your wellbeing.