1. Bundled Payment: Effects on Health Care Spending and Quality

1. Bundled Payment: Effects on Health Care Spending and Quality PDF

Author: U. S. Department Human Services

Publisher: Createspace Independent Pub

Published: 2013-03-21

Total Pages: 156

ISBN-13: 9781483925677

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This review is part of the Closing the Quality Gap: Revisiting the State of the Science series, which aims to provide critical analysis of the existing literature on quality improvement strategies for a selection of diseases and practices. The review focuses on “bundled payment,” a strategy for health care quality improvement and cost containment. This strategy has been the subject of increasing interest, with the Centers for Medicare & Medicaid Services announcing a large national bundled payment initiative in August 2011. Other reviews in the series will address a range of quality improvement topics arising from portfolios (areas of research) of the Agency for Healthcare Research and Quality (AHRQ). We define “bundled payment” as a method in which payments to health care providers are related to the predetermined expected costs of a grouping, or “bundle,” of related health care services. In contrast, fee-for-service payment typically involves payments for individual services, while capitation involves a single per capita prospective payment for all services over a fixed period of time, regardless of the number of services or episodes of care provided within that period. Within the bundled payment model, a variety of specific payment methods are possible. Bundles may be defined in different ways, covering varying periods of time and including single or multiple health care providers of different types. In addition, given the diversity and complexity of the U.S. health care delivery system, bundled payment programs may be implemented in a variety of contexts that may influence their effects on spending and quality. Bundled payment should create a financial incentive for providers to reduce the number and cost of services contained in the bundle. Providers are typically given discretion over the allocation of the services used to treat the patient's episode most effectively. This flexibility may encourage providers to use resources to coordinate care; often, these services are not reimbursed under fee-for-service payment. If the bundle includes services delivered by multiple providers in multiple settings, providers have to create a mechanism for managing the shared payment for a given treatment or condition, which could also foster coordination. Several types of undesired effects of bundled payment have also been postulated. The most significant potential undesired effects include underuse of effective services within the bundle, avoidance of high-risk patients, and an increase in the number of bundles reimbursed (increasing health spending). Providers under bundled payment may “game” the system by changing coding practices to maximize reimbursement for the bundle (“upcoding”) or by moving services in time or location to qualify for separate reimbursement (“unbundling”). This review was designed to address the uncertainties about the effects of bundled payment on spending and quality measures. It should help readers (1) understand what the evidence shows about the effects of bundled payment on health care spending and quality of care, and (2) understand key design and contextual features of bundled payment programs and their association with bundled payment effects. The review addressed three Key Questions: 1. What does the evidence show on the effects of bundled payment versus usual (predominantly fee-for-service) payment on health care spending and quality measures? 2. Does the evidence show differences in the effects of bundled payment systems by key design features? 3. Does the evidence show differences in the effects of bundled payment systems by key contextual factors?

Variation in Health Care Spending

Variation in Health Care Spending PDF

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2013-10-01

Total Pages: 207

ISBN-13: 030928872X

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Health care in the United States is more expensive than in other developed countries, costing $2.7 trillion in 2011, or 17.9 percent of the national gross domestic product. Increasing costs strain budgets at all levels of government and threaten the solvency of Medicare, the nation's largest health insurer. At the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent. In fact, underuse, misuse, and overuse of various services often put patients in danger. Many efforts to improve this situation are focused on Medicare, which mainly pays practitioners on a fee-for-service basis and hospitals on a diagnoses-related group basis, which is a fee for a group of services related to a particular diagnosis. Research has long shown that Medicare spending varies greatly in different regions of the country even when expenditures are adjusted for variation in the costs of doing business, meaning that certain regions have much higher volume and/or intensity of services than others. Further, regions that deliver more services do not appear to achieve better health outcomes than those that deliver less. Variation in Health Care Spending investigates geographic variation in health care spending and quality for Medicare beneficiaries as well as other populations, and analyzes Medicare payment policies that could encourage high-value care. This report concludes that regional differences in Medicare and commercial health care spending and use are real and persist over time. Furthermore, there is much variation within geographic areas, no matter how broadly or narrowly these areas are defined. The report recommends against adoption of a geographically based value index for Medicare payments, because the majority of health care decisions are made at the provider or health care organization level, not by geographic units. Rather, to promote high value services from all providers, Medicare and Medicaid Services should continue to test payment reforms that offer incentives to providers to share clinical data, coordinate patient care, and assume some financial risk for the care of their patients. Medicare covers more than 47 million Americans, including 39 million people age 65 and older and 8 million people with disabilities. Medicare payment reform has the potential to improve health, promote efficiency in the U.S. health care system, and reorient competition in the health care market around the value of services rather than the volume of services provided. The recommendations of Variation in Health Care Spending are designed to help Medicare and Medicaid Services encourage providers to efficiently manage the full range of care for their patients, thereby increasing the value of health care in the United States.

Medicare for All

Medicare for All PDF

Author: Abdul El-Sayed

Publisher: Oxford University Press, USA

Published: 2021

Total Pages: 369

ISBN-13: 0190056622

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A citizen's guide to America's most debated policy-in-waitingAfter languishing for decades on the fringes of political discussion, Medicare-for-All has quickly entered the mainstream debate over what to do about America's persistent healthcare problems. But for most informed Americans, this surge of public and political interest in Medicare-for-All has outpaced a strong understanding of the issues involved. This book seeks to fill this gap in our national discourse, offering an expert analysis of the policy and politics behind Medicare-for-All for theinformed American.

Handbook Integrated Care

Handbook Integrated Care PDF

Author: Volker Amelung

Publisher: Springer

Published: 2017-06-30

Total Pages: 578

ISBN-13: 3319561030

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This handbook gives profound insight into the main ideas and concepts of integrated care. It offers a managed care perspective with a focus on patient orientation, efficiency, and quality by applying widely recognized management approaches to the field of health care. The handbook also provides international best practices and shows how integrated care does work throughout various health systems. The delivery of health and social care is characterised by fragmentation and complexity in most health systems throughout the world. Therefore, much of the recent international discussion in the field of health policy and health management has focused on the topic of integrated care. “Integrated” acknowledges the complexity of patients ́ needs and aims to meet it by taking into account both health and social care aspects. Changing and improving processes in a coordinated way is at the heart of this approach.

Leadership and Systems Improvement for the DNP

Leadership and Systems Improvement for the DNP PDF

Author: Gail Armstrong, PhD, DNP, RN, ACNS-BC, CNE

Publisher: Springer Publishing Company

Published: 2019-08-12

Total Pages: 368

ISBN-13: 082618863X

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Develop the necessary skills to serve as a leader in systems improvement This unique, practical text will help DNP students develop the leadership skills needed to effectively implement and sustain meaningful change in the healthcare system. Presenting improvement methods within the framework of leadership, the book helps students to understand the practical applications of their education. Beyond orienting students to the work of the DNP, the text helps them to understand the scope of practice and how it is related to larger issues and challenges within healthcare. A significant portion of the text is devoted to leadership, particularly from a systems perspective. Using cases and examples, it addresses different ways DNPs can lead in healthcare and elaborates on the types of improvement processes that are initiated by DNPs: translation of EBP and research into practice, process improvement, and program evaluation. The book discusses how improvement is measured and offers several chapters on the DNP project, including its financial implications. PowerPoint slides accompany the text along with an Instructor’s Guide, which provides tips on how instructors can help students assimilate the large body of knowledge required in the DNP program. Key Features: Frames content within the context of leadership Prepares DNPs to serve as leaders of innovation in healthcare Offers an innovative approach to understanding the DNP leader and the DNP project Delivers up-to-date information about improvement work in healthcare systems specific to the needs of DNP students and graduates Includes practical cases and examples Distills resources that faculty and students will return to again and again

The Effects of the DRG-based Prospective Payment System on Quality of Care for Hospitalized Medicare Patients

The Effects of the DRG-based Prospective Payment System on Quality of Care for Hospitalized Medicare Patients PDF

Author:

Publisher: Rand Corporation

Published: 1992

Total Pages: 343

ISBN-13: 9780833012203

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In 1983, in an effort to control rising health care costs, the federal government established a prospective payment system (PPS) to reimburse hospitals for inhospital care of Medicare patients. Under PPS, hospitals are paid an amount based largely on flat rates per admission calculated for each of approximately 470 diagnosis-related groups (DRGs). This new payment system has been somewhat successful at slowing the upward spiral of Medicare costs. However, because PPS presents incentives to decrease lengths of stay and to substitute lower-cost services and procedures, patients, physicians, and policymakers are concerned that, despite the introduction of monitoring by professional review organizations, the quality of health care given Medicare patients may have declined under PPS. This report assesses the quality of inhospital care for Medicare patients age 65 and over, before and after the implementation of PPS, and estimates the effects of the PPS intervention on quality of care, by comparing quality of care now with the best estimate of what it would have been without PPS. Specifically, the authors describe the study's design, sampling, and fieldwork; discuss changes in sickness at admission following the introduction of PPS; consider measurements of the quality of care using explicit criteria before and after implementation of the PPS; compare changes in quality of care between 1981 and 1986 for five diseases as measured by implicit review; and discuss PPS and impairment at discharge.

Handbook Integrated Care

Handbook Integrated Care PDF

Author: Volker Amelung

Publisher: Springer Nature

Published: 2021-07-12

Total Pages: 1212

ISBN-13: 3030692620

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This handbook shares profound insights into the main principles and concepts of integrated care. It offers a multi-disciplinary perspective with a focus on patient orientation, efficiency, and quality by applying widely recognized management approaches to the field of healthcare. The handbook also highlights international best practices and shows how integrated care can work in various health systems. In the majority of health systems around the world, the delivery of healthcare and social care is characterised by fragmentation and complexity. Consequently, much of the recent international discussion in the fields of health policy and health management has focused on the topic of integrated care. “Integrated” acknowledges the complexity of patients’ needs and aims to meet them by taking into account both health and social care aspects. Changing and improving processes in a coordinated way is at the heart of this approach. The second edition offers new chapters on people-centredness, complexity theories and evaluation methods, additional management tools and a wealth of experiences from different countries and localities. It is essential reading both for health policymakers seeking inspiration for legislation and for practitioners involved in the management of public health services who want to learn from good practice.

Health-Care Utilization as a Proxy in Disability Determination

Health-Care Utilization as a Proxy in Disability Determination PDF

Author: National Academies of Sciences, Engineering, and Medicine

Publisher: National Academies Press

Published: 2018-04-02

Total Pages: 161

ISBN-13: 030946921X

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The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.

Best Care at Lower Cost

Best Care at Lower Cost PDF

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2013-05-10

Total Pages: 437

ISBN-13: 0309282810

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America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost. The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009-roughly $750 billion-was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances. About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care. This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.

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