The CMS BPCI “test” is an unquestioned success, and the disruption story for the commercial insurance industry – and the benefit to consumers – will be big news before this decade ends. Billions in potential savings and a better healthcare experience for consumers makes it too important to wait.
The takeaway from Frakt’s article shouldn’t be about CMS’s methodology. Our data from more than 1,000 healthcare organizations shows recurring and consistent savings that average over 6%, significantly higher than the ACO program savings. And the patient stories are even more compelling.
This isn’t a question of whether episodes of care work – it’s about how quickly we can make them work everywhere. Commercial payers, encouraged to act by their employer customers, are implementing episode of care payment programs across the U.S., and we can thank the CMS experience for providing a clear path and metrics to measure success.
Beyond the academic discussion of study design lies the fact that there was little disagreement about the value of episodes, only about how much. There’s quantifiable proof, not disputed in the article, that episodes of care work, are a win-win for payers and providers and align perfectly with how consumers want to experience healthcare. Soon we’ll see the power of episodes nationally, across all health insurance segments, with new ways for employer health plans and consumers to participate.
1
The key comment in this article is that post acute care was reduced with bundled payments. Hospitals and clinics want to maximize their profits. They negotiate agreements for the lowest cost rehab and home health services they can get. This puts intense pressure on post acute care organizations. They appear to be doing joint implants on much younger people, who do not require the same level of support after surgery. Outcomes do improve, but is replacement really necessary at a younger age? Does this mean a blip in replacement surgeries 15 to 20 years from now?
I see many patients who have procedures done in Boston teaching hospitals and then come to a different, local, hospital for treatment of complications- pain, infection, bleeding, just not being able to make it at home postop... How would bundled payments deal with this?
One of the most important cost containment strategies is to restore punitive personal and corporate income taxes to frustrate greed-based decisions.
2
Putting limitations on studies and programs to lower costs (and therefore income for healthcare industry) is a form of sabotage.
Trying to save money on health care is like trying to save money going on vacation....the only way is to not do it....
2
Bundled care,100 patients @6$ apiece and a box of bandages do what you can.
In other words, save money by paying doctors less and less.
Starting in 1996 my Clinic started an IPA and partnered with Florida Blue Cross and the local hospital group. We were capitated and were given a target which we could keep 40% of the savings of the hospital $ pool. At that time we had written the electronic medical record with password protection and remote access. At that time the Tampa Bay Area was using 2200 bed days per 1000 patients per year. We hired consultants to help us allocate the capitation for the specialists and primary physicians. We had help to find our most at risk patients and developed systems to keep them healthy. Within a few months we were able to drop utilization to approximately 925 days/ 1000 per year. Our disenrollment rate was 1% because we did not withhold care. The hospital group had predicted and budgeted for 1600 days. After a few years they effectively pulled the plug on South Pinellas Affiliated Physicians. There are models to save money but the entrenched entities are unwilling to give up their revenue. See my article in Medical Economics co authored with an Economics Professor.
6
In Canada, we have a "bundle program". It's called "Universal Coverage". And yes, it's much cheaper. And yes, our government Pot Stores opening this fall will help fund it. I wouldn't call this an ideal world, but it's a step forward from sending people to jail for possession while letting others die from no coverage.
7
If you want to get costs down at Hospitals and Clinics you can start with the explosion of overhead that has developed since the 1970s.
An Army of suits- none with a background in any aspect of healthcare- have shown up and taken over the operation of hospitals. Their primary missions seem to be:
1- Reduce the number of licensed staff, the people who actually care for patients.
2- Increase their own numbers by adding more committees, boards, silly management programs and a never ending growth of metrics that often have little to do with improving patient care.
They cannot do anything as simple as start an IV, but have the unmitigated gall to tell licensed Medical Professional Staff how they should be able to constantly do more with less. They also constantly reduce clinical headcount while multiplying the overhead that never touch a patient.
Please publish the growth rate of overhead at hospitals and clinics in the US compared to the growth of clinical staff and Physicians compared over the last 4 decades. The numbers are stunning.
7
@David Gregory
I couldn't agree more, David! As a healthcare provider in particular, I would love to see those numbers.
The circumstances you cite seem to reflect the trend that has been occurring in many professional settings over the last few decades. It is certainly what has been happening in the realm of higher education--more and more administrators with inflated salaries and bonuses who seem to have the job of reducing and squeezing faculty and staff while creating more high-paid positions for people not directly involved in the work of educating. I suspect the numbers for this kind of top-heavy approach in universities would tell a similar story regarding the rapid rate of growth in the cost of obtaining a college education as that of the runaway costs of healthcare.
The rise in healthcare costs seems symptomatic of a much larger trend in this country contributing to the kind of social inequality we are experiencing where those at the "top" of the structure blame the actual providers of professional services and encourage initiatives to control those thought to be gaming the system. Who is really doing the gaming?
I hope that we can begin to focus on some of the very real problems driving up the cost of healthcare before we start restricting treatment and forcing healthcare providers to walk a fine line between choosing to be paid appropriately for their work or having to engage in malpractice by denying necessary diagnostic workups and/or treatment.
4
Bundling is a simplistic idea that would harm healthcare and jeopardize the survival of independent physicians.
Dividing the bundled payments would be intensely political and corrupting. What saves money is good preventive care and emphasis on healthy life choices.
Spending more money on healthcare intelligently will create many more productive and higher paying jobs in America and should be an economic goal. Spending less will harm the health care sector and our citizen’s health and will not be offset by better paying jobs in other fields.
Regulating pharmaceutical prices would be a much more reasonable way to make health care costs more affordable and should be a very high priority!
5
I'm an emergency doctor at a community hospital around 40 miles from a major urban area that has a lot of well known hospitals. We see many patients who have procedures at the big city hospitals but who show up in our emergency dept with complications of those procedures such as pain, bleeding, infection. =Bundling doesn't work so well when patients seek follow up care from doctors and hospitals different from those who did the procedure.
3
A lot of money in healthcare gets wasted in moving money around, and paying salaries of paperpushers compounded by the explosion in hospital administrators that never have the wellbeing of the patient in mind . A solution to healthcare necessarily involves addressing the above two issues. Make healthcare simpler. Allow physicians to compete for the patient’s care - offering cash pay options for medical services that bypass insurances. This would work out cheaper in many cases especially if hospitals are not allowed to overcharge for services. Why does the same procedure cost 1.66 times if it is done in a hospital versus if it was done in an ambulatory surgery center?
4
As a rehab practitioner, I find it interesting that this discussion is about almost everything except patient care. Here’s what I see: Joint replacement patients being sent home, to get a few sessions of home based PT, and then a few months of outpatient rehab 1-2 times/week (few actually do as much as they should) But here is what actually happens: Patients are rehabbed up to the point where they can minimally function with the help they have from others at home. They are sent home as soon as they can use the bathroom. They never regain full strength and are left weakened. Their gait remains impaired, stresses other joints, often causes pain and often sets them up for a fall. But none of those poor outcomes are attributed to the inadequate rehab! If the patient does not return to the hospital for 30 days, the surgery is considered a success! For whom? Clearly not for the patient.
14
Thank you for your comment which hits the nail on the head and rightly explains how this system is not really patient centered just money centered. I've had this experience with both of my parents.
In the first case my parent in his 80s had a hip replacement. He was admitted to a "renowned" rehab center. I went to the facility to meet the ambulance from the hospital and fill out the paperwork. Before he even set foot in the facility, before he was even evaluated I was told exactly how long he would be there (which I found strange) It made no difference what his functioning was or how fast or slow he would progress or his age and how much his muscles had atrophied. In other words it had very little to do with the patient it had everything to do with how much they would/could be reimbursed. In essence he was pushed to leave regardless if he was ready or fully functional.
In the second case my parent had in home rehab- again it was money centered. This was a woman in her 80s each session was maybe 20 minutes ( or less ). Because of the supposed progress (which wasn't there) they kept cutting back the number of sessions. It went from 3 times to 2 times to 1 time a week in a bit more then a months time.
In both aforementioned situations neither parent was satisfactorily rehabbed. In both cases I pushed unsuccessfully for additional rehab time. In both cases a lump sum for the "services" was paid to the facility or agency administering the "rehab" It's shameful
8
Bundled care increases the risk of inadequate care and shortcuts in the interest of "efficiency." Medicine is not like making widgets.
6
If these x-rays are from the same patient, the patient gained a LOT of weight prior to the surgery!
Swelling in the post op picture.
1
My patients tell me hospitals are trying to send them directly home alone without their permission and when it's unsafe medically, simply so they can keep the balance of the bundle. So it's not only 3% of patients, and this practice is not without harm. Hospitals have a huge incentive to keep the balance, and could care less about patient outcomes.
6
Most of our industries have reduced cost / increased efficiency by either shipping the jobs to the Pacific Rim or automating and laying off massive numbers of people. That's a tricky proposition for healthcare.
We all know of the obvious excesses, and the drive to upsell, the drive to increase volumes. The cost of medications.
But fundamentally, efficiency delivers more with less. Either we reduce paychecks or we increase workload. Or we reduce the overall amount of service provided, and the people who provide the service.
The reason we are having a hard time with healthcare is that too many people have a huge stake in not getting laid off. Fixing that? It will take a lot more than bundled hip replacements.
4
@Cathy
Healthcare has been an employment driver for many years. Unfortunately, a lot of those jobs are at insurers where healthcare professionals use their knowledge to make things more difficult for healthcare professionals to deliver actual care.
Dismantle the insurance industry (including those who work for providers to help those providers get paid) - and we dislocate many people and kill the job engine.
In the end, moving away from private insurance and all of its reimbursement games, will be the key to getting our healthcare costs under control. But success does not come without sacrifice.
7
Just a few thoughts. Med students are not going into primary care and why should they? To be told by a clerk at an insurance company what they can and cannot do. To be pressured into a large health care conglomerate. To accept smaller reimbursements from Medicare. Physicians unfortunately have missed their moment in time. They gave up
Their solo or small group practices and that was the beginning of the end.
9
Am going to just throw this out there. Capitation was introduced in Primary Care about 25-30 yrs ago. Set fee per patient, no matter how well or sick. Individual physicians had to be lucky and creative to cover office expenses. Shared risk turned out to mean primary care physicians held all the risk, insurance companies and patients none. When a patient assigned to a pcp moved to a new state and needed an organ transplant or stent, the insurer tried to claw back the out of network cost from the now not-attending physician. It got a little, a lot, messy. Bundling per event in a hospital setting might work. But am guessing someone, not a doctor, will figure out how to hold on to the cash, insurance execs will still have seven or eight figure annual compensation with stock on top, health group or hospital organizations will get a cut, and we still won't address access for all, infant mortality rates, sky-rocketing end of life care costs.
7
Interesting study. Conflicts of interest remain however, as physicians may try to justify what they do based on economics, and not necessarily on the need for a given procedure. The U.S. has shown to be more invasive than England, but not necessarily with better results, and certainly more expensive. It is a fact that we all, human beings, are corruptible when unsupervised and unregulated, as greed always lurks around the corner. Perhaps being on a salary (i.e. Mayo Clinic) may remove unnecessary conflicts of conscience, where monetary issues fade away as the main motivators...instead of the 'calling' required to serve patients, whose interests ought to be our main concern. If you want to enrich yourself, medicine ought to definitely not be the profession of choice.
1
Won't the "bundle" model encourage hospitals and providers to cut corners in treatment and procedures?
10
The Upshot doesn’t seem to look at fundamentals.
Our nation spends much more /capita than other nations because of our lack of a national disease care system.
Our costs and the problems faced by people without adequate coverage are caused by that.
I would love to see articles that detail the barriers to implementing a national disease care system with universal coverage in our nation. It could include summaries of the ways this was achieved in other nations around the world.
That would be truly worth my reading.
5
@Stephen Rinsler One of the barriers is the endangered species status of primary care physicians in the US after decades of attack by insurers, minute clinics, and data miners. Countries with universal coverage rely on large numbers of primary care physicians. US med students are not going into primary care.
2
Like many commenting, we have seen schemes of many types come and go, for me over a 57 year span and continuing. What works? Most work until fully understood and then they don't; people adjust to scheme with counter schemes. All legal, all ethical, all defeat the utopian expectations for the scheme.
What will work? When providers get their bonus when patient ills, diseases and precusors of diseases are reduce. An example: A1c measures go from diabetic range to non diabetic range. Pay for diagnosis and some for service but bigger payment for cure than maintenance. Weight control: obesity is curable for most people and requires patient work...as does diabetes elimination
The gist of success is when these disease drivers are slowed and stopped. Example:
a neighbor recently diagnosed with diabetes; he got a drug to help manage. His doctors said lose ten pounds it would help ((and for many such patients diabetes at this early stage can be reversed). I said, are you going to do it? He said, no it would mean giving up some of these deserts (a chocolate confection he was eating). And that it true.. He said, my metaforin (sp?) the doc prescribe will keep things in check. NOT TRUE, the disease mask a number of organ systems slowing losing their ideal function and while he may die before they break down, his care will be costly. And the payment scheme hardly touch this issue. Medicine merely manages decline. Until patients step up, we are in deep trouble.
9
@Monty Brown
My ex is the same way. Crippled with diabetes II, she still insists on having her ice cream in the evening. But I commiserate - it's not easy to grow old and lose life's pleasures.
1
Why must the practice of healing be a business?
As a practicing pediatrician for many years, I watched as HMO's appeared and the Business Model began to permeate office and hospital management. I watched as huge multi-story buildings appeared, proudly decorated with the names of health insurance companies and wondered just what these organizations were contributing to patient care. The answer is NOTHING.
Hospitals touted "win-win" situations and paid expensive business consultants with their suits and white boards. Unfortunately, using low-bid lab services and hiring lower level hourly workers to replace experienced professionals saved money but led to substandard care.
Office management and billing became more than cumbersome, requiring two to three additional clerical staff to comply with insurance barriers to care and reimbursement. Small personalized offices became huge anonymous businesses, eliminating the personal connection that is so essential to care and healing.
No, bundling care is just one more attempt to cram into a mold that works for retail sales the complex process of patient care. Until we remove third party profits from the system costs will continue to rise and patient care will continue to deteriorate.
18
Missing from the equation is the quality of outcomes long term. While healthcare systems might find a method of reducing costs using cheaper hardware and more attention to post-operative care for 30 days, what really matters is how the patient's quality of life - the ability to work and engage in personal activities - is improved long-term following the procedure. A new knee isn't much use if you are not able to function well a year later or have lingering pain management issues. Wouldn't it be a better investment to pay more to the healthcare team that has a large cohort back to work in 3 months and remaining problem free for 5-10 more years? Curiously, few providers track outcomes beyond their duration of financial burden.
The lay public has very poor concept of quality in medical care and cannot really fathom the major differences in outcomes between expert and non-expert providers. It's a lot more complicated than mortally and infection rates. Functional ability and pain free quality of life matters a whole lot to patients.
Without systems in place to track outcomes and pay for risk adjusted success, bundled system are purely economic experiments on the insured. While some programs make look successful to ideologically driven health care economists, I wouldn't claim success based on procedure and post-op costs alone. Healthcare systems payments should be based on true measures of quality with exceptional outcomes rewarded. Healthcare isn't a simple commodity.
6
If your goal here is to "Save Medicare Money", first, you're sadly mistaken in your priorities and, second, you are apparently prepared to ignore the experience of an entire planet and decades of health policy.
Universal, single payer insurance saves money. Lots of it. And results in health outcomes superior to those produced by our health-for-cash system.
You edge toward a Classic American Health Mistake: some monstrous amalgam of private business with lightweight concern for well-being.
HMOs are an excellent example of the travesty that results: "Sure, we'll pay for your kid's emergency life-saving procedure. You'll have to drive to Indianapolis (no, we don't cover travel), find a room, schedule your own appointment. Glad we could help."
As sage commenters noted, get rid of the health insurance cartel. All of it, down to the Venetian blinds. Good start.
Now, because you're health-woke, consider the hip and knee replacement studies you focus on here. Where does that come from, that interest in a few particular joints?
Could it be our pudgy, sedentary population, living in automobile deserts, strapped to their devices, snacking on avocado toast and milkshakes? With universal, single payer insurance, we could fix that for far less cash than new joints all 'round.
And now we can negotiate the cost of new knees and the medications that help them succeed.
Better outcomes, less money, no fake free market, happier people, better country, lower costs, too. We win!
10
Bundled healthcare payments like bundled mortgages? What a concept!
3
Another useless study wastes money, with NO benefit for patients, or doctors. Just admins get richer. We already know that.
"In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR." - so, how did the patients evaluate their care?
"In this observational study of Medicare beneficiaries" - what a waste of money. But, once Ezekiel Emanuel, Dr Death, all noise, no practice, is velcroed to it, there is nothing else one could expect. Patients beware.
5
It's terrific that writers with different view points reference parallel public and private systems in some European countries. (Germany, Netherlands, etc.) It's not terrific that writers don't research facts. Any accurate review on the topic would reveal that ALL of these nations have 1.universal coverage-every resident is covered 2.compulsory insurance (all risks are pooled together, so "risk selection" is eliminated at an overall national or regional level) 3.strict, federal regulation of pricing/profit, 4.strict regulation of benefits in both "public" and "private" systems. (Ironically, in Germany, once income is above a certain level, although folks are required to switch to a "private" insurance fund, prior polls showed that a majority preferred to stay in the public fund.)
There will always be some disparity of care in any system. But total absence of coverage for care for 30 million Americans?
Studies of bundled payments vs. widget system, or incentives to coordinate care, etc. are relevant and important. But a landscape of wasted health dollars diverted to profit, mega-mergers between wall-street traded heath industry players, opaque negotiations between drug makers and pharmacy benefit managers, prohibition of Medicare negotiating drug costs with bigPharma, non-transparent negotiations between huge provider groups and insurers can be changed if Congress creates universal medicare for all. And that will change the variables for lots of these academic studies!
10
There is no equity in healthcare. When the health provision of significant components of society is ignored and regarded merely as profit centers, how does progress occur? About twenty years ago the Institute of Medicine wrote about the role of racism in excess sickness and death in black America. They wrote about the importance of having available black providers for black populations. Nothing has changed. Black physicians are 4% of USA doctors. That was the percentage fifty years ago.
What is the ratio of black patients to whites in the over sixty five (Medicare) age group? The increased pre-sixty five mortality associated with unfavorable care cannot be ignored. Hospital Corporations certainly pay attention to decades of information as they position themselves for profit and increased political influence. Endemic racism.
3
How to really save money? Take insurance companies out of the equation. They had nothing but cost.
20
Single payer. All doctors on the same salary with no production incentives. All hospitals public funding. Not enough primary care doctors? Then put the primary care doctors and the surgical specialists on the same pay scale. Too much unnecessary surgery? Stop paying for it. The government and the insurance carriers will get what they pay for. If they pay for more surgery the patients get more surgery. Money and medical care do not mix.
8
I have been working in healthcare since the 80s and bundled payments do not work for good treatments of patients with different problems . Patients with the same diagnosis have different manifestations . Patients have to be treated individually and not according to a profit motive plan . The way healthcare can be more efficient is to decrease insurance companies involvement with cutting patients off from care and standardize payments for individual procedures . For example there is no reason why a 15 -30min dermatologic procedure should cost $7000 in one office visit .
27
Oh, my, "the next big thing"! I have been in health care for 40 years on the payer and delivery side and I have seen everything from HMOs, to PPOs to Point of Service, to ACOs, "consumer directed", you name it. Did not dent the overall increase in health care costs.
But all this is just fluff. The real problem is that we do not pay any attention to what health plans pay providers. It is too much and encourages inefficiency and ends up with outsized profits. Take four IU Health Hospitals in central Indiana. In the past five years they have made $4.7 billion in profits on $18.1 billion or 26%. How did this happen? Well the state's largest health insurer pays three times Medicare that's how! Most health plans in the US are under 200% of Medicare. So the people of central Indiana are paying through the nose for health care just so public benefit health systems can make outlandish profits.
You can read all about it here....
https://link.springer.com/article/10.1007/s10754-018-9249-9?wt_mc=Intern...
Sorry, it is a bit of a slog but its an economics paper. "The market" cannot fix the health care cost problem. Only regulation will work.
12
In these studies, do the patients know they are being treated under a ‘bundled care’ payment scheme? Do they know who/whom to call, write if their post-op care is....less, more than proper? Do they even know what post-op care should be in their case? Sounds like a recipe for delivering minimal care to unsuspecting patients if they are unaware and not contacted, educated on all aspects of this....experiment. On them.
9
I’m an Ortho Surgeon involved in a bundled care program for joint replacement. The short answer is “yes”, patients know they are involved because we spend enormous amounts of time trying to modify their comorbidities (weight, diabetes,etc) so their procedures go well and they stay out of the hospital after discharge.
One relative disadvantage of bundled care systems is that patients with morbid obesity and other chronic conditions don’t get surgery because their risk of readmission in the 30 day post op period is too high. Readmissions come out of the hospital and surgeons’ reimbursement.
7
@Craig in Orygun - Disadvantage? Sounds to me like a feature, not a bug! Fewer surgeries on high risk patients = lots of money saved by Medicare!
It's a great idea, but hard to implement as the outside PT or rehab facility is often outside of the direct control of the physician or hospital and they are a significant contributor to cost.
Or you could try allowing CMS to negotiate with drug companies. Oooh! There's an idea!
7
As long as greed and the profit motive are the engines behind health care, no program, no matter how well designed, can possibly work.
24
In the early 70’s I was an intern at Bellevue hospital in NY. If you wound up at that hospital you got treated - as necessary, without money. From people living on the street, to criminals, to the rich and famous who got sick on the sidewalks of New York. They all got taken care of. There were interns just out of medical school supervised by more experienced residents supervised as necessary by chief residents, fellows in subspecialties, and by NYU faculty physicians as needed. Anyone and everyone got the care they needed. Most patients were treated in large open wards, others in ICUs, some in a prison ward. No one praised the food. We learned nothing about money or finance. Private hospitals “dumped “ indigent patients on Bellevue and they were all taken care of. Bottom line, it worked!
One day as I walked home from Bellevue I passed a newsstand showing both Time and Newsweek announcing the advent of proprietary medicine. Healthcare was becoming business. From hospitals to Pharma to for profit everything.
Healthcare is certainly a utility, not a voracious winner take all business. Everyone one needs it sooner or later. It wasn’t always like this. We need leaders who can get big business out of medicine! LOCK THEM UP!
3
@EMW - great memories, the county hospital where I did my residency was exactly like that too. Good news is, it still is, as are all the city/ county hosptials ice worked in over the years.
Greed and profit do not drive the design, it's the design that drives greed and profit. There is a way out of greed and profit - change the design.
my health care provider attempts to control costs by attempting to look at the long term outcomes. Preventive treatment systems are well managed and effective.
3
I worked as a geriatric social worker in Philadelphia for 15 years. I saw people in all levels of care: hospital, skilled nursing, personal care, and home based. If there is one thing I can tell you for sure, it is this: if "bundled payments reduced the use of post-acute care", it's because some people were denied the post-acute care that they needed.
Studies can be designed and interpreted to support any position. Anyone who has worked with or is part of the target population can tell you it will mean denying care to people who need it. Those who live alone with few social supports will suffer the most.
21
Sadly, the economist is right; generalizing from an orthopedic problem to chronic and systemic illness isn't going to work. But even bundling this procedure could be trouble.
As an occupational therapist who used to work in post-acute rehab, Medicare patients come out of THR and TKR surgery in many different levels of need. If a facility or doctor are financially dinged for ordering pre and post-surgical rehab, the outcome might be limiting these services.
If the result is less mobility or more pain, it may not register as a "poor outcome" for Medicare.
It most certainly would be a poor outcome for the patient.
I am saving and investing now, years before Medicare, certain that I will have to pay out-of-pocket for therapies that will give me the best chance at a decent life.
12
People interested in learning more about the Medicare mandatory hip and knee model discussed here may want to check out the recently released independent evaluation report at https://innovation.cms.gov/initiatives/cjr. In addition to the full report, there’s a two page “Findings at a Glance” document (https://innovation.cms.gov/Files/reports/cjr-fg-firstannrpt.pdf). The report talks about the impact of the model on both costs and patient outcomes. It also discusses some of the approaches taken by the hospitals including improving how they do patient education before surgery to help identify opportunities for patients to safely return to the comfort of their own homes more quickly.
1
I know how we could reduce Medicare costs very quickly. Just pass the required statutes allowing Medicare to pay for medical treatments in other countries. Since most medical procedures cost twice as much on the USA as in any other country, any treatments farmed out to other national health systems would save 50 percent, give or take. The EU countries already have agreements to treat one another's citizens. I would gladly spend half the year in France or England or Germany and have my health care done there. Social Security is portable to foreign countries, and many US retirees live abroad. Those national health systems have rigorous billing and treatment standards, so I think this might even reduce Medicare fraud.
14
@cowboyabq
Great idea. It is a struggle for expats to get care or afford it in foreign countries. Why import a doctor or nurses from India or Pakistan to the US when the patients can go there? In fact, with medicare we often see Indian and Pakistani elderly coming to the US because they have younger relatives who have sponsored them who come simply for a total joint. They go right back home as soon as the surgery and post op care is done. We could reverse this process and simply pay the surgeons in their home areas when their kids sponsor them meaning putting them on Medicare.
1
I am happy to see that this issue is being covered on a national stage. Too many times, the conversation about health care and potential practical solutions to decreasing cost while preserving (or improving) quality are debated in generalization and political rhetoric.
Bundled payments in orthopaedics, in particular, are in their infancy but do show promise in forming comprehensive care models that have the potential to find inefficiencies and help patient experience.
I do worry about a potential "race to the bottom" as most of the incentives provided to hospitals and surgeons are based on decreasing cost from years prior. Also, despite the research presented in this article, I worry about potential cherry picking of healthy patients that carry a higher potential for savings and, thus, payouts, in turn, leaving patients who would benefit from surgery but have a less ideal medical profile without surgical care.
6
Northwester Memorial is a Medicare "bundling" hospital for hip and knee surgery. Despite the fact that I am 72 and live alone, I was told I would spend 1 or 2 nights in hospital after surgery and then go home for post-operative home PT and nurse care. I was never given the option to go to rehab as I was told I was to go home after 2 nights, despite not being ready to do so. Because I could not climb into my bed, I gained 18 lbs of fluid in my legs. It was not until the PT suggested an expensive lift chair to get my pegs above my heart (a $300 Medicare payment was possible had I had a doctor's prescription) that the fluid drained over the next 10 days. Whether due to Medicare's bundled payment or inadvertence and ignorance by the surgeon and his team (or both), I suffered a lot more than I should have. If bundling means cutting back care for those who live alone, then Medicare should offer options for those who need them
35
Until the United States will keep this “ for profit Wall Street managed “ fractured healthcare system , there is going to be no solution ..
Universal care for all , accessible and affordable, like Canada and Europe where healthcare costs are much lower and results much better .
Americans undergo plenty of unnecessary surgery and they are at the mercy of Big Pharma , that makes them the most overmedicated population of the world .
Prescription opioids crisis is typically American .
15
This sounds like just another half-hearted piecemeal plan to me so I have some questions:
How much is the consumer responsible for?
Is the consumer responsible for the difference in what insurance pays and what the provider charges?
Are all complications covered under the single fee?
Will this be extended to chronic medical conditions?
I am not very restricted in my everyday activities; I work full time; and I take no meds on a daily basis but I constantly worry that I will be bankrupt by paying deductibles, co-pays, and "differences" before I'm even old enough for medicare.
I pay monthly on every bill I get but I'm constantly hounded, by phone and mail, to pay the full amount immediately or larger monthly amounts.
I spend hours every month looking for and frequently finding erroneous and fraudulent charges on my bills. Then I spend additional hours haggling with the provider and my employer based insurance company.
I've stopped seeing the dermatologist, even though I've had skin cancer in the past; I refuse to buy the most expensive of the 4 meds prescribed for me; and I'm putting off a much needed joint replacement for now, possibly until I'm old enough for medicare.
I will likely vote for ANYONE who has an actual detailed workable plan for reducing or helping cover health care costs instead of pie-in-the-sky Trumpcare promises - remember those - better! cheaper!?
26
Remember Diagnosis Related Groups (DRGs)? The same arguments were made for these. The result was a protracted game of upcoding, preventing upcoding, modifying for risk factors and comorbidities, limiting payments for those, etc. For years, DRGs overpaid for everything, followed by years when the DRG payments did not even meet the cost of supplies for many procedures. The cost of administration skyrocketed, while quality fell due to a rush to push people into lower levels of care in order to maximize profits under DRGs. Every accounting approach to reducing medical costs seriously increases administrative costs. If they save money, a questionable proposition, they do so at the cost of decreased quality of care. Single payer is the system that would actually save money, by preventing all of this administrative waste. What currently gets diverted from health care to insurance company profits would also be saved. To understand why we refuse to learn this lesson, follow the money.
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One question: How’s it done in Europe, in countries with lower cost, universal, regulated health care? We continually discus and report on American health care as if we are unique. We’re simply brainwashed that we’re great and ignore how how care in America is big business and by (that is, by providers seeking personal wealthy) and for the wealthy. This author’s focus continues to be on gimmicks that only dance around the issue of a for-profit system not a care system.
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And we have a system characterized by perhaps 30% unnecessary care , alarming overuse of antibiotics, weak oversight of Big Pharma , and a GOP governing class is quite happy with the status quo because it serves their own, personal financial situation.
4
Lets look at less controversial areas to save money.
1- Administration costs-due to our complicated Insurance and billing we spend 30 % of our health care dollar on administrative costs. Much more then Canada. The average health care worker spends 20 hours a week dealing with administration of billing. Nurses spend 10 times the time Canadian nurses do on administration. Each doctor spends $83,000 on administrative costs each year, $60,000 more then Canada. Administrative costs in medicine are raising much more then medical costs.
Yes, we can save money by a single payer system.
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Our health care system is fragmented. Providers don't communicate, the EHR systems cannot communicate across their platforms, and patients, the ones about whom most of the communication is, are often left in the dark about who knows what about them and what they can expect on anything from bills to results.
We need a single payor system that covers everyone, that doesn't allow any one to balance bill, and that doesn't allow for opting out. Doctors with licenses are approved providers. This way patients don't have to worry every year that their "health" insurance is going to drop their internist, their children's pediatrician, the ob-gyn, or a specialist they need to see every few months.
It's time to stop avoiding the real issue here. Receiving health care, whether it's dental, eye, foot, or what is commonly accepted as health care, should not be an occasion of major stress when it comes to finances or making arrangements. Yet our politicians (and a great many others) refuse to accept what other countries have accepted: access to medical care is a human right. Change that and we'd get better results.
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@hen3ry
"We need a single payor system that covers everyone, that doesn't allow any one to balance bill, and that doesn't allow for opting out. "
That system really doesn't exist anywhere in the world. Pretty much every country has a private parallel system where the best doctors operate outside the nationalized system.
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@RIO
Thank you so much for pointing out that the" pie in the sky "foreign health care systems that everyone points to is a 2 tiered system. Government supported and then the private pay aspect of healtcare. You want it now...pay out of your own pocket.
@hen3ry
Why would anyone sane, repeat the "single-payer" errors of others?
https://www.wsj.com/articles/u-k-s-national-health-service-struggles-wit...
You want to waste money, that's on you, you waste your own money. Many refuse to repeat gross mistakes of others.
You could run the bundled payment study 100 different times with the brightest statisticians in the world and you would still not solve the problem, because any unethical hospital or doctor that knows it is being studied is going to behave differently then one that isn’t (i.e. the real world).
10
The problem is that different parts of medical care are provided by different providers: for example often the rehabilitation care is provided by nursing homes or rehab hospitals and the actual surgery is provided in a hospital. what this will do is encourage conglomeration of services. This means that a physical therapist will not have freedom to treat the patient with his/her own judgment: instead the surgical hospital will be controlling treatment: usually meaning that the reimbursement can be skewed. For joint replacements, especially, rehab and PT is enormously important. Unless Medicare absolutely specifies every step of the treatment required for the global payment and informs the patient of what should happen, there will be skimping on something.
Example: Friend was a retired naval captain of nuclear submarines. After retirement he consulted with private industry for nuclear power: ALL the private nuclear power providers wanted to cut corners on safety. Navy nuclear subs have NEVER had a nuclear accident. Private industry MUST increase profits quarterly: they can raise prices or cut costs. Cutting costs usually involves cutting quality, service, dependability, or safety.
Not acceptable in medical care. We MUSt go all in on medical quality and cut out the financial middle man. Private profit making on health care makes no sense.
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If only there were examples elsewhere in the world that already demonstrate how to deliver better outcomes at less cost.
Meanwhile, back to the drawing board: a better wheel is out there somewhere!
22
"Price control" is the only way to keep medical care costs down. We control the price of our utilities (electricity and natural gas) - why not do it for our medical care system? All the other efforts, including, "bundled payments," don't work. All the other advanced countries on the planet control the prices of their medical care and as a result have better outcomes at much lower costs.
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@John Booke
You have no idea of which you speak. The rest of the world largely runs two parallel health care systems public and private. If you have money, you pay extra for the best to skip the waiting lists for doctors and clinics in the private sector. Those prices are most certainly not controlled by a central government
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@RIO Rio
Please name the "advanced" countries that do not control "medical care" prices. We're not talking about third world countries that don't consider medical care a "right."
@John Booke
Y'all think you're going to dictate to MDs and PhD/MDs, what they are to do, and their pay? That's as obtuse as "only $2,500 a year."
You don't think, they'd move to Asia or Europe, if only to get away from HHS bureaucrats?
Time for mature adults to take over.
1
Wow. Well that is just a lovely, clear cut column about ways for Medicare to save money designed by people who know all kinds of statistics but never actually TREAT patients. Yes, replacing a hip or knee joint is a very straightforward procedure. The person having the surgery is unique. "Oh, my doctor said I didn't need PT. I'm fine, I just can't lie on that side anymore because it hurts." - 4 months after the surgery. "My doctor said I didn't have to go to PT right away." - as they arrive 2 months post knee replacement lacking 10 - 20 degrees of not only knee but also hip extension (should be 0 and 10 degrees respectively) and can't bend their knee past 70 degrees (should be 110) and the healing tissues are no longer amenable to lengthening in response to stretching. Don't even get me started on weak muscles. It's a great idea, if only it didn't mean less care equals more money for surgeons and corporate hospitals.
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@Been there, done that
When outcomes are included in the overall evaluation, doctors are incentives to ensure patient gets ALL appropriate follows up rehab.
I speak from recent personal experience. Friend's bundled package began PT 5 hours post-op with therapists who are part of physician team. She left hospital after one day, with a schedule of PT appointments already set. PT talks to docs routinely and doc monitors. 0T also included along with great RN pre-op and post-op extensive education. She also went home with everything she would need -- ice packs compressionsocksN all her OTC §d
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@KathyinCT
Comment cut off .. .
She went home with all OTC mess and products. Her post-op stay was not in a germ factory hospital but private suites in a building with an ER if needed. And nurse to patient ratio was 1:2 so superb care in hotel-like setting.
These surgeons created and manage whole program and they focus everything on OUTCOMES first. So fewer complications, readmissions etc. And flat rate is about 10% less than if they're were 5 different providers involved (surgeon. Hospital OR and room. PT. Anesthesia ).
BUT only for private insurance patients. MEDICARE needs to get on this bandwagon fast. Not appropriate for all pts or procedures but sure works here.
1