Affordable Care Organizations and Bundled Pricing

Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services’ Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty.

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As implementation of various measures unfold, research is necessary to determine the success of these models and the possibility of integrating them for arthroplasty patients.

Developing a bundle payment service line for arthroplasty procedures requires investment and commitment from all providers and institutions involved in the process of care delivery. There are several considerations that must be addressed when contemplating the implementation of a bundled reimbursement model. First, participants willing to provide care and to commit to the success of the program should be identified. The involvement of administrators, nursing coordinators, anesthesia providers, physical and occupational therapists, discharge coordinators, and PAC leadership, among others, is crucial for the program. Financial and legal representation may also be required for negotiations between various providers. The next step is to determine the capability of an individual organization to undergo a transition into bundled payments. Health care systems that include physician network groups allow for the coordination of care and risk distribution among providers within the network. Increased risk by hospitals and physicians can lead to substantial losses in a poorly managed service line. As such, a thorough historical analysis of claims data within a provider group is essential to determine the success of model implementation. If a particular provider or service line has a trend of increased costs over several years, then a bundle payment plan would be detrimental to the organization. It is recommended that cost analysis of providers be historically neutral or down-trending before developing a bundle payment model. The American Association of Medical Colleges also recommends that a minimum volume of 100 cases per year is essential to reduce the effect of variability and outliers on bundles. Once the decision to implement bundle payments reaches agreement between various stakeholders, the focus shifts toward determining the components of the bundle.

Affordable Care Organization Limitations

Care coordination is often challenging, and although theoretically appealing, there remains lack of evidence on positive impact of this approach on realization of cost reduction. Even with all the right tools in place, the implementation of ACOs carries considerable challenges. Pay-for-performance and shared savings programs may not lead to improved quality of care. Additionally, the ability of orthopedic surgeons to provide quality care coordination is highly dependent on the primary care physician, who acts as the central physician for all of the patient’s care. With a shortage of primary care physicians able to cover the large increase in patients eligible for Medicare, the surgeon’s role may be compromised. As such, there is a great need to establish patient care pathways that will improve efficiency and outcomes for beneficiaries.

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As implementation of various measures unfold, research is necessary to determine the success of these models and the possibility of integrating them for arthroplasty patients.

References

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