Posts Tagged ‘episode-based payments’

Infographic: Maternity Episodes of Care

January 16th, 2017 by Melanie Matthews

Maternity Episodes of CareThe cost of maternity care varies significantly by payer (commercial or Medicaid), by type of birth (vaginal or cesarean section), and by setting (hospital or birth center). Too often, women are not experiencing optimal outcomes in maternity care despite the significant resources spent, according to a new infographic by the Health Care Payment Learning & Action Network.

The infographic examines how an episode of care could be applied to maternity care—from an episode timeline for prenatal through postpartum care; episode parameters; operational considerations; and maternity care design elements.

Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) has awarded $3 million to 51 specialty medical practices as part of a shared savings arrangement through the company’s Episodes of Care (EOC) program. The doctors, in five different specialty areas, earned the payments by achieving quality, cost efficiency and patient satisfaction goals in 2014 while treating more than 8,000 Horizon BCBSNJ members. As the largest commercial payor of Episodes of Care in the United States, Horizon BCBSNJ recently reported far lower hospital readmission rates and improved clinical outcomes for members in its EOC practices versus non-EOC practices in 2014.

During Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship, a March 31, 2016 webinar, available for replay, Lili Brillstein, director of the Horizon EOC program, shares the details behind the health plan’s EOC program, from the episodes they have bundled to the goals and results from the program.

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Bundled Payments and Provider Partners: Who Should Take the Risk?

January 27th, 2014 by Patricia Donovan
bundled payment

Bundled payments are changing the face of healthcare reimbursement.

In the new healthcare realm, where every touch now translates to an expense rather than revenue, providers must determine which entity will take the risk before entering into a bundled payment agreement, advises Jay Sultan, associate vice president and chief product portfolio architect for TriZetto®.

Think about whether it’s physicians or hospitals; do you want to be the one owning the episode, taking the risk, indemnifying other parties, giving orders? Or do you want to be an entity that’s taking orders and treated as a vendor? If you’re a hospital, do you really want your doctors deciding which hospital to use?

This can help when you are vertically integrated, but ownership does not equal alignment. You need to think about which providers you need to use. The model where everybody owns each other is not necessarily the best one. In fact, we’ve seen more often than not provider organizations that are not co-owned getting involved in bundles and being successful.

There are a lot of issues. You need to look into what legal form you should create. Again, a lot of people are making new companies that are taking on the risk. You should also consider things like STARK and Civil Monetary Penalty (CMP), and Racketeer Influenced and Corrupt Organizations Act (RICO). You need someone to help you make sure you’ve done all that correctly.

Finally, I’d like to talk about sharing risk among your provider partners. You’re going to have to contract with each other, find a way of sharing gains with each other that everybody can agree to. One traditional model is that the hospital takes all the risk. They indemnify the physicians, and they’re in an upside-only program with the physicians. I think of better models where everybody is at risk and everybody is putting in capital. And if you’re dealing with employed physicians, you need the variable portion of that to be highly aligned with what you’re trying to do in the program.

Excerpted from: Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance