One thinks of the outbreak of heart bypass, an initiative that lasted from 1991 to 1996. CMS proposed a group payment for coronary transplantation operations covering all services provided to the hospital, as well as 90 days of withdrawal. The pilot saved Medicare $42.3 million, or about 10% of the expected expenditures at the seven participating hospitals. Hospital mortality rates decreased in all hospitals and patient satisfaction improved. Although there are no definitive results yet, our discussions with payers and government authorities in the United States, Sweden and elsewhere have found no evidence that bundled payments have resulted in unnecessary transactions or other treatments. Group payments are adjusted for risk and lead to transparent results, and fixed payment will prevent unnecessary procedures, testing and other services. Group payments (and all care services) should include appropriate use criteria (CSA) that use scientific knowledge to define qualifications for certain treatments. The bundled payment should cover the total cost of treating a patient throughout the care cycle for a given condition or over time for chronic diseases or primary care. The extent of care must be defined from the patient`s point of view (“Having a healthy child”). Care should include all necessary services, including the management of comorbidities and related complications.
For primary and preventive care, group payments should include all necessary care for each defined patient segment (e.g. B, healthy adults or low-income seniors). A bundled payment should cover the total cost of the necessary supply as well as a margin for suppliers using effective and effective clinical and administrative processes. It should not cover unnecessary services or inefficient care services. Capitation provides a strong incentive for a health system to provide all care within its system, as the allocation of external services reduces net revenue and results in insufficient use of existing internal capacity. In the health sector, there is even a term – avoid leaks – and many systems monitor and explicitly control it. Capitated health systems encourage or require patients (and their referral physicians) home providers (the ultimate narrow network) to use. Patients are often penalized by additional costs when they do not use services within the system, even though external providers have more experience and get better results for the treatment of the specific condition of the patient.
Capitation essentially creates a monopoly provider for all patients in the population. Consumers cannot choose the best provider to meet their specific needs. In addition, DRG payments do not depend on getting good results for patients. Indeed, many DGGs cover many support services that are essential for achieving good results and total value, such as patient education and counselling, behavioural health and systematic follow-up. As a result, under the DRG system, specialized health care elevators have remained largely intact. And providers are still not encouraged to innovate to improve patient outcomes. Critics say it will be difficult to negotiate bundled payments under all conditions and reach agreement on the definition of health status, the extent of the cycle of care and the benefits contained. This objection is, at best, weak. A reasonable number of conditions represent a large part of the health costs, and we can start and expand over time.
The care needed for most diseases is well established and experience in defining clusters is rapidly accumulating. Commercial methods and tools, such as the use of complete sets of damaging data, are widespread. Service companies that help suppliers set conditions, create teams and manage payments are created, as are software tools that deal with f