There is widespread agreement that if the United States is to achieve sustainable levels of health care spending, it must make greater use of payment mechanisms that reward physicians, hospitals, and health systems for the results achieved. The vexing question is how best to make this transition.
Today, payers and providers are using a range of strategies to accomplish this goal, including patient-centered medical homes, value-based contracting, and accountable care organizations (ACOs). We applaud this trend. However, our research and experience have convinced us that the transition to outcomes-based payment will occur more easily if both payers and providers take an intermediate step and make greater use of retrospective episode-based payment (REBP).
REBP focuses on “episodes of care” (any clinical situations that have relatively predictable start and end points such as procedures, hospitalizations, acute outpatient care, and some treatments for cancer and behavioral health conditions). REBP identifies which provider is in the best position to affect the clinical outcomes and total costs associated with an episode of care; it then assesses (through retrospective analysis of claims data) the outcomes achieved and costs incurred during each episode over a specific period of time (e.g., quarterly). The identified providers are then rewarded or penalized based on their average performance across all the episodes.
The desire to jump straight to outcomes-based payment models focused on the total cost of care for an entire population has led many payers and providers to overlook, or give up on, episode-based payment. We believe it is worth reconsidering.
REBP offers a number of advantages. For example, because it uses the current fee-for-services claims system as its administrative platform, it does not require providers to make significant investments in new infrastructure or establish new contractual arrangements with other providers. And because it focuses on acute episodes, REBP acts as a necessary complement to payment and care-delivery models designed to improve prevention and chronic-care management. Furthermore, administering and/or participating in an REBP model can help both payers and providers develop many of the capabilities they will need for total-cost-of-care management. In short, REBP can serve as a bridge to more comprehensive total-cost-of-care approaches.
How Does REPB Work?
In the U.S. health system today, a dozen or more providers may be involved in an episode of care, and each provider typically bills separately. None of these providers is rewarded financially for helping ensure that the desired clinical outcome is delivered with the highest quality at lowest cost across the entire episode.
REBP is designed to change that. It is somewhat similar to and shares many of the same goals as the “prospective bundled payment” approach, which calls for making a single payment (or budget) to the accountable provider for all the services used to treat each specific episode for each specific patient. But key differences in design and administration make REBP more scalable in the current U.S. health system.
The six core steps required to implement REBP are listed in the exhibit “Steps Required to Implement REPB.”
Why Should Payers Pursue REBP?
Our analysis of data from private insurers, Medicaid, and Medicare suggests that 50% to 70% of all health care spending could be included within episodes of care. REBP establishes end-to-end accountability for more than half that spending.
REBP also gives payers a direct way to incentivize providers to reduce health care waste. We have consistently observed that some providers deliver the same or better clinical outcomes at dramatically lower costs than other providers in the same market. The exhibit “Average Cost Per Episode Varies Significantly Across Providers” illustrates variations in average, total per-patient costs for three different episodes in three different states. Even after we excluded patients with certain complicated conditions and adjusted for patient severity, the average cost per episode in each market still varied from 60% to over 300%. Further analysis showed that much of this variation could be explained by differences in practice patterns (e.g., decisions about device selection, diagnostics use, discharge planning, hospital admission).
REBP also offers a quick path forward, because it requires only modest additional infrastructure. We have seen multiple payers define and implement the necessary infrastructure within six months of when they agreed on an episode’s definition. Turnkey analytic vendors are also beginning to emerge.
In addition, REBP gives payers considerable strategic flexibility. Many REBP parameters can be adapted to address local conditions, align with network and member-engagement approaches, and strengthen competitive advantage. Among these parameters are cost thresholds, stop-loss provisions, the degree of gain- and risk-sharing, whether and how to normalize unit prices, and whether to steer members to certain providers.
Finally, REBP gives payers a way to prepare for the future, when episode-based performance management is likely to be a required capability. Most providers do not have access to sufficient claims data to assess performance on their own. If providers are to accept partial or total cost-of-care accountability, payers will need to offer them a performance-management infrastructure to understand clinical outcomes and costs.
Why Should Providers Pursue REBP?
If contractual terms are fair, REBP can deliver meaningful value to acute-care providers in particular. For example, it has the potential to give them a net increase in margin, because many of the sources of savings are either variable costs to these providers (e.g., implantable devices, extra care required for surgical complications) or are associated with upstream or downstream providers (e.g., pharmaceuticals, physical therapy, skilled nursing facility care). REBP can also help acute-care providers reinforce and accelerate existing strategic priorities, such as improving how hospitals influence and partner with physicians, increase adoption of clinical pathways, and reduce input costs.
REBP empowers all accountable providers by reducing the need for payers to monitor clinical decision making (e.g., through preauthorization). It also positions them to assume a stronger role in influencing the performance of upstream and downstream providers.
Strong episode performance has the potential to strengthen a provider’s value proposition to patients, employers, and payers. It may also be grounds for negotiating a stronger network position.
Furthermore, REBP requires providers to make only small, if any, investments in new infrastructure — at least initially. And it will enable them to strengthen their ability to understand end-to-end performance, a capability any providers considering more holistic total-cost-of-care payment models will need.
What Changes Must Payers Make?
To implement REBP at scale, most payers will have to shift their focus from prospective to retrospective models in most markets. Doing so will enable payers to simplify their infrastructure and focus on analytic processes that are separate from claims adjudication. This infrastructure is less invasive, requires less investment, and offers faster time-to-market than do solutions that necessitate material changes to claims-adjudication processes.
Second, payers will need to develop greater technical sophistication to ensure fairness (e.g., through episode-specific risk adjustments) and provider acceptance. They will also have to develop or adopt new standards as they emerge. The Center for Medicare and Medicaid Innovation’s efforts to create standard episode definitions, including through the Bundled Payments for Care Improvement Initiative, are a promising starting point.)
Finally, if REBP is to succeed, payers will have to implement it at scale by promoting REBP, whenever possible, across all books of business and all network providers. Most payers should also strongly consider participating in multi-payer efforts to set standards to help overcome common barriers to implementation.
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