bundles,” Croegaert continues. “High- end surgical procedures, such as joint replacement, spine, bariatric or cardiac diagnostic procedures, are most inter- esting due to the high cost per proce- dure and the historical variation in bill- ing patterns. However, ASCs should also look at other elective or routine- type procedures and diagnostics unique to their facility that could be made into bundles.” These could include pro- cedures like hysterectomies,
hernia
repairs, colonoscopies, pain manage- ment and appendectomies. Since these types of procedures are already being done at ASCs, Croegaert says, the abil- ity to “sell” to the payer will require packaging the existing facility services with professional, ancillary and post- acute care services. The more com- plete the package of services, the more likely the payer will be interested in a contractual relationship.
Along with the contract package, ASCs should think through the mar- ket of patients for whom such a service would be preferable, he says. “Bundles are ideal for patients with high deduct- ible plans since first dollar payment is required and being able to add the assurance of ‘complete coverage’ for a predictable price is a great value prop- osition. Likewise, asking employer- sponsored plans for a waiver of copays or certain deductibles for using the bundle has a high likelihood of suc- cess. Bundles for use in a fully insured or low-deductible environment are less valuable to the payer unless those plans are part of an otherwise accountable or managed care plan.” The potential pitfalls of this kind of plan revolve around three points, Croegaert says: 1. understanding the risk of the bun- dle to the stakeholders,
2. assuring that the bundle participants are the best at what they do, and
3. the ability to meet the adminis- trative requirements necessary to make the bundle work.
ASCs stand in a unique place to drive, participate in and succeed in this new risk- and value- based reimbursement environment, assuming they are willing to build and adapt to the new contracting model requirements.”
— Brian Croegaert Arcadia Healthcare Solutions
Understanding the risk primarily means that the providers understand the definitions or requirements of the bundle. “What is covered and what is excluded needs to be clearly defined in the contract,” he says. “Will the provid- ers be responsible for any care outside of the bundle? Are there any penal- ties for postop emergency or inpatient admission? What happens when the patient suffers from an exacerbation of a condition not directly linked to the bundled service?” Structuring a partnership that will
include all of the providers supply- ing services covered by the bundled payment is a significant undertaking, Croegaert says. “The community of providers needs to be vetted for pro- fessional skill and commitment to the payment model. The bundle needs to have the right number and types of pro- viders especially around the post-acute care services as they are sent home or at the end of the bundle. Contracts with all providers in the service bun- dle need to be clear. How will each be paid? How will financial penalties be assessed? What is the process for add- ing additional providers or removing existing providers within the bundle?” Administrative services can make or break the bundled payment’s success for ASCs. “Understanding and build- ing the infrastructure necessary to make
the process work will include contract- ing, credentialing, financial model- ing, analytics and claims payments in which all will need to be developed and implemented,” Croegaert explains. “For example, under pay for perfor- mance (P4P) contracts, reporting and measuring of outcomes require scoring mechanisms and data transfer capabili- ties. The ability to complete all of the required administrative services within a bundled budget will impact the devel- opment of infrastructure significantly.” Regardless of the appetite for risk
and value-based reimbursement mod- els, CMS has signaled its appetite for bundled payments, he says. “Commer- cial- or employer-sponsored plans are rarely far behind CMS relating to cost containment functionality,” he says. “ASCs stand in a unique place to drive, participate in and succeed in this new risk- and value-based reimbursement environment, assuming they are will- ing to build and adapt to the new con- tracting model requirements.”
Migration to Lower Cost Settings Bill Kampine, senior vice president and cofounder of Healthcare Blue- book, believes insurers can do a num- ber of things to keep costs down by supporting site of service migra- tion to a lower cost setting such as an ASC. Healthcare Bluebook provides transparency solutions to self-insured employers, third party administra- tors (TPA) and regional payers. Blue- book price and quality transparency tools help patients understand the cost of care, compare providers and effec- tively shop for care. In some cases, Bluebook even rewards its members for using the more cost-effective set- ting, he says.
Kampine recommends the following
strategies that can help bring costs down: 1. Provide effective, easy-to-use price transparency for
patients. Help
patients be in the right mind to shop for care and make the right
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