FEATURE
ers—ASCs, surgeons and anesthesiol- ogists— has been intact for five years, 451 bundled surgical cases were per- formed in 2015, paid by commercial carriers and a self-insured union group with 9,000 covered lives.” The average allowable procedure
reimbursement rate—hospital, sur- geon and anesthesiologist—for the 451 cases performed in Monterey County in 2015 would have been $18,957 if these cases had been performed in the local hospitals as an inpatient pro- cedure or in the hospital outpatient department (HOPD), she says. The average bundled fee rate for the pro- vider network was $11,309. “We estimate the ambulatory bun-
dled payment model can save CMS in excess of $500 million annually for diagnosis-related groups (DRG) 460, 470 and 473 alone,” Wilson says. In 2013, more than 500,000 (540,598 discharges) of these three procedures were performed on CMS beneficia- ries in inpatient settings alone, and the number is increasing rapidly.” The hike in that number is due to the increased number of baby boomers aging and needing this service, as well as to advances in surgical technique, pain control medication and implant technol- ogy, Wilson says. “According to CMS hospital data, Medicare spent more than $7.1 billion for DRG 470 alone in 2015. Our ambulatory bundled payment pro- gram is estimated to save 12.5 percent to 15 percent on the current CMS spend. We also conservatively estimate that potentially 50 percent of CMS beneficia- ries are medically appropriate to be tran- sitioned to the ASC setting.”
Satisfaction All Around Nearly half of all patients in the bun- dled program completed a satisfac- tion survey, and many commented that they appreciated the all-inclusive rate of the bundled fee that incorporates the facility, surgeon, anesthesiologist, first assistant (if necessary), pathology
cases migrate from the inpatient set- ting to the more efficient ambulatory environment, he adds. “Provided the reimbursement rates are fair, ASCs generally sought to participate in our bundled payment facility network.”
and any laboratory tests, Leggett says. “Consumers expect price transparency and desire one-stop shopping with no hidden fees,” he says. “As co-payments and deductibles continue to increase, patients will expect this transparency to allow them to make an informed decision on their treatment options.” Physicians also appreciate the value proposition that they are financially rewarded for their focus on best practices, generating greater efficiencies and reduc- tion of waste, Leggett says. “They are willing to accept financial risk of reduced payments if a readmission occurs as they benefit from the financial rewards result- ing from the majority of their patients who experience excellent outcomes,” he says. “They also value a well-run, streamlined, high-quality surgery center that focuses solely on surgery, their spe- cialty.” In addition, if their patients are satisfied with the bundled payment pro- tocol, it contributes to their overall high level of personal satisfaction of function- ing within this system, he adds. ASCs, as well, welcome the bundled
model. “ASCs have survived in a global facility fee environment for more than 35 years,” Wilson says. “Extending the reimbursement bundle to include the physician providers is a welcomed evo- lution since the ASCs are owned by the physicians. This creates a financially aligned collaborative approach to care, encouraging adoption of best practices and rewarding greater efficiency.” The bundled payment methodol-
ogy rapidly generates a new business opportunity for the ASC as complex
Outcomes G1 tracked outcomes including readmis- sions, ER visits, infections and falls at the Monterey facilities in 2015. “In the study period, we performed 451 bundled pay- ment surgeries with two ER visits (0.44 percent) and one readmission (0.22 per- cent),” Wilson says. “There were no falls and no surgical site infections within 30 days. The complication rate was 0.67 percent.” All patients recovered success- fully; all complications were thoroughly analyzed, he says.
Lessons Learned “Over a five-year period, we have seen that the bundled payment methodology is extremely successful in the ambula- tory setting for commercially insured patients,” Wilson says. “The model fea- turing ASCs outperformed acute care facilities in a statewide demonstration project.” This success is attributable to the partnership structure of the ASCs that unites the major stakeholders as owners/administrators, he explains. “The physician ownership of ASCs financially aligns the surgeons, anesthe- siologists and the facility to adopt best practices, reduce waste and standardize supplies and expensive implants. This enables the facility to scale purchases at lower costs and eliminates redundan- cies. The results are savings of 30 per- cent or more to the commercial payer with total complication rates signifi- cantly less than 1 percent.” Galbraith says, “The same ele- ments that enable the bundled payment method to succeed in the commercial market can be applied to federal pro- grams (CMS) with similar results. The time is now for CMS to embrace bun- dled payments in ASCs.”
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