Wednesday, June 17, 2009

Bundling – What will it mean?

In a lot of the healthcare policy talk I feel like an outlier.  Most of the healthcare policy talk is directed more towards the primary care specialties.  As a “potential” patient and as a medical specialist, I watch and read with interest.   Often I am unsure as to the definitions being thrown around in the discussion.  Take bundling for example.  Currently, many of the surgical payments are already “bundled” in that the surgery and the first 90 days postop are linked or “bundled” together. 

When I do a breast reduction on a patient, the fee I receive covers the surgery itself and any visits during the first 90 days postoperative.   I see each of these patients the morning of surgery to do the preop marking and answer any new questions.  I then do the surgery and check on them in recovery.  Most breast reduction surgery is outpatient these days so there isn’t hospital rounds to make.   I call each of my patients the evening of surgery.  I see each of them at 5-6 days postop.  I try to get them to return at one month postop and then again at 3 months.  So the average patient will be seen 2-3 times in that post-operative time frame.  All this patient interaction, including all the office work for the insurance billing, is “bundled” into one fee.  If the patient needs or simply wants to be seen more often, it would still be included in the one fee.

So what are the policy wonks discussing in this new bundling talk?  I apparently am not the only one wondering as evidenced by this:

James Bentley, senior vice president of strategic policy planning at the AHA, says that to debate the merits and drawbacks of bundling, we need a clear definition of what bundling really is.

"Most people who talk about bundling talk about combining the physician payment and the hospital payment," but currently, the focus is on combining the acute payment with the postacute payment, he says. Bentley says fundamental questions like this spring up due to the lack of detail in the president's budget proposal, which Congress has already approved in principle. Details are expected to be worked out in conference between the two houses over the summer.

"Our membership is asking a lot of questions that we can't answer," Bentley says, including whether a new system would include all diagnosis-related groups, or just some, or whether the new formula will incorporate the historically wide disparity in Medicare payments per capita by region, for example.

One big potential problem with bundling payments is the assumption that much of the anticipated savings come from the idea that chronic care patients use lots of services and are high cost; but such chronic care services are the hardest to describe for bundling.

"If there are a lot of comorbid conditions, what's the primary condition, where does the bundle start and where does it end?" Bentley asks.

Are the new bundling talks aimed at the family practice doctors and internists?  Surgeons have been living with “bundling” for a while now.

How the policy wonks decide to “bundle” medical care for diabetics will be interesting.  What will that mean to the family practice clinics?

 

This next part is still on the health policy issue, but has nothing to do with bundling.  It is just interesting to me.

I am like Dr Bruce Campbell  who wrote in his post --Health Care, House Building and Ethics:

I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me. 

Read Dr Campbell’s entire post on his viewpoint of the recent article in the The New Yorker by surgeon-writer Atul Gawande, MD.

Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation. 

 

Then read this one (Gawande) by Dr Jeffrey Parks (Buckeye Surgeon) on his perspective of the same article by Dr Gawande:

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking…..

But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point……….

But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common.

 

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