The eventual bundling experiences at all five demonstration sites will likely be positive, Dr. Aguirre says, given that they were carefully chosen to maximize the likelihood of success. “Where the rubber will hit the road is, how do you translate where you’re obviously going to be successful at five sites to implementing it across maybe a thousand sites and making it successful?” he asks.
I think the current bundling project is a vast improvement and I think it’s a very different animal from old capitation … and pivots absolutely critically on the physician involvement at the heart of quality, at the heart of decision-making. That’s never happened before.—Lisa Kettering, MD, vice president of medical affairs, CMO, Exempla St. Joseph Hospital, Denver, former SHM board member
All Eggs in One Basket?
One thing is certain: For bundling to expand, it will have to convince some fierce critics of its staying power. IPC’s Dr. Singer says so much emphasis has been placed on bundling that it has drowned out any discussion of other alternatives. “It seems like we as a society are hell-bent on putting this in as the method of payment, but I don’t really see all the elements that really would promote a higher-quality product that would reduce cost, which is what it should be about,” he says.
If not bundling, what? For some observers, payment-reform options follow a continuum arcing away from the fee-for-service system, though not everyone agrees on just how widely each might—or should—depart from the status quo. Some healthcare leaders, for example, contend that it would be easiest to simply devise new DRG categories for hospitalists or primary-care physicians (PCPs) to replace the existing fee-for-service CPT codes. “It’s a very simple way of aligning the doctor and the hospital without combining the doctor and the hospital into one entity, which is what bundling does,” Dr. Singer says.
Even some bundling advocates say the solution might ease some anxiety over who controls the purse strings, though such a system would need to account for critical-access hospitals, which currently don’t use the DRG system at all. Alternatively, some analysts see broadened gain-sharing rules as a good way to align incentives toward more efficient care, regardless of whether the incentive system accompanies bundling.
Although still in their formative stages, accountable-care organizations (ACOs) and patient-centered medical homes (PCMHs)—and the implicit bundling of medical services across patient populations—are being advanced as longer-term reforms. Even then, analysts argue over whether such models will be sufficiently free from a fee-for-service foundation. Despite the vigorous debate, most observers agree that Medicare officials are keen to offload more of the risk, whether onto physicians or onto hospitals. “They’re saying, ‘Here’s the dollar. You administer it. And if you end up in the negative, you do, but if it’s in the positive, you get a share of everything,’ ” Dr. Aguirre says.