10.27.20
美国的产妇保健正处于十字路口. 这个bet8娱乐领域在成本上充满了不一致, 结果, 和经验, even as the nation faces a declining birth rate and a rise in high-risk births, 有助于提高全国对不良产妇结局的认识.[1]
These factors have created a tremendous need to revamp this service area.
The most effective way to do so may be to address its cost through innovative value-based payment strategies. 通过正确的设计, a value-based model for maternity care involving bundled payment can help address these issues by:
- Reducing the rate of C-sections and other birthing interventions while encouraging support for vaginal and vaginal birth after cesarean deliveries
- Improving 结果 for patients by lowering risk of infections and shortening recovery time
- 扩大低成本资源的利用, 例如助产士和产前检查的高级实践提供者
- Improving patient satisfaction through better care coordination and 结果
Another advantage of such an approach is that it recognizes a number of truths about maternity patients:
- 他们没有“生病”,也不需要治疗才能治愈.
- They are the most likely among patients treated at hospitals to seek care as 消费者.
- In many instances, maternity care may result in their first hospital stay.
如何在产科护理中应用基于价值的支付
价值取向的付款, 虽然对产科护理并不陌生, 这条bet8娱乐线路还没有被广泛采用吗. Yet w在这里 payers and 供应商 have experimented with value-based payment models in this area, 他们取得了成功的成果, 如下面的案例示例所示.
The case examples involve the use of blended case rates and bundled payments, respectively.
在这两种模式下, the provider receives a single payment reflecting preset spending targets informed by the provider’s average historical expenses. The provider carries most of the financial risk and can realize shared savings if it remains under these targets or can incur a loss if it exceeds them. The key difference between the models is the number of maternity care episode components.
案例示例:混合分娩率. In 2014, hoping to demonstrate that removing any financial incentive from performing a C-section would increase vaginal deliveries, the California Health Care Foundation launched a program in which physicians and hospitals received a single case-rate payment regardless of delivery method.[2] A initiative’s primary goal was to reduce California’s C-section rate for low-risk mothers to under 23.9% by 2020. 仅仅一年的时间, the three participating hospitals reduced low-risk C-section rates by 20% (from 27%–33% to 19%–24%).
各参与医院剖腹产率变化曲线图
The pilot program was a partnership among the hospitals and select health plan partners. The hospitals used the case rate for only 10% to 20% of their total births, 然而,这种影响波及到所有在医院分娩的人. This pilot resulted in nearly $2 million in immediate savings for the three hospitals, 假设保守的平均节省估计为5美元,每剖腹产1万美元. These changes can also potentially lessen the number of future C-sections, representing $4 million in avoided costs for one year in the three hospitals.
混合案件费率提供了足够大的储蓄,足以产生影响, 但它们只解决了产妇护理的分娩部分. 节省更多钱的机会就在怀孕期间, w在这里 a bundled payment can cover preventive actions that help avoid high-risk delivery and reduce the number of C-sections and associated expenses.
案例示例:产妇护理捆绑付款. Although published results from commercial maternity bundled payment programs are limited, 有一些成功的医疗补助计划. The Health Care Incentives Improvement Institute collaborated with a Medicaid HMO in southeastern Texas, 社区健康选择, to launch a maternity care plus newborn bundled payment pilot program with two health systems.[3] 在该计划的捆绑下, the two participating health systems were reimbursed for three delineated components (pregnancy, 分娩和新生儿)基于他们的历史成本.
During the first year, the health systems completed 1,246 maternity care episodes. 捆绑付款有以下组成部分:
怀孕组件:
- 根据每个提供者的历史数据得出的平均产前费用
- Prorated based on when the mother actually starts receiving care (between months 2 and 5 of the pregnancy)
交付组件:
- 使用阴道和剖腹产历史数据的混合病例率
- 对每个病人的风险因素进行分析, 包括人口统计, 合并症、护理发作的类型和严重程度
新生的组件:
- 根据新生儿的平均历史成本[4]
Overall, the financial results differed between the two health systems (see the exhibit below). 尽管两家医院都没有采取公开措施来降低剖腹产率, provider B achieved cost savings as a result of an enhanced focus on prenatal care (the pregnancy component), a shift from C-section to vaginal deliveries (the delivery component) and fewer complications for babies (the newborn component).
基于价值的产妇护理设计
The key elements of value-based design for a maternity care are the episode-of-care parameters, 问责方和支付机制.
参数集.The episode of care should focus solely on the mother and include all services, 专业和设施bet8娱乐, 怀孕9个月至产后提供[5] 该事件应包括产前护理(如.g., ultrasounds, obstetric checkups), the inpatient stay, clinicians’ fees during delivery (e.g.,妇产科,麻醉)和产后护理(e.g.、随访).
This model is best implemented with women who have a low-risk pregnancy, absent of risk factors that indicate either the pregnancy or labor would be atypical (e.g., preeclampsia, gestational diabetes, breech positioning, high/low amniotic fluid levels). Because a pregnancy can go from low- to high-risk during the prenatal and labor periods, it may be difficult for 供应商 and payers to identify upfront which women would qualify for the episode-of-care. 因此, 供应商 must develop adaptable care pathways designed for managing not only the low-risk pregnancies for which they are accountable but also the high-risk pregnancies that will ultimately be excluded from the risk arrangement.
特定剧集参数, 包括包含/排除, would be negotiated between the provider and payer and should be based on acceptable industry standards. It is important that the episode be well understood by all participants and relatively straightforward to manage and adjudicate.
负责任的政党.要有效率, an episode-of-care model requires an accountable party responsible for developing, 实施和监测护理转变. 这个派对也有风险, 如果项目成功了, 它会收到一部分共享储蓄, 如果不是, 它欠付款人一笔钱. For a maternity episode, either the hospital or physician group can be the accountable party. 另外, 这一集可以共同拥有, with a health system managing the program and contracting with physicians, 分担风险和节省开支. Such an approach could be favorable for situations that involve the use of OB hospitalists or laborists.
支付机制.限制鼓励提供不必要的剖腹产分娩, the episode-based payment should include blended facility and professional fee rates for births, 无论是阴道分娩还是剖腹产. 付款应考虑以下因素:
- 质量. The arrangement should include quality metrics that align with the episode of care and other strategic priorities to ensure patients are not negatively impacted by reduced services. If 供应商 do not meet quality thresholds, a portion of payment may be withheld.
- 目标price. 价格应根据历史基准期确定, 对区域支出和未充分利用的bet8娱乐进行调整, 如果有必要的话.
- 资金流转.The arrangement should start with a retrospective methodology (w在这里 all 供应商 are paid on a fee-for-service basis with a retrospective reconciliation) and shift to a prospective methodology (w在这里 the risk-bearing entity is paid a lump sum and is responsible for paying downstream 供应商).
- 风险水平. The arrangement should include enough upside and downside risk to motivate real engagement.
- 福利设计. Tiered or narrow networks should be created to encourage members to seek out 供应商 that are using the bundles.
组装部件
许多商业保险公司(Aetna), 信诺, 胡玛纳, BCBS) offer obstetric practices upside-only bundled payment arrangements. 他们相信与bet8网站备用达成协议, 而不是医院, 控制住院费用的最佳方法是什么.
但感兴趣的产科团体应迅速采取行动. 随着商业保险项目的成熟, 设计捆绑包的机会可能会减少, 这使得产科组织几乎没有谈判条款的权力. 也, 如果一个产科小组已经在努力降低剖腹产率, the potential shared savings it receives may be limited if it enters an arrangement having completed much of the care transformation work.
Because commercial insurers tend to focus their maternity episode-of-care efforts on obstetric groups, the biggest opportunity for hospitals is in direct-to-employer (DTE) contracting arrangements. 像沃尔玛这样的大雇主, Boeing and Lowe’s employ a center of excellence model to implement bundled payments. 并将让员工飞到选定的地点进行选择性手术. 显然,这种方法不适用于产妇护理. A hospital could target smaller employers that operate in a single location, 然而, 以本地首选供应商的身份订立数码直接通讯bet8娱乐安排. 最成功的DTE安排往往是与市政当局(例如.g., state government, a teachers’ union that works with a local health system).
早期采用者将引领潮流
孕妇包是适合病人的模式, 消费者, 供应商, 自行投保的雇主和付款人. 随着时间的推移, these models can help meet the nation’s huge need for reduced costs and improved maternal 结果. The current COVID-19 pandemic and its devastating impact on both the healthcare system and our economy underscores the need to bring healthcare stakeholders together to pursue such innovations that improve affordability and quality.
Organizations interested in pursuing an episode-of-care model should start by assembling key stakeholders and mapping out an ideal patient pathway from pregnancy through postpartum. This exercise will help them analyze and articulate which services should be included in a bundle and illuminate gaps and barriers that may limit success.
Organizations also should perform preliminary analyses to ensure they can maintain sufficient margins under a bundled arrangement. 一旦组织了解其当前状态, it should begin conversations with payers and employers to determine interest. Early adopters will have a strong advantage in maintaining market position and growing volumes in this increasingly competitive service line, w在这里 消费者 can make well-informed decisions about w在这里 and how they will seek maternity care.
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脚注
- 1.
Chappell B., “U.S. births fell to a 32-years low in 2018: CDC says birthrate is in record slump,” NPR, 2019年5月15日.
- 2.
加州卫生保健基金会, “减少加州不必要的剖腹产,” 2018年7月10日.
- 3.
De Brantes, F.爱,K., “在产科护理中构建捆绑支付流程,”NEJM的催化剂10月. 24, 2016.
- 4.
Newborns with high-acuity conditions were excluded from the study because they would skew the average episode costs significantly.
- 5.
不像许多现有的产科护理项目, newborn care should not be included because (1) the mother and baby are separate patients cared for by distinct 供应商 who have different focuses, and bundling them may have adverse 结果; (2) the feasibility of bundling these services may be limited from a payment perspective, “正常新生儿”drg的患者可以在新生儿重症监护病房度过一段时间, which would be logistically challenging to pay retrospectively; and (3) t在这里 is significant variation in these costs (NICU versus no NICU) and limited ability for 供应商 to control for this variability. However, once the program is successful, newborn services could be added as a pilot program. The postpartum period can be customized according to provider and payer preference, 通常包括产后六到八周的检查.