Discussion. Part 2
One obvious barrier is that the settings of many of the studies reviewed are not typical of the current fragmented U.S. delivery system. Another is that the current payment system does not encourage care coordination or the prudent use of services. Delivery system transformation and payment reforms are probably equally important in order for most practices to realize the kind of savings we describe here (Mechanic and Altman 2009).
Geisinger Health System’s ProvenCare model is an example of such a combination of delivery and payment restructure in the acute care setting. In that system all services related to certain procedures, including preoperative, intraoperative, and postoperative care for 90 days after surgery, is included in a single price. By implementing best practices as part of their protocols they are holding the providers financially at risk for complications. Geisinger has reported a decline of 21 percent in the complication rate and a 44 percent decline in readmission rate for coronary bypass surgery (Davis and Stremikis 2009).
The Prometheus Payment model provides a similar potential option with bundled payments for procedural care, acute care, and chronic care. It introduces severity-adjusted case rates with allowances for PACs. By creating an allowance for PACs within each episode bundle, the Prometheus Payment model creates incentives for providers to reduce defects below that included in the allowance (de Brantes, D’Andrea, and Rosenthal 2009). In modeling the effects of the payment model in a prototypical practice, we find that reducing PACs from current average rates to observed second decile levels would create higher margins to the practice than achieved in fee-for-service. Higher PAC rate reductions seem plausible given the findings from our literature review and could yield significantly higher margins. The total calculated margin opportunity for the practice is close to U.S.$600,000 but is subject to avoidance of PACs and a likely significant internal investment toward clinical reengineering. The incentives in the Prometheus Payment appear to create the impetus for reduction in PACs; however, the ability for the practice to achieve these reductions, and the investment cost in human and capital resources it would need, remain unknown and subject to further study.
Efforts to introduce payment and delivery system reforms to improve chronic care management are underway in many payer and delivery system contexts, including two pilot sites testing the Prometheus model for chronic care. While these pilots should help shed some light on the ability and willingness of physicians to respond to a new set of incentives, further research will be needed to demonstrate which combination of care settings and incentives helps health professionals most effectively minimize defects in chronic care and their related high costs.