A Plan to Move from Volume to Quality

Man having blood pressure taken

Currently, our health care system is set up as a fee-for-service model, so doctors, hospitals and other health care providers are reimbursed based on the number of visits and procedures completed. According to Charles Chodroff, MD, MBA, FACP, Senior Vice President and Chief Clinical Officer for WellSpan Health, “Fee-for-service doesn’t provide the right incentive though; it promotes volume, but not quality.”

With the mission to improve quality care, WellSpan Health has been studying the options for transitioning the health payment system from its current state to a new model. Seeing that this fits into Aligning Forces for Quality – South Central PA’s mission, AF4Q was asked to bring together members of the medical community, insurers and employers to start moving towards a payment system that focuses on quality.

Following the discussion at AF4Q’s “Improving the Quality & Value of Health Care – A Summit for Employers and Providers” in October, WellSpan Health, its hospitals and medical groups; Hanover Hospital; Hanover’s primary care practices; Lancaster Hospital; Lancaster’s primary care practices; Highmark; Capital Blue Cross; South Central Preferred; Pennsylvania Employees Benefit Trust Fund; Glatfelter Paper; and Glatfelter Insurance Group came together to organize an effort focused on payment reform.

“All of us have the same goal, which is to define what will be paid for, and how the payment system should function. Through discussions, we’ve developed a plan that will include Bundled Payment for inpatient procedures, and payment support for the Patient-Centered Medical Home (PCMH),” stated Chodroff.

Rather than pay for individual visits or procedures, the Bundled Payment is a single budgeted amount that will pay for episodes of care relating to surgical procedures or ongoing medical conditions. The payment support for the PCMH suggests physicians are paid for the time spent to coordinate care, which in the end turns into better health outcomes.

“As part of our plan, we’re discussing how to apply the Bundled Payment to coronary bypass surgeries. But, because there are many elements in coronary bypass surgeries, potentially including valve replacements or treatment of other diseases, we must determine what costs are included and excluded from the bundled budget,” added Chodroff.

To help make this determination, the team is exploring the PROMETHEUS Payment®model.

According to the Health Care Incentives Improvement Institute, “PROMETHEUS Payment® compensates providers fairly, and rewards excellence by allowing top performers to earn more; offers direct and powerful incentives for providers to deliver greater value and better outcomes; encourages caregivers to work in teams, share information, and take collective responsibility for a patient's health; provides a realistic framework to transform the system into a more integrated and accountable one.”

“As we move forward with this locally, we’ll be working with a facilitator, Michael Bailit to carry through the initial 6-month plan. Contracted by the Robert Wood Johnson Foundation, Mr. Bailit is a national expert in payment reform, and will be able to guide our community from discussion to solutions,” stated Chodroff.

Though this group has begun working through the 6-month plan, they will be looking for more input in July from employers and providers. “Employers play a big role in this, as they’ll have to work through the insurance companies, such as Highmark and Capital Blue Cross. Employers can help drive the design of the benefit plan, and be the voice between the providers and the payers,” said Chodroff.

Join the I Can! Challenge

Have diabetes or heart disease? Join the 12-week, step-by-step program to help you learn how to set goals, partner with your doctor, and incorporate healthy eating and exercise into your life. Like I Can! on Facebook!