A U G U S T 2 0 1 7 O U T P A T I E N TS U R G E R Y. N E T 7
begins when cases are scheduled and ends 90 days after surgery. Every aspect
of patient care is covered in the lump sum, from pre-op testing to post-op
rehab. Two main types of bundled payments models have let us enhance
patient care and limit our spending:
• Prospective bundles involve coming to an agreement with payers — a pri-
vate corporation or commercial insurer — on a set rate for a joint replacement.
That means you receive the same lump sum for every procedure performed.
Negotiating a fair bundle with payers demands knowing exactly how much is
spent on every detail of patient care. That demands a deep dive into the true
costs of caring for patients and you must get all ancillary services that touch the
patient along the clinical pathway — anesthesia, radiology and physical therapy,
for example — to agree to a flat per-patient fee they'll receive in the bundle.
Everyone involved in the ancillary services that care for patients has to deter-
mine their true cost of care, but must also figure out ways to become more effi-
cient and must work harder for patients than they have in the past. It's a signifi-
cant challenge that demands a change in mindset and time to implement.
• Retrospective bundles are based on the normal fee-for-service billing model
with insurers. When the episode of care is completed, a process is in place to
measure quality care metrics — no complications, readmissions or infections
occur, for example — and determine the true cost of care, which is compared to
a targeted amount based on past performance. Everyone who touches the
patient along the continuum of care must have a shared vision of providing
excellent care and reducing costs. If they do, quality metrics will be met and
costs will be reduced. When that happens, you're eligible for a portion of the
shared savings from the payer.
You're guaranteed to get paid under the retrospective model, but might miss
out on the extra bump in reimbursement if you fail to provide quality care or
control your case costs. The prospective bundle, however, puts you at risk
because if the cost of the 90-day episode exceeds the contracted bundled
