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Topical Review
Section Editors: Larry Goldstein, MD, and Anne Abbott, PhD
Bundled Payment and Care of Acute Stroke
What Does it Take to Make it Work?
David Bruce Matchar, MD; Hai V. Nguyen, PhD; Yuan Tian, MSc
W
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ith nearly 800 000 strokes occurring a year, stroke
remains the leading cause of disability and the fourth
most common cause of death in the United States.1 Stroke also
imposes an enormous economic burden, including long-term
care costs and productivity losses. Total direct medical strokerelated costs to US economy are projected to triple from $71.6
billion in 2012 to $184.1 billion in 2030.1
Although treatment for acute stroke is generally not vividly
effective, the type and quality of stroke care can effect outcomes. Appropriate and prompt use of tissue-type plasminogen activator, reducing risk of acute medical complications,
such as deep vein thrombosis, prophylaxis, and prevention of
aspiration, secondary prevention, such as anticoagulation for
atrial fibrillation, and early institution of aggressive rehabilitation can have substantial impacts on survival and disability.1,2
Moreover, given the high cost of disabling strokes, even care
that is modestly effective in reducing functional loss can be
highly cost-effective.3
Evidence suggests we could treat patients with acute stroke
more effectively and at lower cost. A review showed large
variation in patient-level cost of strokes (between 2 and 4-fold
difference) across hospitals that is not explained by improved
process of care or clinical outcomes.4 Other studies found
similar wide cost variation.5–7 Substantial variation also exists
in clinical outcomes of stroke patients that is unexplained
by patient and hospital characteristics.8 Programs such as
Get-With-The Guidelines have documented that systematic
improvements in stroke care are possible.9
The high variation in costs of stroke and outcomes reflects
not only the complex nature of the process of treating and
managing stroke patients but also points to inefficiencies in
the process of care. It has been argued that these inefficiencies
are partly attributable to the current payment system, which
is mostly based on volume of services rather than on quality of care (eg, as measured by conformance to recommended
practices) and outcomes.10,11 Under the Patient Protection and
Affordable Care Act (commonly referred to as the Affordable
Care Act), several alternative models of value-based payment
are promoted to mend the current dysfunctional reimbursement system.12 Under the rubric of bundled payment and
Accountable Care Organization, these models are intended
to incentivize providers to coordinate care and optimize on
the basis of evidence-supported practice.12 Under the bundled
payment approach, a single payment is provided to multiple
providers for a set of services related to an episode of care
within a set time period. Bundled payment models are particularly suited for a well-defined episode with clear start and end
points, with amount of care predictable and quantifiable based
on standardized protocols and with the risk mostly under the
control of providers.13
As stroke is often characterized by a hyper acute care stage
followed by an episode of inpatient care before transitioning
into skilled nursing home or rehabilitation, it could be a suitable candidate for bundled payment. In this report, we consider the potential impact of bundled payment on the delivery
of stroke care (including technological, clinical workflow, and
administrative changes) and its cost implications. We approach
this objective by (1) considering the theoretical impact of bundled payments in general and potentially for acute stroke and
(2) reviewing the empirical evidence on the implementation
of bundled payments and the impact of bundled payment on
delivery of care, including cost. In the absence of evidence for
stroke per se, we focus on arguably similar conditions. Similar
conditions are defined as those that include an acute phase that
needs prompt diagnosis and immediate treatment or surgery
and a postacute phase that primarily requires secondary prevention or rehabilitation. We considered bundles that covered
all hospital and physician services during the acute phase or
postacute care.
Theoretical Impact of Bundled Payments
Bundled payments can be thought of as an extension of diagnosis-related groups (DRGs). In 1980s, Medicare started paying hospitals for episodes of care (eg, hip replacements) based
on DRGs. Bundled payment goes beyond the DRG because
the payer makes one payment for a package of services or
care provided by multiple providers (eg, hospitals, physicians,
posthospital services) for a defined episode of care within
a defined time period. Bundled payment models set quality metrics for health providers to achieve (such as inpatient
Received March 11, 2015; final revision received March 11, 2015; accepted March 13, 2015.
From the Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.); and Program in Health Services and Systems Research,
Duke-NUS Medical School, Singapore (D.B.M., H.V.N., Y.T.).
Correspondence to David B. Matchar, MD, Program in Health Services and Systems Research, Duke-NUS Medical School, 8 College Rd, 169857,
Singapore. E-mail [email protected]
(Stroke. 2015;46:1414-1421. DOI: 10.1161/STROKEAHA.115.009089.)
© 2015 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.115.009089
1414
Matchar et al Implications of Bundled Payments for Stroke Care 1415
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mortality, readmission rate, or conformance to guidelines)
and allow them to share savings if cost targets are surpassed.
As such, bundled payments offer health providers a financial
incentive to choose the practices and redesign care that optimizes the provision of valued services and eliminates services
that add costs without offering meaningful benefits.
Bundled payments may also offer adverse incentives. There
is concern that health providers adopting bundled payment
may select healthier, low-risk patients or reduce not only
unnecessary but also appropriate care to generate larger savings. It is also possible that health providers increase the number of episodes eligible for bundled payments in the same way
as they did in the conventional fee-for-service system.
Several authors have speculated on the potential of bundled
payment to control costs through care redesign.6,13–17 In addition to the qualitative assessments of the potential of bundling,
modeling has been used to project the likely impact of standardizing care delivery based on evidence-based clinical practice guidelines. One study predicted that bundled payments
could lead to annual savings of $15 billion if it was applied
to 245 episode types in Medicare and paid at the median of
the current Medicare existing service fees.15 Another study
estimated that under optimistic scenarios, bundled payment
for 6 chronic conditions and 4 acute conditions or procedures
requiring hospitalization could reduce national healthcare
spending by 5.4% between 2010 and 2019.18 Interestingly,
the authors also forecasted that bundling payments applied to
hospital-based services only would reduce spending by just
0.1%. This is because Medicare already bundles hospital payments through the DRG mechanism, resulting in limited savings opportunities.
For stroke care, a recent review predicted that if the new
payment models, including bundling methods, promote the
Figure. Review procedure.
use of innovative care delivery in stroke, the cost savings
would be substantial.14,19 The authors of the review identified 4 main innovative care delivery methods for ischemic
stroke care: (1) use of a team of nurses and certified nursing assistants to maximize use of preventative medications;
(2) transition of the care for low-risk patients with transient
ischemic attack from inpatient settings to outpatient clinics
or observation units; (3) increases in access to and delivery of
tissue-type plasminogen activator via tele-stroke systems and
remote expert supervision to avoid potential delay in emergency care; and (4) strengthening of community programs to
ensure smooth transition to home programs to reduce readmission for individuals at high risk. Their model forecasted
that widespread adoption of these high value care delivery
methods would lead to a reduction in direct healthcare spending for ischemic stroke care by 10% in 3 years.
Despite its conceptual appeal and prospects for cost savings,
bundled payments remain largely at the demonstration phase.
The Affordable Care Act-authorized Bundled Payments for
Care Improvement (BPCI) initiative was launched to explore
this innovative payment method in 2013. Under the BPCI,
healthcare providers can choose from 48 episodes of care,
including stroke, and enter into payment arrangements with
Medicare with accountability for cost and performance.20 This
is against a backdrop of relatively low and decreasing uptake
of bundled payment in the private sector, that is, from 1.6% in
2013 to 0.1% in 2014.21
Review of the Literature
Methods
The search criteria and strategies used for identifying the published
literature relevant for review are detailed in Figure. We searched
1416 Stroke May 2015
MEDLINE, WEB OF SCIENCE, and ECONLIT for English language literature published between January 1996 and September 2014
using the term bundled payment or episode payment. For ECONLIT,
we further combined them with the terms medicine or medical or
health to restrict the records to be health-related. References in identified papers were examined for potential additional studies. Regarding
applicability,22 we sought only studies related to stroke or similar conditions (ie, conditions that involve a period of acute care followed
immediately by postacute care typically in a separate setting.) We
included all studies with empirical data regardless of study design.
Given the lack of experimental studies with consistent outcome measures, the summarization below focuses on descriptions of the experiences with implementation of bundled payments and the purported
impacts of bundled payments on care delivery and costs.
Results
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Our first search yielded a total of 731 separate papers. Titles
and abstracts of these articles were then screened by one
author (Y. Tian) based on inclusion criteria, leaving 75 articles
for full-text review by 2 authors (Y. Tian, H.V. Nguyen). After
further excluding nonempirical studies (ie, opinion and commentary), studies focusing on traditional DRGs, and studies
on bundling but not for stroke-like conditions (eg, renal dialysis and cancer), we were left with 12 papers which form our
final sample.
These 12 identified studies assessed a total of 7 bundled
payment demonstration projects. These demonstration projects are (1) Texas Institute Heart Cardiovascular Surgery
(for heart surgery), (2) the Geisinger’s ProvenCare program
(for coronary artery bypass graft [CABG] surgery), (3) the
PROMETHEUS project (for chronic conditions, acute conditions, and surgical procedures), (4) the Integrated Health
Association Demonstration (for orthopedic surgery), (5)
the Medicare Participating Heart Bypass Demonstration
(for CABG), (6) the Medicare Cataract Surgery Alternative
Payment Demonstration (for cataract surgery), and (7) the
Acute Care Episode (ACE) Demonstration (for cardiac and
orthopedic procedures).
Except for the PROMETHEUS, none of these demonstrations involved stroke care (Table) and none involved randomization. Only one study (evaluating the Cataract Surgery
Demonstration) included a concurrent control group. Notably,
only 2 demonstrations (ie, the Geisinger’s ProvenCare program and the PROMETHEUS project) tested bundled payments that included posthospital care.
Evidence on Implementation
Among 4 demonstration projects in the private sector, 2 were
implemented successfully, whereas the other 2 did not pass
the implementation stage. The first successful bundled payment demonstration was conducted by the Texas Institute
Heart Cardiovascular Surgery in 1984.23 Bundles in this demonstration included all services for 16 selected cardiovascular
surgical procedures during hospitalization. The second successful demonstration is Geisinger Health System that implemented the ProvenCare (SM) program in 2006 to test bundled
payment for CABG surgery.24,25 Geisinger Health System is an
integrated health delivery system in Pennsylvania. It has 3 tertiary medical centers and a health insurance plan with 215 000
registered members. In this experiment that targeted members
of the health plan requiring CABG surgery, the bundle was
defined to include hospital and other facility costs, preoperative care, inpatient services, and postoperative care within 90
days.
The 2 recent bundled payment efforts in the private sector
were not successful. The first is the PROMETHEUS project
that covered 3 sites and began in 2008.26 In this experiment,
13 bundles were defined at the beginning of the experiment:
6 for chronic medical conditions, 4 for surgical procedures,
and 3 for acute medical conditions (including stroke).27 For
each bundle, the program assigned an evidence-based case
reimbursement rate that covers all inpatient and outpatient
care (including rehabilitation). The project has faced substantial implementation challenges, which resulted in longerthan-expected setup. These challenges include the complexity
of the payment model (partly because it built on the existing fee-for-service payment system), difficulty in defining
bundles, confusion around interpreting several terms that the
PROMETHEUS used (such as typical costs, potentially avoidable complications, and evidence-informed case rates), failure
to agree between payers and providers on acceptable division
of financial risks, and allocation of payments, as well as the
lack of engagement of frontline physicians, despite the support of physicians and management at pilot sites. As a result,
none of the 3 pilot sites had executed contracts or made any
bundled payments as of May 2011.
The second unsuccessful bundled payment effort was initiated by the Integrated Health Association (IHA) in California.28
The IHA collaborated with the RAND Corporation to implement bundled payment for orthopedic surgery targeting commercially insured Californians <65 years old. The role of
IHA was to manage the planning and implementation process, including forming a technical committee consisting of
specialist physicians and representatives of health plans and
hospitals to define the bundled payment. The bundle for knee
replacement and total hip replacement included facility, professional, and medical implement device charges for inpatient
stay plus a 90 day postsurgical warranty to cover services
related to complications and readmissions; other postacute
care was excluded. Despite optimism and intensive efforts by
the IHA, the study suffered several setbacks and experienced
significant delay in implementation. In particular, parties
could not agree on a bundle definition. Further, several plans
and hospitals dropped out of the project, and ultimately, only
2 hospitals eventually signed contract with the health plans.
The resulting low volume of orthopedic procedures subject to
bundling (only 35 cases over 3 years) precluded an evaluation
of the impact of the demonstration project on cost and quality
for orthopedic procedures.
In the public sector, 3 major bundled payment projects
have been tested by Medicare.29–34 The Medicare Participating
Heart Bypass Demonstration29,30 was launched in 1988. In this
demonstration, a single global price was paid to hospitals for
all hospital and routine physician services provided during the
patient’s CABG hospital stay. When reimbursing the physicians, hospitals introduced financial incentives (in the form of
bonuses) if they exceed the quality goals. Under the Medicare
Cataract Surgery Alternative Payment Demonstration,31 which
ran from 1993 to 1996, participating provider sites were
paid a single prospectively negotiated fee. This fee included
Matchar et al Implications of Bundled Payments for Stroke Care 1417
preoperative diagnostic tests, preoperative surgical evaluation, all surgical services, all postoperative exams ≤120 days
after surgery, and all common complications. In 2009, the
ACE Demonstration tested the use of bundled payment for
Medicare Part A and Part B for cardiac and orthopedic procedures.32–34 The bundles covered hospital and physician services during the inpatient stay.
Evidence on Changes in Care Delivery and Costs
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In considering reports on the relationship between the bundled
care and care delivery and cost, we focus here on the 5 programs that advanced to actual implementation (2 public and
3 private).
Although little data were provided on the quantitative
impact of Texas Institute’s bundles for cardiovascular surgery
on care delivery, qualitatively the effort was reported to lead
to higher coordination of clinical care among specialists and
between specialists and primary care physicians. More specific data were available for costs: in 1985, the flat fee for
coronary artery bypass surgery at the Institute was $13 800
compared with the average Medicare payment of $24 588.
This was largely attributable to reduction in length of stay,
as well as administrative savings as a result of uncollected
bills, and streamlined billing process. It is worth noting that
although costs were reduced, the authors indicated that high
quality of care was maintained throughout the study period.
Several factors were posited as contributing to the positive
impact of the Texas Institute’s effort. First, the bundle applied
to a large volume of homogeneous patients in need of organspecific standardized procedures. The demonstration also
benefited from the presence of an extensive patient database,
which allowed an accurate assessment of profiling the population to be covered in the bundle and tracking actual costs.
Other factors include physician-lead efforts in cooperating
with providers and payers and the involvement of physician
specialists with an established history of working together to
provide patient care.
Several care delivery changes were reported for the
Geisinger experiment. Surgeons reviewed published guidelines and translated them into verifiable, actionable care
processes with unequivocal definitions; 40 elements of care
were identified and became the foundation for care process
changes that were practical, measurable, and accountable to
specific individuals. The experiment also led to better outcomes in hospital care utilization. Compared with the conventional care group of 137 patients, the treatment group of 117
patients under the ProvenCare program had a 16% reduction
in total length of stay and a 5.2% decrease in hospital charges.
Adherence to the full set of 40 care elements increased from
59% to 100%. However, no statistically significant improvement was observed in clinical outcomes, except that patients
in the treatment group were significantly more likely to be
discharged to home.
Bundled payments adopted in the Heart Bypass demonstration spurred several changes to care delivery. These include
use of clinical nurse specialists as care coordinators to oversee
the admission, development of an intensive care unit protocol for uncomplicated patients, and introduction of surgery on
the day of admission. New cost-cutting strategies were also
adopted, including a shift from generic to brand-name drugs,
and surgeons’ and cardiologists’ consolidation of their equipment and supply purchases to obtain more favorable bulk
prices.
For the Cataract Surgery demonstration, Medicare reported
modest savings of between 2% and 5% relative to prior feefor-service rates. There was no change in the clinical outcomes
(visual acuity, complication rates, and changes in Snellan
lines). Neither was there any reduction in use of specific services in the bundle.
Care redesign was also observed in the ACE demonstration,
which has delivered a total of 12 501 episodes of care. Notable
changes, primarily in the direction of better coordinating hospitals and physicians, include standardized operating procedures and materials, hiring of specialized patient navigators,
and use of physician report cards for quality and cost metrics.
In addition, the hospitals negotiated with vendors for reduced
prices of surgical devices to control costs.
Under the ACE demonstration, Medicare saved $585
per episode on average from Medicare Part A and Part B
expected payments. The greatest aggregate savings were
from the orthopedic service line ($1.15 million) and smallest total savings from percutaneous coronary intervention
($303 767). Per episode savings are highest for defibrillator
placement ($1077) and smallest for percutaneous coronary
intervention ($71). Though the ACE demonstration did not
include postacute care in the bundle payment, the analysis
of postacute care found some changes attributed to the ACE
demonstration, such as lower costs of doctor visits for valve
and percutaneous coronary intervention procedures. There
was no evidence of decreased care quality, preference for
having healthier and low-risk patients, substitution among the
different types of postacute care (eg, skilled nursing facility
instead of inpatient rehabilitation), or significant changes in
volume and market share.
Implications of Bundled Payments for
Acute Stroke
In addition to improving access to health services,16 a key goal
of the Affordable Care Act is to enhance care quality and efficiency. The Act has breathed new life into efforts to reduce
reliance on fee-for-service payment. For acute stroke care,
the payment strategy most relevant is bundled payment for an
episode of care, for example, from acute admission through
rehabilitation. In anticipation of such payment revision, it
is useful to consider the potential impacts and challenges of
bundled payments for stroke care. In this report, we addressed
this question by considering the theoretical implications of
bundling and by evaluating the published literature on the
impact of bundling on care of stroke or similar conditions,
particularly on care process and costs. Although far from conclusive—indeed only 1 (unsuccessful) effort included bundled
payment for stroke and none involved randomization—the 7
demonstrations described here provide some insights into the
potential of bundling in the context of acute stroke care.
Two salient points emerge from the review of the existing
empirical literature. First, use of bundled payment is still at
1418 Stroke May 2015
Table. US Bundled Payment Experiments Including Multiple Providers/Sites of Care
Pilot
Payer
Number of Sites
Date
Bundles Targeted
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Texas Heart Institute
Cardiovascular Surgery23
Self-insured
corporations, prepaid
health plans, union
trusts, and Medicare.
1 Site
Geisinger ProvenCare24,25
Geisinger Health Plan
3 Hospitals
PROMETHEUS Model26,27
Health plans and selfinsured employers and
healthcare delivery
organizations.
3 Pilot sites (Two of the sites 2008–2011 4 for surgical procedure
(hip and knee
chose to focus on chronic
replacement, etc); 6
medical conditions, whereas
for chronic medical
the third focused on the
conditions (diabetes
procedures.)
mellitus, etc); 3 for
acute medical conditions
(stroke, etc); 8 others
have been developed
subsequently.
8 hospitals
2010–2013 Orthopedic surgery
The IHA Bundled Payment Health Plans
Demonstration28
1984–1996 Cardiovascular surgery
2006
Elective CABGs
Bundle Description
All applicable charges (including physician and
hospital charges) were bundled into a flat fee
for Non-Medicare population. The approach was
extended to Medicare patients later.
Bundled payment for preoperative, inpatient and
postoperative care within 90 days.
Evidence-based development processes for
bundles and case rates.
A PROMETHEUS Engine was developed to analyze
the insurance claims and to determine whether
the service covered by the claim was part of a
bundle, and if it was, adding it into a running total
budget for the case rate.
Bundled payment for physician and hospital
services during an inpatient stay and a 90day warranty for related complications and
readmissions.
Medicare Coronary
Bypass Procedures29,30
Medicare
7 demonstration sites
1991–1996 CABG
Bundled payment covering inpatient institutional
and physician services for Medicare bypass
patients discharged in DRG 106 and 107.
Medicare Cataract
Surgery Alternative
Payment Demonstration31
Medicare
4 demonstration sites
1991–1996 Cataract removal with an
intraocular lens implant.
The bundle includes preoperative services before
surgery, surgical services, and postoperative
exams for 120 days.
Medicare Acute
Care Episode (ACE)
Demonstration32–34
Medicare
5 ACE sites
Bundle of Part A and Part B services provided to
2009–2013 Cardiac valve and other
Medicare FFS beneficiaries during an inpatient
major cardiothoracic
valve; cardiac defibrillator stay for specific MS-DRGs.
implant; CABG; cardiac
pacemaker implant or
revision; PCI; hip or knee
replacement or revision
The unbundle PAC costs following the inpatient
ACE episodes were analyzed for a 30-day
postdischarge period.
ACE indicates Acute Care Episode; CABG, coronary artery bypass graft; ESRD, end-stage renal disease; FFS, fee-for-service; ICU, intensive care unit; IT, information
technology; MS-DRGs, Medicare severity diagnosis-related groups; PAC, postacute care; PCI, percutaneous coronary intervention; and PPS, prospective payment system.
Matchar et al Implications of Bundled Payments for Stroke Care 1419
Patient
Volume
Risks/Gains Sharing Arrangement
…
Patients with high hospital charges and longer
length of stay (>15 days) were not included in the
bundled payment but were reimbursed on a per
case basis. Evidence-based schedule of hospital
charges were used.
117
…
Changes in Care Delivery
The streamlined billing process
facilitated both the physicians and
the hospital to manage patients and
to reduce overhead expenses and
uncollected bills. Affordable highquality medical care increased patient
access.
Identify the best practices to reduce
complications of CABGs.
Experiences and Lessons
Learned
Extensive database, large
volume of patients, physiciandirected collaboration with
hospital and payers, and
cooperated team in care
delivery were keys to the
plan’s success.
Electronic record-enabled
integrated delivery system.
Develop risk-based pricing.
Re-design the workflow with active
engagement of many parties.
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…
The provider controlled the technical risk to
reduce the potentially avoidable complications
with adequate health systems, training and
planning.
Shared saving model was initially chosen, but no
contract had been executed yet.
35
Difficulties in defining the
bundle. It was hard to build
on the FFS system. Some
challenges were from IT
system and data sharing.
Better coordination and early stages of Frontline physicians were not
planning for clinical redesign.
engaged.
The implementation
experienced significant delay.
The volume was insufficient
to test hypotheses about the
impact of bundled payments
on quality and costs.
The implementation
Over 10 000 In 2 institutions, hospitals shared their saving with Length of stay at ICU was reduced in
experienced considerable
the physicians for efficient patient care, whereas most hospitals.
Clinical Nurse Specialists were in
challenges, particularly,
in the other 2 medical centers, physicians were
charge of bypass patients’ stay.
in the revenue sharing
salaried with no cost-sharing.
Same-day surgery was implemented, and coordination between
and brand drugs were substituted with physicians and hospitals.
their generic equivalents.
4565
12 501
…
Building on existing FFS claim
infrastructure.
…
Quality of Care and Cost Outcomes
Length of stay reduced. The annual
bill for CABG surgery could decrease
by 15% ($192 million) if adopting the
site’s price.
Decrease in total length of stay
by 16% and fall in mean hospital
charges by 5.2%.
Increase in adherence to the
evidence-based practice components
to 100%.
No statistically significant difference
in clinical outcomes compared with
the conventional care group.
…
…
Inpatient mortality rate declined to
5.4% in 1996.
Aggregate Medicare spending on
bypass patients (including the 90-day
postdischarge period) decreased by
10%. A total saving to Medicare and
its beneficiaries was $17.2 million
within 3 y.
There were no changes in clinical
Difficulties in marketing to
2% to 5% discount was negotiated with providers No evidence available on redesigned
inform Medicare beneficiaries outcomes which could be attributable
care was directly attributable to the
compared with the payment under the FFS
to the demonstration.
of their participation in the
demonstration.
system.
Surgical volume or specific services
demonstration.
did not decrease.
Providers at 3 out of 4 sites reported
cost reduction.
No evidence was confirmed about
Standardized and evidenceEach site negotiated the discount from Medicare’s Hospitals and physicians coordithe demonstration effect on volume
nated care, case by case, by adopting based order sets developed
usual payment. Hospitals and physicians could
through collaborative efforts; and market share change, decrease
evidence-based standardized order
share saving if they could meet quality reporting
sets and materials. Early involvement cost and quality data sharing in quality of care and bias toward
and monitoring requirements. Physicians’ gain
low-risk patients.
with physicians; identified
of physicians in design and implesharing was capped at 25% of the fee schedule
mentation of program helped hospitals high quality and cost-effective Medicare saved an average of $585
payment.
medical devices; use of care per episode from Medicare Part A
negotiate reduced price for devices
and B (a total of $7.3 million across
identified to be high quality and cost- navigator in coordination.
12 501 episodes).
effective.
Increase in postacute care (PAC)
Transparency in quality and cost data
cost, particular the PAC for PCI,
sharing was achieved through the use
offset the saving by ≈45%, resulting
of monthly physician report card.
in per-episode saving of $319 (net
saving of ≈$4 million).
1420 Stroke May 2015
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the demonstration stage in the United States Consequently,
there are few studies that evaluate the use of bundled payment models and its impacts on care delivery. In particular,
we were unable to identify any published studies or reports
on the bundling of stroke care or care for similar situations
with an acute event signaling an episode that persists into a
posthospital phase (in particular, incorporating rehabilitation).
Second, the private sector faced a substantial practical challenge in implementing bundled payment. The health delivery
system in private sector is often fragmented, and it is difficult
to align diverse interests of multiple payers and providers. A
particularly successful effort seems to be Geisinger’s demonstration, in which a single entity served as both payer and
provider of services and was able to implement bundling in
the context of an existing culture of integration enabled by an
electronic record system.
Bundled payment interventions initiated by Medicare have
tended to be implemented successfully. Among the projects
that went past the implementation stage, results are consistent
with cost-savings and some positive changes in care process,
such as explicit shifts to best practices, and the set-up and
strengthening of information technology systems.
The failure of the PROMETHIUS and IHA projects seems
to reflect the difficulty in bringing multiple partners with
diverse interests together to agree on design aspects of bundled
payments, such as types of services to be included, length of
episode, as well as the nature and mechanism of risk sharing.
Underlying this difficult negotiation are issues of trust and
competing interests. Successful implementation of bundled
payment seems to depend on the leadership of a large or dominant player who is able to move forward or bypass the negotiation process. Again, Geisinger is a notable case in which one
administrative entity is both the health plan and the provider. In
the same spirit, success of Medicare’s bundled payment experiments may reflect its status as a dominant payer.
Our review suggests other common features of bundled
payment that may be conducive to successful implementation:
(1) a strong electronic information system that can facilitate
evidence-based practice, track costs, as well as follow and
monitor clinical events and quality; (2) incentives aligned
whereby physicians should not only be paid on the basis of
compliance with meeting quality targets but also be given
bonus if exceeding ambitious high-quality targets; (3) sufficiently high volume of patients (IHA failed because a low
volume of patients was insufficient to justify required care
process changes or modifications in benefit design to attract
patients into the bundled payment model), and (4) an adequate
mechanism for distributing risk between payers and providers
(ie, bundles should incentivize providers based on their control of technical risks or performance risks, whereas insurance
risks should be assumed by payers.)
Although some of these implementation issues are general, consideration should be given to the special challenges
in establishing a successful bundled payment for stroke. For
example, a distinguishing feature of stroke is heterogeneity,
that is, stroke occurs to individuals with a wide range of preevent disability and comorbidity, and its effects and management are similarly diverse. Patients with acute stroke typically
have multiple comorbidities, in particular cardiovascular
disease, and risks during the stroke episode are largely driven
by these other comorbidities. Strategies for dealing with these
issues include narrowing the case definition or transferring risk
for outlier costs to the payer or a third party insurer. Another
salient feature of stroke is that the opportunity for improving
patient outcomes and care efficiency is normally not in the
hospital phase (where length of stay has already been driven
down and there is generally no high cost procedure to streamline), but in the postacute period. If bundled payment is to
make a positive difference for stroke patients, it must include
secondary prevention and rehabilitation. Here, coordination is
especially crucial.
Though the empirical data available on bundled payment
is currently limited, this situation should improve as results
emerge from the ongoing CMS BPCI Initiative. Under the
BPCI, 6256 organizations are participating in providing
stroke care under bundled payments.20 Of these participants,
70% chose to be paid for postacute care only (so-called Model
3), whereas 29% enrolled in a bundled for acute care hospital
stay plus postacute care (so-called Model 2). The majority of
participants selected to include an episode of care definition
extending 90 days from discharge (Model 2) or initiation of
the postacute episode (Model 3).
Through better alignment of payment with goals of care,
alternatives to fee-for-service care, such as bundled payments
for episodes of care, offer promising tools for improving quality and efficiency in healthcare. However, much work remains
to be done, not least for stroke care, to turn a conceptually
attractive model into a successful reality.
Sources of Funding
This work was funded by the Singapore Ministry of Health’s National
Medical Research Council under its STaR Award Grant (grant number
NMRC|STaR|0005|2009).
Disclosures
None.
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Key Words: Affordable Care Act ◼ stroke
Bundled Payment and Care of Acute Stroke: What Does it Take to Make it Work?
David Bruce Matchar, Hai V. Nguyen and Yuan Tian
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
Stroke. 2015;46:1414-1421; originally published online April 9, 2015;
doi: 10.1161/STROKEAHA.115.009089
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