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Please provide an overview of stroke payment
Hello! Thanks for your question, "Please provide an overview of stroke payment."
The short version is that an overview of stroke payment as currently prevalent in United States, comprises of types of payment models, value-based payment model, bundled payment model for strokes, percentage of stroke paid by Medicare, payment given/received by hospitals/private payers, and part of stroke as given in the Joint Commission Core Measures.
Below you will find a deep dive of my findings.
METHODOLOGY
Extensive search was undertaken, which yielded several authoritative secondary sources. The collected data was collated with a view to gain hard numbers and citations wherever possible. Since prior research was indicated as not beyond "what is a DRG in Medicare", and as much background detail as possible was requested, the researcher provided a detailed background briefing, along with hard numbers, which may help for market analysis as well as for investor inquiry.
Besides answering the research question, the collated data was also analysed to specifically answer the requested queries, "--In the US, what are the bundled payments for stroke? --How do private payers/hospitals pay for stroke - is it different? --What do hospitals get paid for? --What parts of stroke are in the Joint Commission Core Measures? --What percentage of stroke is paid for by Medicare? "
The analyzed data is presented in the form of paragraphs, beginning with "Introduction" and ending with "Conclusion", which concludes this study.
INTRODUCTION
In the United States, the fourth most common cause of death is a stroke, and approximately 800,000 strokes occur per year. "Total direct medical stroke-related costs to US economy are projected to reach $184.1 billion in 2030."
TYPES OF PAYMENT MODELS
In the U.S., eight types of healthcare reimbursement/payment models are seen. They are:
- Pay-for-Coordination
- Pay-for-Performance (P4P) or value-based reimbursement
- Bundled Payment or Episode-of-Care Payment
- Upside Shared Savings Programs (Centers for Medicare and Medicaid Services (CMS) or Commercial)
- Downside Shared Savings Programs (CMS or Commercial)
- Partial or Full Capitation, and
- Global Budget."
VALUE-BASED PAYMENT MODEL
Currently, fee-for-service is the most prevalent healthcare payment model. Nevertheless, since past few years, a shift towards alternative payment models, aiming for lower costs and higher quality is witnessed. For example, in 2013, approximately 1.6% of commercial payments, were fee-for-service with pay-for-performance; while 11% of commercial payments were value-oriented. Again, patients, providers, payers, and purchasers of healthcare, have formed a coalition named as Health Care Transformation Task Force (HCTTF), which aims to bring 75% of their businesses under the alternative payment model of value-based payment by January, 2020.
The government is also aiming for the value-based payment model. CMS in its January, 2015 media release announced four categories of payment for healthcare providers, as follows:
category 2—fee-for-service with a link of payment to quality
category 3—alternative payment models built on fee-for-service architecture
category 4—population-based payment."
With respect to the above categories:
"- by the end of 2018, the U.S. Department of Health & Human Services (HHS) has set a goal to have 50% of Medicare payments in alternative payment models (categories 3 and 4).
- overall, by 2018, HHS aims to have 90% of Medicare fee-for-service payments in value-based purchasing categories 2 to 4.
- this will be achieved through investment in alternative payment models such as Accountable Care Organizations (ACOs), advanced primary care medical home models, new models of bundling payments for episodes of care, and integrated care demonstrations for beneficiaries that are Medicare-Medicaid enrollees."
Alternative payment models may achieve success by the following ways:
"- Physician practices need support and guidance to optimize the quantity and content of physician work under alternative payment models.
- Addressing physicians’ concerns about the operational details of alternative payment models could improve their effectiveness.
- To succeed in alternative payment models, physician practices need data and resources for data management and analysis.
- Harmonizing key components of alternative payment models, especially performance measures, would help physician practices respond constructively."
From the above discussion, it is evident that the alternative payment model, particularly the Pay-for-Performance (P4P) or value-based reimbursement model, is being increasingly adopted by the members of the healthcare industry. The payment for stroke also follows the overall P4P payment model in four specific bundled payment models.
WHAT ARE THE BUNDLED PAYMENTS FOR STROKE?
"On Oct. 1, 2013, the Center for Medicare and Medicaid Innovation (CMMI) officially launched the Medicare Bundled Payment for Care Improvement (BPCI) initiative. Bundled payment sets a single spending target for all applicable health care services provided during a clinical episode of care over a specified time period."
Under BPCI, an Awardee is an entity that bears direct financial risk and pays for the episode of care expenses. Episode Initiators are entities that initiate episodes of care; and they do not directly bear the risk (unless they are also an Awardee). Episode initiators participate in the BPCI program by an agreement with an Awardee. Episode initiators include skilled nursing facilities (SNFs), acute care hospitals, home health agencies, physician group practices, long-term care hospitals, and inpatient rehabilitation facilities.
The BPCI program, as on January 1, 2017, had "1364 participants (1078 episode initiators, 286 awardees), which included 622 SNFs, 341 acute care hospitals, 252 physician group practices, 81 home health agencies, and 9 inpatient rehabilitation facilities."
Under the BPCI program, where the episode of care is a stroke, the Medicare Severity - Diagnosis Related Groups (MS-DRGs), are 61, 62, 63, 64, 65, and 66, as detailed below:
* 62 - Acute ischemic stroke with use of thrombolytic agent with complication or comorbidity
* 63 - Acute ischemic stroke with use of thrombolytic agent without complication or comorbidity or major complication or comorbidity
* 64 - Intracranial hemorrhage or cerebral infarction with major complication or comorbidity
* 65 - Intracranial hemorrhage or cerebral infarction with complication or comorbidity or tPA in 24 hours
* 66 - Intracranial hemorrhage or cerebral infarction without complication or comorbidity or major complication or comorbidity."
- participation is voluntary
- covers the entire nation
- duration was from 2013 to 2016. It has now extended for another two years till 2018.
- a total of 48 clinical episodes are considered. Stroke is one of the 48 episodes.
- the episode length may be 30/60/90 days
- the responsibility lies with hospitals and physicians
- the target price is provider-specific
- the CMS discount is 2% for 90-day bundles and 3% for other bundles
- the reconciliation is done quarterly
- the risk adjustment is for MS-DRG only
- the maximum gain is 20%
- the maximum loss is 20%
- the quality is monitored.
There are 4 models for bundled payment for stroke. Model 1 concluded on December 31, 2016, and is no longer applicable. The Models 2, 3, and 4, are implemented in two phases. Phase 1 completed on September 30, 2015. Phase two having Models 2, 3, and 4 completed on December 31, 2016, and were extended for another two years until 2018.
In Model 2, the episode includes acute care hospital stay, hospital post-acute care and all other related services after discharge from hospital till 90 days.
In Model 3, the episode includes acute care hospital stay, but post-acute care has to start within 30 days, at SNF, or home health agency, or long-term care hospital, or inpatient rehabilitation facility.
In Model 4, the episode includes acute care and post acute care at hospital stay, plus re-admissions, if any.
WHAT PERCENTAGE OF STROKE IS PAID BY MEDICARE?
The percentage of medicare payment for stroke varies according to Models for bundled payment and CMS calculated target price.
In Models 2 and 3, bundled payment is retrospective. Medicare pays the physicians by making fee-for-service (FFS) payments. The total expenditure is then reconciled against the target price as calculated by CMS. The target price is calculated by CMS based on three-year data of historical claims of each participant; adjustments for geographic wage index differences; removal of disproportionate share, medical education, and special payments (these are to be paid outside the bundle); and taking of mandatory discount (discount applies to the full bundle price and not the reconciled amount). After the reconciliation the subsequent payment is made by Medicare.
In Model 4, a single prospectively determined bundled payment is made by CMS to the hospital, which encompasses all the services as provided by the hospital, physicians, and other practitioners. From the bundled payment, the hospital pays the physicians and other practitioners, who submit a "no-pay" claim to Medicare.
In all models, a stop-loss and stop-gain limits capped at 20% of the total target amount are placed, to provide hospitals with financial protection.
WHAT DO HOSPITALS GET PAID FOR?
In stroke related cases, hospitals get paid for the services rendered, which includes acute care, and may or may not include post-acute care services.
HOW DO PRIVATE PAYERS/ HOSPITALS PAY FOR STROKE - IS IT DIFFERENT?
Private insurance and government insurance work differently and pay differently. A patient can have private health insurance from any private insurance company. A patient can have government insurance by enrolling in CMS programs of Medicare or Medicaid. Hospitals pay for stroke if they have voluntarily enrolled for the BPCI Program of the CMS. Private payers pay for an episode of stroke, according to the terms and conditions laid down in the policy taken by the patient. They may also pay for the patient's bundle payment or other payment models as outlined earlier, if applicable according to the patient's policy. The amount and method of payment for stroke, varies from policy to policy and one private insurer to another.
While taking a health-insurance policy, the patient should be aware of what expenses are covered by the insurance company, and what expenses will have to be paid out-of-pocket. A study found that stroke patients fared better with private insurers than Medicaid. Whereas others say public insurance is better than private. Meanwhile, the debate of private versus public insurance rages on.
WHAT PARTS OF STROKE ARE IN THE JOINT COMMISSION CORE MEASURES?
In the Joint Commission core measures, the parts of stroke relate to Stroke (STK) and Comprehensive Stroke (CSTK).
"STK-1 - Venous Thromboembolism (VTE Prophylaxis)
STK-2 - Discharged on Antithrombotic Therapy
STK-3 - Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-4 - Thrombolytic Therapy
STK-5 - Antithrombotic Therapy By End of Hospital Day Two
STK-6 - Discharged on Statin Medication
STK-8 - Stroke Education
STK-10 - Assessed for Rehabilitation"
"CSTK-01 - National Institutes of Health Stroke Scale (NIHSS Score Performed for Ischemic Stroke Patients)
CSTK-02 - Modified Rankin Score (mRS at 90 Days)
CSTK-03 - Severity Measurement Performed for SAH and ICH Patients (Overall Rate)
CSTK-04 - Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )
CSTK-05 - Hemorrhagic Transformation (Overall Rate)
CSTK-06 - Nimodipine Treatment Administered
CSTK-07 - Median Time to Revascularization * * SUSPENDED Effective January 1, 2016 * *
CSTK-08 - Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)
CSTK-09 - Arrival Time to Skin Puncture"
CONCLUSION
To wrap it up, this study concludes that the U.S. health care industry is witnessing several changes in payment models. A trend is seen in the healthcare payment model, which is shifting from the Pay-for-service model to the Pay-for-Performance (P4P) or value-based reimbursement model.
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