By Dhruv Khullar, Amitabh Chandra, Rahul Rajkumar
Health Affairs Blog, May 18, 2018
Spending on hospital care accounts for one-third of US health care expenditures, or $1.1 trillion—a sum that exceeds total medical spending for all health care goods and services in some other high-income countries.
While total spending on health care services is a product of how many services we use and how much we pay for each, most efforts to limit cost growth have focused primarily on reducing the delivery of unnecessary or low-value care; there has been relatively little attention given to reducing the level of prices. But higher prices—not necessarily higher rates of utilization—drive excess spending in the United States.
Accountable care organizations (ACOs) have been a major focus of delivery system reform, proposed as a way to promote high-value care and reduce costs. ACOs may encourage integration of care, shift spending toward important non-clinical services (for example, care management), and discourage delivery of unnecessary services. But they have yet to produce substantial cost savings and are unlikely to directly confront the fundamental problem of high prices.
One reason ACOs have thus far generated limited savings may be that they attempt to organize and provide all care within their network of providers. This may allow for better care integration and coordination, but it prevents them from taking advantage of providers outside the ACO who may be able to deliver lower-price, high-quality care because of their greater specialization. We can address this problem if we reimagine ACOs—along with other delivery system innovations such as medical homes—as consumers, with more sophistication, incentive, and bargaining power than patients. Conceptualized this way, ACOs can encourage competition among bundlers of hospital care and help lower prices.
Barriers To Hospital Price Competition And The Limits Of Patient Consumerism
In most industries, consumers apply competitive pressure on vendors to reduce the price and improve the quality of available products. But in health care, the ability of patients to shop effectively and create meaningful competition among providers is limited. This is particularly true for hospital care, for which prices vary widely across the country with little relation to outcomes. Can consumerism work when it comes to hospital care? And can ACOs be part of the solution?
Two principal factors prevent patients from functioning as traditional consumers. First, hospital care is not organized into well-defined, easily understood, clinically meaningful units. Instead, each service is billed for separately, and a complex menu of “charges” for thousands of individual billing codes—entirely divorced from outcomes—makes it difficult to shop for episodes such as childbirth, joint replacement, or treatment of coronary artery disease.
Second, health insurance largely insulates patients from costs, so they are not well-positioned to apply competitive pressure on hospitals for expensive care. Because most hospital spending occurs above out-of-pocket maximums, high-deductible plans are unlikely to help. Even below the deductible, it is not clear that patients shop effectively for health care services.
These two forces—opaque pricing and poorly incented patients—constrain the ability of markets to take on a growing challenge: Prices for hospital services are often not the result of competition among providers. Public payers generally use regulated prices, which offer similar prices to high- and low-quality hospitals. For private payers, prices are largely determined by hospitals’ bargaining leverage, which is problematic in rural areas, in markets where hospitals have considerable brand identity and clout, and in regions with substantial hospital consolidation.
Bundled Payments As A Path To Greater Pricing Competition
What Is The Product Being Delivered?
Bundles include care for the full cycle of a well-defined medical condition and offer several advantages over traditional ways of organizing care: They capture the receipt of care for the duration of a medical episode; they put delivery of effective care largely within the control of providers; and they mimic how consumers generally purchase goods and services in other industries.
How Are Prices Determined?
Bundling services allows for more competitive pricing than ACOs and similar approaches through two channels. First, more providers can compete on a given bundle than can compete to assume responsibility for a large population. Smaller hospitals and ambulatory surgical centers, for example, can offer bundles to compete with larger, incumbent hospitals on specific services but are unlikely to have the capital and scale to compete on all services.
Second, if bundles are standardized by private or public payers—and price and outcomes data are publicly reported—insurers, ACOs, and patients can more effectively compare service delivery cost and quality across providers.
Who Is The Consumer?
Bundled payments allow ACOs and medical homes to function as consumers. ACO providers, usually primary care physicians, often engage other providers to deliver specialized care and must evaluate the price and quality of the services they offer patients. ACOs are in a better position to identify high-value services than are individual patients and could facilitate price competition among contracting providers.
Current iterations of bundled payments take steps toward achieving these goals, but there is more to be done. Medicare bundles are mostly administered retrospectively, so physicians still report fee-for-service claims, which does little to disrupt existing practice patterns.
Future iterations of bundled payments may allow for greater use of complementary pricing initiatives, such as reference pricing, by which payers agree to pay a set price for a bundle and additional costs are borne by consumers.
Bundled services could also allow for expanding Medicare’s competitive bidding program, which currently only includes certain medical equipment and supplies, to include Medicare Part B services offered by providers competing on bundles.
Combining bundles with ACOs and medical homes also allows for progress on some traditional challenges with bundles. For example, it is not clear how bundles should be structured for preventive and primary care services, or for comorbid chronic disease management. Moreover, while bundles encourage care efficiency within the bundle, they do not limit the total number of bundles. However, a payment structure that funds difficult-to-bundle care through capitated payments to physician-led ACOs and medical homes—and gives them the option to shop for and purchase hospital care using bundles—may mitigate these problems and lower the cost of care.
Bundles still need refinement. As with other payment models, risk adjustment and outcomes measurement are challenges. Dividing a single bundled payment among several providers can be difficult, and bundling hospital and postacute care, physician and nursing care, and drugs and devices will require large organizational changes within hospitals and investments in cost accounting. Nevertheless, expanded use of bundled payments is a potential path toward greater price competition for hospital services. Bundles have often been thought of as a mechanism to integrate care, but their greatest impact may be increasing the number of providers in the health care markets, and redefining and strengthening the role of the consumer.
By Stephen Kemble, M.D.
Two problems with this proposal:
1. Bundles incentivize delivering more bundles of care for low risk patients, which can mean more unnecessary care.
2. The majority of health care is not in the form of discrete episodes of care for acute conditions or specific procedures. It is for care of chronic conditions for which there are no clear end-points for starting and ending a bundle.
I believe the whole idea of trying to control prices via competition is not likely to work. For one thing, in many markets, including rural and poverty areas with a high percentage of Medicaid and uninsured patients, hospitals are already losing money and can’t afford to reduce prices. We should be focusing on reducing administrative cost and burdens combined with price controls, instead of competition, if we want to reduce prices without destroying care for large segments of the population, including those who are poor, chronically ill, or elderly, and who need care the most.
By Don McCanne, M.D.
The policy community remains obsessed with the concept of using competition to harness the power of the consumer in order to bring under control our high health care prices in the United States. The record to date demonstrates the utter failure of this approach, but that does not keep them from trying, no matter how lame their various proposed innovations.
Today’s proposal acknowledges that patients do not function well as consumers in the health care environment, But to save the concept of consumerism, they suggest that the health care providers consolidate, bundle together what can be bundled, while clumping together difficult-to-bundle care as ACOs or medical homes, and then delegating themselves as consumers of their own bundled services, serving as proxies for their patient-consumers. Egad!
Our colleague, Stephen Kemble, in his posted comment, sees through this policy smokescreen. In spite of all the talk about bundling care, most care does not package into neat bundles. Second, the providers that do have bundles to sell want to sell more of them when it is not only prices but also quantity that determines the total health care spending.
Kemble’s most important point is that, instead of relying on competition, “we should be focusing on reducing administrative cost and burdens combined with price controls.” Administrative waste and high prices have been proven to be the two greatest sources of recoverable waste in our runaway health care spending. Competition has not controlled them; in fact, the markets have only made them worse.
It is astonishing that these market ideologues do not acknowledge the beneficial health financing policies that are just outside their box – automatic lifetime coverage for everyone prepaid through equitable, public financing, in a system that is publicly administered far more efficiently than with our fragmented, multi-payer system. Maybe someone should attach a door knocker onto their box so we can get their attention.
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