Researchers and wonks are talking about the idea of taking a hot acute health care concept -- payment bundling -- and applying the idea to long-term care (LTC) services.
Some people love the payment bundling idea; some people simply mutter "capitation" and "1990s" and change the subject.
It's hard to know whether a health payment strategy will really work until providers and insurers try the strategy in the real world, on a large scale, and check to see if it works. Impeccable logic is no match for field work.
But it seems as if, if creating care teams for older Americans and paying those teams as teams did work, a well-designed, well-implemented payment bundling approach could make writing private long-term care insurance (LTCI) more profitable, by reducing the incidence of claims and reducing the intensity of the care that insureds who do file claims need.
A team of researchers led by Mary Naylor, a gerontologist at the University of Pennsylvania nursing school, talks about strategies for elder care payment bundling in a commentary that appears behind a pay wall this month in Health Affairs, an academic journal that covers health finance and health care delivery.
The drafters of the Patient Protection and Affordable Care Act of 2010 (PPACA) tried to do something about the mishmash of care many Americans get by including the Hospital Readmissions Reduction Program. The program is supposed to impose a penalty on hospitals with high percentages of patients who come back to the hospital within 30 days of charge.
The penalty is set to start 1% in federal fiscal year 2013, which starts Oct. 1, and rise to 3% in 2015.
PPACA also created acute care payment bundling pilot programs.
Naylor and her colleagues say they wish PPACA drafters had thought harder about how the care coordination programs might affect the kinds of frail elderly adults who need LTC services.
The readmissions reduction program sounds great on paper, for example, but some hospitals might cut readmissions rates the nasty way: by shutting out desperately ill patients.
Or, hospital billing wizards could make rehospitalizations disappear by taking an eye-of-newt and toe-of-frog approach to billing codes.
Here's how the conversation might go: "Hey! You there, with the bad infection resulting from that catheter we inserted while you were here with your heart attack. We'll keep you overnight 'for observation.' For a week."
One side effect of "observational care" coding abuse: The patients who are "observed" may not qualify for Medicare reimbursement for care in skilled nursing facilities.
Another big PPACA cost control strategy -- a push toward use of bundled payment programs and other new reimbursement strategies -- could fix coding problems.
A Medicare bundled payment would cover the cost of the inpatient, outpatient, physician and post-acute care services associated with an "episode of care" that could begin three days before a patient entered the hospital and extend to 30 or 90 days after discharge, the researchers say.
Problem: The Medicare bundled payment pilot program exlucdes LTC services from the bundle.
"By definition, such services are chronic in nature and would not lend themselves to this payment model," the researchers say. "Thus, little incentive exists to coordinate care before or beyond the episode."
Worse problem: The bundling system might make LTC nursing home services even harder to find, by encouraging nursing homes to specialize in providing post-acute care that fits in episode-of-care payment bundles.
The researchers have a solution: Someone could create a bundled-payment program aimed at elderly adults who are already getting LTC services. Medicare could tie part of the LTC services payments to a patient's health, quality of life and the overall cost of the patient's care.
Maybe LTC providers who did a good job of keeping patients out of the hospital could get higher payments.
My thought: Maybe an LTC provider that's providing one level of care could get an incentive to help a patient move to a lower level of care, or at least stay at the same level of care, rather than moving up a level. A patient who could continue to get by with a little home care, for example, rather than full-time home care, would probably be happier and cost Medicare and a LTCI carrier less money than a patient who deteriorated rapidly and had to move straight into a nursing home.