Wednesday, January 28, 2009

Nashville leads effort to combine health payments

Nashville companies are on the leading edge of one of the significant concepts being touted as a major tenet of health reform.

Health-care delivery, like medical education, has long been organized in micro systems. These systems tend to function effectively in their own specialized universes, but the intersection of these specialty worlds can be like the meeting of the tectonic plates, subject to significant disaffection — even earthquakes — that disrupt health-care delivery.

Earlier this year, Centers for Medicare and Medicaid Services Administrator Kerry Weems referred to these health-care micro systems as "silos in health care," and announced a demonstration project to bring about a single, comprehensive payment to cover a bundle of services.

The demonstration project, called Acute Care Episode Demonstration, is intended to facilitate a coordinated and integrated approach to achieving clinical oversight and financial savings in delivery for a single episode of care — such as a stroke or coronary arterial bypass surgery.

The Centers for Medicare and Medicaid Services announced five major health systems had been selected to participate in the project to explore the concept.

Two of the participants, Hillcrest Medical Center in Tulsa, Okla., and Lovelace Health System in Albuquerque, N.M., are owned by Ardent Health Services of Nashville.

Also selected was Baptist Health System in San Antonio, owned by Vanguard Health System in Nashville. The final two participants are the Oklahoma Heart Hospital in Oklahoma City and Exempla Saint Joseph Hospital in Denver.

How payments work now

In the current clinical and payment world, many health-care services are a la carte. The hospital may bill the diagnostic-related group, but the physicians submit individual bills.

This might include separate bills from the surgeon, pathologist, anesthesiologist and various consulting specialties. There may also be separate bills for lab and imaging, depending on the procedure.

Finally, any subsequent care, such as rehabilitation, skilled nursing or home health services, is also billed and paid under separate payments and even separate reimbursement methodologies.

Any of us who have been through, or had a family member go through, a major procedure know there are bills coming from multiple vendors for services we did not even know occurred.

The concept of a single payment for an acute care episode is sound in theory, but there are those tectonic plates. Let's hope that Nashville again proves to be a leader in innovation and aids the nation in making progress integrating essential and necessary health-care services.

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