美国的产妇保健正处于十字路口. 这个bet8娱乐领域在成本上充满了不一致, 结果, 和经验, even as the nation faces a declining birth rate and a rise in high-risk births, 有助于提高全国对不良产妇结局的认识.[1]
These factors have created a tremendous need to revamp this service area.
要做到这一点,最有效的方法可能是通过创新的基于价值的支付策略来解决其成本问题. 通过正确的设计, a value-based model for maternity care involving bundled payment can help address these issues by:
- 降低剖腹产率和其他分娩干预措施,同时鼓励支持剖宫产后的阴道分娩和阴道分娩
- Improving 结果 for patients by lowering risk of infections and shortening recovery time
- 扩大低成本资源的利用, 例如助产士和产前检查的高级实践提供者
- Improving patient satisfaction through better care coordination and 结果
这种方法的另一个优点是,它认识到产妇的一些真相:
- 他们没有“生病”,也不需要治疗才能治愈.
- They are the most likely among patients treated at hospitals to seek care as 消费者.
- In many instances, maternity care may result in their first hospital stay.
如何在产科护理中应用基于价值的支付
价值取向的付款, 虽然对产科护理并不陌生, 这条bet8娱乐线路还没有被广泛采用吗. Yet w在这里 payers and 供应商 have experimented with value-based payment models in this area, 他们取得了成功的成果, 如下面的案例示例所示.
The case examples involve the use of blended case rates and bundled payments, respectively.
在这两种模式下, 提供商收到一笔付款,该付款反映了由提供商的平均历史费用通知的预设支出目标. 供应商承担了大部分财务风险,如果保持在这些目标以下,则可以实现共同节省,如果超过这些目标,则可能招致损失. The key difference between the models is the number of maternity care episode components.
案例示例:混合分娩率. In 2014, 希望证明取消剖腹产的经济刺激会增加阴道分娩, 加州卫生保健基金会启动了一项计划,在该计划中,无论分娩方式如何,bet8网站备用和医院都能获得单一病例率的付款.[2] A initiative’s primary goal was to reduce California’s C-section rate for low-risk mothers to under 23.9% by 2020. 仅仅一年的时间, the three participating hospitals reduced low-risk C-section rates by 20% (from 27%–33% to 19%–24%).
各参与医院剖腹产率变化曲线图
The pilot program was a partnership among the hospitals and select health plan partners. The hospitals used the case rate for only 10% to 20% of their total births, 然而,这种影响波及到所有在医院分娩的人. This pilot resulted in nearly $2 million in immediate savings for the three hospitals, 假设保守的平均节省估计为5美元,每剖腹产1万美元. These changes can also potentially lessen the number of future C-sections, representing $4 million in avoided costs for one year in the three hospitals.
混合案件费率提供了足够大的储蓄,足以产生影响, 但它们只解决了产妇护理的分娩部分. 节省更多钱的机会就在怀孕期间, 在那里,捆绑付款可以支付预防措施,帮助避免高风险分娩,减少剖腹产次数和相关费用.
案例示例:产妇护理捆绑付款. Although published results from commercial maternity bundled payment programs are limited, 有一些成功的医疗补助计划. 医疗激励改进研究所与德克萨斯州东南部的医疗补助组织合作, 社区健康选择, to launch a maternity care plus newborn bundled payment pilot program with two health systems.[3] 在该计划的捆绑下, the two participating health systems were reimbursed for three delineated components (pregnancy, 分娩和新生儿)基于他们的历史成本.
During the first year, the health systems completed 1,246 maternity care episodes. 捆绑付款有以下组成部分:
怀孕组件:
- 根据每个提供者的历史数据得出的平均产前费用
- 根据母亲实际开始接受护理的时间(怀孕2至5个月之间)按比例分配
交付组件:
- 使用阴道和剖腹产历史数据的混合病例率
- 对每个病人的风险因素进行分析, 包括人口统计, 合并症、护理发作的类型和严重程度
新生的组件:
- 根据新生儿的平均历史成本[4]
Overall, the financial results differed between the two health systems (see the exhibit below). 尽管两家医院都没有采取公开措施来降低剖腹产率, 由于更加注重产前护理(怀孕部分),提供者B实现了成本节约。, 从剖腹产到阴道分娩(分娩部分)的转变以及婴儿并发症的减少(新生儿部分).
基于价值的产妇护理设计
The key elements of value-based design for a maternity care are the episode-of-care parameters, 问责方和支付机制.
参数集.The episode of care should focus solely on the mother and include all services, 专业和设施bet8娱乐, 怀孕9个月至产后提供[5] 该事件应包括产前护理(如.g., ultrasounds, obstetric checkups), the inpatient stay, clinicians’ fees during delivery (e.g.,妇产科,麻醉)和产后护理(e.g.、随访).
这种模式最适合低风险怀孕的女性, absent of risk factors that indicate either the pregnancy or labor would be atypical (e.g., preeclampsia, gestational diabetes, breech positioning, high/low amniotic fluid levels). Because a pregnancy can go from low- to high-risk during the prenatal and labor periods, 提供者和付款人可能很难预先确定哪些妇女有资格获得护理. 因此, 提供者必须开发适应性强的护理途径,不仅要管理他们负责的低风险妊娠,还要管理最终将被排除在风险安排之外的高风险妊娠.
特定剧集参数, 包括包含/排除, 是否应由提供者和付款人协商,并应以可接受的行业标准为基础. 重要的是,所有参与者都能很好地理解这一情节,并且相对简单地管理和裁决.
负责任的政党.要有效率, an episode-of-care model requires an accountable party responsible for developing, 实施和监测护理转变. 这个派对也有风险, 如果项目成功了, 它会收到一部分共享储蓄, 如果不是, 它欠付款人一笔钱. For a maternity episode, either the hospital or physician group can be the accountable party. 另外, 这一集可以共同拥有, with a health system managing the program and contracting with physicians, 分担风险和节省开支. 这种方法可能是有利的情况下,涉及使用产科bet8网站备用或助产士.
支付机制.限制鼓励提供不必要的剖腹产分娩, the episode-based payment should include blended facility and professional fee rates for births, 无论是阴道分娩还是剖腹产. 付款应考虑以下因素:
- 质量. 该安排应包括与护理情节和其他战略重点相一致的质量指标,以确保患者不会因减少bet8娱乐而受到负面影响. If 供应商 do not meet quality thresholds, a portion of payment may be withheld.
- 目标price. 价格应根据历史基准期确定, 对区域支出和未充分利用的bet8娱乐进行调整, 如果有必要的话.
- 资金流转.这种安排应该从追溯方法开始(所有供应商都是在按bet8娱乐收费的基础上支付的,并有追溯对账),然后转向前瞻性方法(承担风险的实体一次性支付,并负责向下游供应商付款)。.
- 风险水平. The arrangement should include enough upside and downside risk to motivate real engagement.
- 福利设计. 应该创建分层或窄网络,以鼓励会员寻找使用捆绑包的提供商.
组装部件
许多商业保险公司(Aetna), 信诺, 胡玛纳, BCBS) offer obstetric practices upside-only bundled payment arrangements. 他们相信与bet8网站备用达成协议, 而不是医院, 控制住院费用的最佳方法是什么.
但感兴趣的产科团体应迅速采取行动. 随着商业保险项目的成熟, 设计捆绑包的机会可能会减少, 这使得产科组织几乎没有谈判条款的权力. 也, 如果一个产科小组已经在努力降低剖腹产率, 如果它已经完成了大部分护理转型工作,那么它所获得的潜在共同节省可能是有限的.
Because commercial insurers tend to focus their maternity episode-of-care efforts on obstetric groups, the biggest opportunity for hospitals is in direct-to-employer (DTE) contracting arrangements. 像沃尔玛这样的大雇主, Boeing and Lowe’s employ a center of excellence model to implement bundled payments. 并将让员工飞到选定的地点进行选择性手术. Obviously, that approach would not work for a maternity episode of care. A hospital could target smaller employers that operate in a single location, 然而, 以本地首选供应商的身份订立数码直接通讯bet8娱乐安排. 最成功的DTE安排往往是与市政当局(例如.g., state government, a teachers’ union that works with a local health system).
早期采用者将引领潮流
孕妇包是适合病人的模式, 消费者, 供应商, 自行投保的雇主和付款人. 随着时间的推移, these models can help meet the nation’s huge need for reduced costs and improved maternal 结果. 当前的COVID-19大流行及其对医疗保健系统和经济的破坏性影响凸显了将医疗保健利益攸关方聚集在一起追求提高可负担性和质量的创新的必要性.
有兴趣追求护理模式的组织应该从召集关键利益相关者开始,并规划出从怀孕到产后的理想患者路径. 这个练习将帮助他们分析和明确哪些bet8娱乐应该包含在一个包中,并阐明可能限制成功的差距和障碍.
组织还应该进行初步分析,以确保他们能够在捆绑安排下保持足够的利润. 一旦组织了解其当前状态, it should begin conversations with payers and employers to determine interest. 在这个竞争日益激烈的bet8娱乐领域,早期采用者将在保持市场地位和增加销量方面拥有强大的优势, w在这里 消费者 can make well-informed decisions about w在这里 and how they will seek maternity care.
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脚注
- 1.
Chappell B., “U.S. births fell to a 32-years low in 2018: CDC says birthrate is in record slump,” NPR, 2019年5月15日.
- 2.
加州卫生保健基金会, “减少加州不必要的剖腹产,” 2018年7月10日.
- 3.
De Brantes, F.爱,K., “在产科护理中构建捆绑支付流程,”NEJM的催化剂10月. 24, 2016.
- 4.
患有高敏度疾病的新生儿被排除在研究之外,因为他们会显著地扭曲平均发作费用.
- 5.
不像许多现有的产科护理项目, 新生儿护理不应包括在内,因为(1)母亲和婴儿是分开的病人,由不同的提供者照顾,他们有不同的重点, and bundling them may have adverse 结果; (2) the feasibility of bundling these services may be limited from a payment perspective, “正常新生儿”drg的患者可以在新生儿重症监护病房度过一段时间, which would be logistically challenging to pay retrospectively; and (3) t在这里 is significant variation in these costs (NICU versus no NICU) and limited ability for 供应商 to control for this variability. However, once the program is successful, newborn services could be added as a pilot program. The postpartum period can be customized according to provider and payer preference, 通常包括产后六到八周的检查.
2020年10月27日发布