These hurdles include defining the bundles in terms of which services are included or excluded and determining accountability for each episode of care when many providers care for a patient.
The watchword is specificity
When defining the length of an episode, the AMA recommends identifying a specific diagnosis or procedure code that triggers the start of an episode as well as identifying which services will be covered until it ends. Even with seemingly obviously defined episodes such as hip-fracture treatment, specificity is recommended.
“It is important to include specific contractual language to specify whether the episode includes follow-up care or surgery, management of complications from surgery,” the AMA resource says. The contract should also specify whether health conditions not related to the initial episode—such as developing community-acquired pneumonia within 30 days of the surgery—are considered part of the episode of care included in the bundled payment.
“In general, more detail is better than less when defining the episode in the agreement,” the resource advises.
Defining the beginning and end of episodes are particularly important in scenarios where services are provided by multiple physicians and providers in multiple settings.
“An episodic, bundled payment for a patient who has experienced chronic heart failure might be limited to the time period of an inpatient admission for a heart attack, or may extend to include the initial inpatient admission, follow-up outpatient care, and cardiac rehab (including the services of multiple physicians and non-physician practitioners within each setting),” the resource states.
Plan for the unexpected
Physicians also should include a contract provision that protects them against unforeseen events that could create a dramatic increase in care costs beyond their ability to control.
“Uncontrollable, game-changing events, such as the introduction of a high-cost specialty drug or a national drug shortage, can adversely affect the financial benefit of participation in a bundled or episode-based model,” the AMA resource states. The resource’s model contract language includes a provision terminating the agreement if such circumstances occur.
“Physician shall have the right to immediately terminate this Agreement,” the model contract states. “For purposes of this agreement ‘substantially exceeds’ shall mean an increase of 100 percent or more of the stated episode payment.”