Using Innovative Payment Models to Drive Improvement in Perioperative Care

Key Points

All payment models fundamentally seek to leverage financial incentives for healthcare organizations, providers, and patients to drive behavior changes that reduce spending on healthcare services and improve health outcomes.
Understanding the basic design of payment models is necessary to take advantage of new opportunities to improve perioperative care.
Episode-based bundled payment models are one of many innovative models that may impact perioperative care.
Payment models often force providers or healthcare organizations to take on financial risk for the opportunity to gain additional revenue.
Success in payment models depends on the ability of providers and healthcare organizations to deliver services efficiently, improve coordination of care across providers and treatment settings, improve health outcomes, and monitor use and costs of care.

Healthcare Spending in the United States

The United States (US) spent roughly $3.8 trillion dollars on health care in 2019, which represents approximately $11,582 per person and 17.7% of the gross domestic product (GDP). Spending on surgical care is estimated to be nearly 30% of all US spending on health care. There is a general perception that spending on health care in the US, inclusive of surgical services, is too high relative to health outcomes in other developed countries. The etiology for high spending includes an array of factors that fit into the existing fee-for-service model of care delivery, including wide unsubstantiated variations in price and intensity of services delivered, lack of price and outcomes transparency, aging population needs, higher unit prices of services relative to other industrialized nations, care fragmentation, malpractice concerns, and wasteful/unnecessary spending. Surgical care is a focus of policymakers given the episodic nature and documented variations in spending and clinical outcomes at the region, hospital, and provider level, suggestive of opportunities for care redesign to meaningful dampen spending and improve outcomes.

In the context of high spending on health care in the US, there has been a several decades-long effort by the Centers for Medicare and Medicaid Services (CMS) to control spending at the healthcare system level through a variety of payment models, some of which remain in existence today ( Fig. 20.1 ). It is important to recognize that the intrinsic value of innovative payment models is largely anchored by the ability to modify financial incentives and drive behavior change that reduces spending. These models are often temporary and dynamic, but fit into the broader objective of improving delivery of efficient, high-quality care.

Fig. 20.1, Overview of Centers for Medicare and Medicaid Services payment models.

Why Is Payment Reform Important in Perioperative Medicine?

Payment reforms may significantly affect the quality and quantity of care across the five phases of the surgical continuum (i.e., preoperative, perioperative, intraoperative, postoperative, and functional recovery). Providers should not only understand payment models as they are being discussed and implemented but should seek to provide input to limit unanticipated consequences, spillover effects, and ultimately improve the value of care delivered to patients.

Payment Models With Provider-Focused Incentives

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