Mar 17, 2011 - had undergone testing of glycat- ed hemoglobin levels or of renal clearance in the previous 12 months) or changes in costs. In- formation on ...
PERSPE C T I V E
Integrating Care through Bundled Payments
Integrating Care through Bundled Payments — Lessons from the Netherlands Jeroen N. Struijs, Ph.D., and Caroline A. Baan, Ph.D.
I
n industrialized countries, the number of people with chronic diseases continues to increase, putting tremendous pressure on health care systems. At the same time, there is a growing need for more patient-centered care.1 Various approaches to addressing these challenges have been introduced, including, in the United States, the concept of the accountable care organization (ACO) — a vehicle for implementing comprehensive payment reform and redesign of the health care system in an effort to control growth in health care costs and improve value.2-4 In the Netherlands, numerous initiatives were introduced to enhance the quality and continuity of care for chronic diseases, but their fragmentary funding hampered the establishment of long-term programs. In 2007, the Dutch minister of health therefore approved the introduction of a bundled-payment approach for integrated chronic care, initially on an experimental basis with a focus on diabetes. In 2010, the bundled-payment concept was approved for nationwide implementation for diabetes, chronic obstructive pulmonary disease (COPD), and vascular risk management. Under this system, insurers pay a single fee to a principal contracting entity — the “care group” — to cover a full range of chronic disease (diabetes, COPD, or vascular disease) care services for a fixed period. A care group is a newly created actor in the health care system, consisting of a legal entity formed by multiple 990
health care providers, who are often exclusively general practitioners (GPs). The care group assumes both clinical and financial responsibility for all assigned patients in the diabetes care program. For the various components of diabetes care, the care group either delivers services itself or subcontracts with other care providers. The bundled-payment approach supersedes traditional health care purchasing for the condition and divides the market into two segments — one in which health insurance companies contract care from care groups and one in which care groups contract services from individual providers, be they GPs, specialists, dietitians, or laboratories. The price for the bundle of services is freely negotiated by insurers and care groups, and the fees for the subcontracted care providers are similarly freely negotiated by the care group and providers. General decisions about patient services to be covered in the diabetes care bundle were made at a national level and are codified in the Dutch Diabetes Federation Health Care Standard (DFHCS) for type 2 diabetes, which was approved by all national provider and patient associations. The DFHCS is limited to generic diabetes care and specifies only the treatment activities to be included, not who is to provide them or by what means. The services in the diabetes bundle are provided free of charge to patients, since they are covered by the standard insurance
package that all Dutch citizens must carry. The aims of these care groups are similar to those of ACOs, as currently conceived in the United States, but there are differences in some essential features. For example, care groups are dominated by GPs, whereas ACOs may comprise a wide range of providers — at least primary care physicians, specialists, and one or more hospitals. In addition, patients are to be assigned to ACOs on the basis of their patterns of service use, whereas patients are assigned to a care group on the basis of their disease (beginning with diabetes). In addition, the care group bears the full financial risk for the cost of care, whereas ACOs won’t bear the risk of higher-than-expected costs.4 Both concepts are relatively new: the ACO concept has not been fully tested, and the Medicare ACO program doesn’t begin until January 2012; care groups were launched on an experimental basis in 2007, focused only on type 2 diabetes. The implementation process for the bundledpayment system is under evaluation, and data from electronic health records of 10 care groups, extensive interviews with stakeholders, and patient questionnaires are being used to assess the satisfaction of all stakeholders and the quality of delivered care.5 Nevertheless, a number of lessons can be taken from the Dutch experiment on the basis of the evaluation of 10 care groups.
n engl j med 364;11 nejm.org march 17, 2011
The New England Journal of Medicine Downloaded from nejm.org at RIVM BDA on May 27, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved.
PERSPECTIVE
First, we found that in 2007, the amounts that care groups were reimbursed for diabetes care bundles varied widely (from €258 to €474 per patient per year), as a consequence of the free negotiations between care groups and insurers. Differences in prices were only partly explained by actual differences in the care provided (e.g., additional GP consultations, frequency of dietary advice, guidance in smoking cessation, and support for patient self-management) and by the inexperience of both insurers and care groups in setting prices for the newly developed diabetes care bundles. During 2008, 2009, and 2010, when insurers and care groups were more experienced, the price variations persisted, indicating that the DFHCS was being interpreted in various ways by insurers seeking to stint on care in order to contain costs. Second, almost all care providers reported that the care delivery process improved thanks to the introduction of bundled payments and care groups — probably because the care groups are fully responsible for the organizational arrangements, which they formalized by clearly defining which activities would be performed by whom and at what price. As a consequence, coordination among care providers improved, as did protocol adherence, attendance at multidisciplinary consultations, and further training of subcontracted providers to facilitate protocol-driven work processes and use of the electronic health records. Third, the transparency of care increased, thanks to record-keeping obligations that were included in the contracts with individual care providers. These changes
Integrating Care through Bundled Payments
permitted more performance benchmarks to be set and provided information that can be used by care groups in developing quality-improvement projects. Nevertheless, information technology capabilities will have to be improved further in order to fulfill the increasing information needs of all stakeholders. Fourth, it is still too early to draw conclusions about the quality of care or the effects on the overall cost of care. We found no substantial changes in outcome indicators such as the percentage of patients with wellcontrolled glycated hemoglobin levels or target cholesterol levels, nor in the level of patient satisfaction. However, performance on most of these quality indicators was already good at baseline. Since the evaluation covered only a 1-year follow-up period, it is not yet possible to assess improvements in process measures (e.g., the percentage of patients who had undergone testing of glycated hemoglobin levels or of renal clearance in the previous 12 months) or changes in costs. Information on these aspects with a follow-up period of 3 years will become available in 2011. Fifth, the subcontracted caregivers felt that their relationships with the care group were distorted by the groups’ substantial market power. In particular, questions were raised about the potential conflict of interest of GPs, since in all care groups, GPs are simultaneously commissioning and providing care. Another unforeseen side effect of the introduction of care groups was that patients’ freedom of choice with regard to care providers was minimized, since a care group works with its preferred providers.
Thus, the introduction of bundled payment for diabetes care has had both positive consequences — improvements in care delivery processes and in the transparency of delivered care — and negative ones — antitrust concerns and limited choice for patients. In addition, there are still several key unknowns — for instance, how best to take coexisting conditions into account, how to avoid shifting the costs of patient services outside the care bundle, and what the effect is on overall costs of care. Still, our findings seem relevant to the implementation of ACOs, and as more information becomes available on the effects of bundled payment on the quality, accessibility, and affordability of care, it can be used in optimizing policies regarding these new delivery models. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the National Institute of Public Health and the Environment, Bilthoven, the Netherlands. 1. Bodenheimer T. Coordinating care — a perilous journey through the health care system. N Engl J Med 2008;358:1064-71. 2. Devers KJ, Berenson RA. Can accountable care organizations improve the value of health care by solving the cost and quality quandaries? Timely analysis of immediate health policy issues. Washington, DC: Urban Institute, 2009. (http://www.urban.org/ health_policy/url.cfm?ID=411975.) 3. de Brantes F, Rosenthal MB, Painter MP. Building a bridge from fragmentation to accountability — the Prometheus Payment model. N Engl J Med 2009;361:1033-6. 4. Luft HS. Becoming accountable — opportunities and obstacles for ACOs. N Engl J Med 2010;363:1389-91. 5. Struijs JN, van Til JT, Baan CA. Experimenting with a bundled payment system for diabetes care in the Netherlands: the first tangible effects. Bilthoven, the Netherlands: National Institute of Public Health and the Environment, 2010. (http://www.rivm.nl/ bibliotheek/rapporten/260224002.html.) Copyright © 2011 Massachusetts Medical Society.
n engl j med 364;11 nejm.org march 17, 2011
The New England Journal of Medicine Downloaded from nejm.org at RIVM BDA on May 27, 2011. For personal use only. No other uses without permission. Copyright © 2011 Massachusetts Medical Society. All rights reserved.
991
