4 Problems With Bundled Payments

How Will They Affect Your Income?

Kenneth J. Terry


January 19, 2012

In This Article

Problem #3: Agreeing on Protocols

At Baptist Health, for example, about 200 physicians eventually participated in the ACE program, but only a dozen doctors were interested in it at first, recalls Zucker. Those doctors did all the work of developing the clinical protocols for the program.

At first, no one else followed the guidelines. But over time, physicians began to make recommendations on how to refine the protocols. "Today, if that protocol is not on the face of the chart, doctors are asking where it is," he notes.

Unlike Baptist, which dealt only with private-practice physicians, Spectrum developed its bundling program with its own physician group. When Spectrum started working on the project 2 years ago, that group was brand new, explains Fifer. That meant it had no formal structure in place to create the protocols on which the "evidence-based case rates" of Prometheus would be based.

"We had a steering committee that had 6 physicians on it -- a couple from our medical group, a couple from the health plan, and 2 from the hospital. They provided the overall guidance for protocol development," Fifer says. Although practicing physicians represented the medical group, he admits, most of the 32 primary care physicians involved in the pilot did not participate in creating the guidelines they will be using.

Nevertheless, he points out, "The protocols that are necessary to improve the care processes are already being worked on within our medical group, anyway. What we're rolling out to the physicians is not much different from the overall agenda they've been working on."

The same is true at Fairview Health Services, a Minneapolis healthcare system that adopted 8 "care packages," or chronic-care bundles, in 2009. While Fairview is offering these bundles to payers as part of overall rate negotiations, they aren't being priced individually, notes Terry Carroll, Senior Vice President for Transformation and CIO of Fairview.

Instead, he says, "We were using those vehicles to build in best practices so we could improve the quality of the product and the services we were offering to specific patient populations." At the same time, they were being used to meet the goals of performance-based insurance contracts that Fairview already had.

Carroll stresses that the medical group was solely responsible for developing the protocols. Where necessary, he said, they pulled in "other parts of the care continuum," such as outside specialists, to build the guidelines. They also relied on protocols for chronic care that all Minnesota groups had participated in creating through the Institute for Clinical Systems Integration.

"Our basic premise behind all the work we're doing is that the only way to change how we deliver care is to have the people who deliver it change it. So we provided the vehicles and mechanisms for them to be able to do that work, and the clinicians did it," Carroll says.


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