Episode analytics can help health insurers thrive under value-based healthcare models like payment bundling, according to a new whitepaper from SAS.
Insurers must find ways to succeed as bundled payments generate increasing momentum across the healthcare industry as a way to reduce costs and boost transparency.
For payers, the biggest challenge to payment bundling is defining episodes of care and what to include in them, according to David Redfearn, advanced analytics senior consultant for WellPoint, who spoke for himself and not for WellPoint in the whitepaper.
For example, when bundling for cardiac bypass, payers must decide the length of the follow-up period (30 days, 60 days, 90 days), whether to include readmissions, and if so, primary diagnosis of hospitalization or all-cause readmissions, he noted.
The definition of an episode can vary widely, but should span care settings, such as the care of a patient's chronic condition for a year, according to the whitepaper.
To overcome bundle pricing challenges, payers can use episode analytics to achieve greater flexibility in defining clinical episodes as well as the ability to measure and analyze variations in treatment choices and intensity.
When looking at the experiences of Yale-New Haven Health System and Intermountain Healthcare with bundled payments, the whitepaper noted providers can use episode analytics to price bundles in negotiations with payers. It also called on providers to use data to collaborate with payers to eliminate waste.
As insurers embrace value-based models like bundled payments, they may find they're paying shared savings for the same patient to more than one provider. It's possible, for example, that insurers could be responsible for paying a specialist doctor participating in a bundled payment contract as well as the primary care physician who treated the same patient as part of an accountable care organization or medical home, FierceHealthPayer previously reported.
- check out the whitepaper (registration required)