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Bundled payments are catching on as a new payment model for healthcare services but not all bundled payments are the same.

A bundled payment is a flat fee paid to a healthcare provider for a full episode of care such as joint replacement surgery. By limiting the payment, it forces the provider to reduce the cost of care for the defined service and guarantee a certain outcome.

If you’re considering using a bundled payment arrangement as a way to control your healthcare costs, there are several questions that you should ask to make an informed decision. 

1/ Who are the providers included in the network? 

Not all providers are included in every network or selected in the same way. Ask about the criteria for network participation and where the providers are located [country, city and state]. Your local providers may or may not be willing to provide the after care needed if you receive care outside of your local community. 

2/ What is the scope of service included? 

The services and the amount of service included in the flat rate will vary bundle-to-bundle. At a minimum, most bundled payments include the cost of the facility, surgeon and anesthesiologist needed to perform the service but some bundled payments also include some or all follow up appointments and physical therapy sessions. Services not included may be covered under your health insurance policy according to the terms and conditions of the policy [deductible, coinsurance, copay and out of pocket maximum].

3/ How is a quality outcome defined? 

Will you receive enough care to be returned to pre-injury condition or returned to a basic ambulatory state or returned to work or something else? The amount of care needed for each outcome is different especially if you have a chronic health conditions such as diabetes or lack the motivation needed to do assigned rehab exercises on your own.

4/ How much control will you have over the surgery? 

Can you select all of your providers [facility, surgeon and anesthesiologist, physical therapist] or just some of them. Will you have any control over the location, the time or the supplies and implants used? Under some bundled arrangements, your case will be assigned to the facility of your choosing and the facility then chooses the physicians and other professionals needed to manage your case as well as all supplies and implants.

5/ What is the expected cost savings over in network rates? 

What level of savings makes it worth it to you? Think through the details carefully to understand what you’re getting and trading off for a lower cost of healthcare. 

 

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