What is episode of care

Episodes-of-care refers to an all-inclusive health-and-payment model in which a single, bundled payment includes all services associated with the treatment for an illness, condition or medical event rather than a separate fee-for-service model.

Episodes-of-care programs bring together comprehensive care and cost reduction through an approach that also improves the member experience. Episodes-of-care programs are designed to address those financial and medical realities.

For example, an episode-of-care single-payment model would include all physician, inpatient and outpatient care for a knee replacement procedure vs. Similarly, it would include all the care for a person who has one or more chronic conditions. Drivers of cost savings The two primary benefits of an episodes-of-care program are financial and quality-of-care, and they go hand-in-hand.

The financial incentives negotiated with participating providers are based on improved patient outcomes in a model where a more integrated approach to patient treatment drives greater efficiencies and lower costs. For example, in the case of treatment for an event such as open heart surgery, payers create a guaranteed price and hold providers accountable for delivering the outcome over the entire duration of care, including any specific clinical problems that may arise during that time period.

Health benefits The quality criteria met by the provider translates into a health benefit for the patient. By tying cost incentives to the clinical outcome rather than provider productivity or other time-based metrics, the quality of patient care remains central to the episodes-of-care model. Quality criteria are stipulated in the contractual agreement with providers, who are kept informed on their performance while the patient is still within the episode-of-care.

At every critical decision point, providers are aware of what they must do in order to achieve both the target price and improve quality of care. This provides linkage between medical and pharmacy claims during established coverage periods and is critical for the implementation of Episode of Care reporting. For Historic Data collected, eligibility is to be reported for all Colorado residents who were covered members during that reporting month.

For inpatient care, the Episode of Care is complete at discharge. For individuals with a mental health diagnosis, an Episode of Care for an outpatient service with an Out-of-Network Provider will not exceed two 2 years from the date of Enrollment.

Episode of Care means a specific medical problem , condition , or specific illness being managed including tests , procedures and rehabilitation initially requested by health care practitioner , to be performed at the site of service , excluding out of network care: Provided , That any additional testing or procedures related or unrelated to the specific medical problem, condition, or specific illness being managed may require a separate prior authorization. Sample 1. The initiative is designed to provide doctors the freedom to care for their patients the way they think will deliver the best outcomes and to pay them for achieving results and improving care.

Second Opinion: The crawling pace of doctor-payment reform. Under the Bundled Payments for Care Improvement initiative, organizations will enter into payment arrangements that include financial and performance accountability for episodes of care.

These models may lead to higher quality, more coordinated care at a lower cost to Medicare. CMS announces additional participants in pilot project to improve care and reduce costs for Medicare - August 13, Over 2, participants in performance period of Bundled Payments for Care Improvement initiative.

The participants include organizations that have entered into agreements with CMS to participate in the Bundled Payments for Care Improvement initiative and an additional 1, providers who have partnered with those organizations.

CMS defines an episode of care as the set of services provided to treat a clinical condition or procedure, such as a heart bypass surgery or a hip replacement. Background: Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. This approach can result in fragmented care with minimal coordination across providers and health care settings. Payment rewards the quantity of services offered by providers rather than the quality of care furnished.

Research has shown that bundled payments can align incentives for providers — hospitals, post-acute care providers, physicians, and other practitioners— allowing them to work closely together across all specialties and settings. The 4 Models: The Bundled Payments initiative is comprised of four broadly defined models of care, which link payments for multiple services beneficiaries receive during an episode of care.

Model 1 includes an episode of care focused on the acute care inpatient hospitalization. Awardees agree to provide a standard discount to Medicare from the usual Part A hospital inpatient payments. Models 2 and 3 involve a retrospective bundled payment arrangement where actual expenditures are reconciled against a target price for an episode of care.

Model 4 involves a prospective bundled payment arrangement, where a lump sum payment is made to a provider for the entire episode of care. Over the course of the three-year initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare.