At Harvard Pilgrim, we like to say that collaborating with providers is in our DNA. We know it’s important to continue working together to create innovative solutions that help contain costs, while providing better outcomes.
Leveraging provider best practices
With this in mind, we implemented a unique bundled payment agreement with Maine Heart Center, a network of five Maine hospitals dedicated to upholding and sharing best practices for the treatment of cardiovascular conditions. A bundled payment is a shared risk arrangement in which the insurer makes one fixed payment for services to the provider when a member/patient has a health care episode. This payment takes into account most of the treatments, services and care a patient receives related to that episode, including readmissions related to the original procedure. Certain quality measures and targets are evaluated to ensure that our members receive the highest-quality care.
Collaborative approach to risk sharing
For this arrangement, the bundled payment applies when a member has coronary artery bypass surgery, coronary angioplasty or cardiac catheterization at one of the five facilities in Maine Heart Center’s network. The arrangement is informed by years of available best-practice data; Harvard Pilgrim and Maine Heart Center performed detailed analyses of all the costs associated with these procedures.
Maine Heart Center’s providers are incentivized to stay within the budget while providing the best care. Risk protection is also factored in for highly complex cases so that any potential financial loss achieves the right balance between the two organizations. The member also benefits from the bundled payment arrangement, being responsible only for his or her plan’s cost-sharing responsibility associated with the bundle.
A sharp focus on coordinated care
Susan J. Seekins, R.N., B.S.N., an experienced cardiac care nurse, is the program manager for quality and value-based care at Maine Heart Center. She emphasizes that bundled payment programs promote collaborative and better coordinated care. “Patients benefit from a provider network where care is shared and standardized around clinical practice guidelines. From referral to hospital admission, through discharge and transition to home, care is coordinated to prevent complications and unnecessary readmission and to support a healthy cardiac recovery.”