A Complex Payment Landscape: Co-occurring Health Conditions Challenge Bundled Payments

Pneumonia is one of the leading causes of hospitalization in the elderly. With the continued push toward value-based care and alternative payment models that incentivize providers to improve care and lower costs, this makes it a good candidate for episode-based care models. As an acute infection, pneumonia may be more naturally suited for episode-based payment than hospital admissions for exacerbations of chronic conditions, such as heart failure. But in practice, it’s not that simple, and there are obstacles to reforming payment for pneumonia care.

Although pneumonia is common, it often comes with other conditions that can make designing a successful payment bundle difficult. In a new study titled Pneumonia is Not Just Pneumonia, LDI Executive Director Rachel M. Werner, Senior Fellow Amol S. Navathe, and colleague Jessica T. Lee found that pneumonia-related conditions aggravate in the payment landscape for patients and providers.

Common comorbidities of pneumonia, such as chronic obstructive pulmonary disease (COPD) and heart failure, play a major role in affecting treatment patterns and therefore costs of care for patients with pneumonia. Investigators want to understand how comorbidities influence the use of postacute care, such as care provided by nursing facilities, because it accounts for a large portion of costs and/or savings in others’ other bundled payments.

To explore the prevalence of comorbidities for pneumonia and their association with postacute care costs and utilization, investigators analyzed hospital discharges of Medicare beneficiaries hospitalized for pneumonia, with and without included, using Medicare claims data from 2010-2016.

The investigators found that, as hypothesized, patients with COPD and/or heart failure comorbidities had higher total charges within 90 days after hospitalization. Not surprisingly, payments were highest in patients with more comorbidities compared to those with fewer.

Although, surprisingly, more comorbidities do not always translate into more time in institutional postacute care: Compared to patients with pneumonia alone, patients with pneumonia and COPD or with pneumonia, COPD, and failure to heart were more likely to be discharged from a facility, and those discharged from a facility spent fewer days there.

According to co-investigator Jessica T. Lee, It makes clinical sense that patients who still qualify for hospital admission without the most common comorbidities may be sicker in ways that are hard to detect in claims data. , like not being able to eat enough. at home while they have pneumonia, factors that will influence their need for help after discharge. But that may mean that diagnoses that appear to be chronic conditions, such as infections, may require care that is more reflective of the patient’s status than the admission diagnosis, even if you adjust for comorbidities.

These results highlight how a patient’s co-morbid conditions of pneumonia can significantly influence their costs and course of care, offering valuable insight for planning value-based care interventions. The investigators suggested that to design the most effective alternative payment models for common conditions such as pneumonia and other conditions with high hospitalization rates, health care leaders and policymakers should consider comorbidities in addition to other patient characteristics.

The study, Pneumonia Is Not Just Pneumonia: Differences in Utilization and Costs with Common Comorbidities, was published on October 10, 2023 in Journal of Hospital Medicine. Authors include Jessica T. Lee, Amol S. Navathe, and Rachel M. Werner.


Miles Meline

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