David Grabowski: Even if we just think about hospital payment, we used to have cost-based payment. We obviously moved to a prospective payment system based on the diagnosis- related groups, or DRGs, in the early '80s, and that was a hope that we can begin to curb some of the high spending and high utilization in the hospital sector.
I think we've seen a big decrease in length of stay, but what that caused was a lot of shifting across settings, and the use of post-acute care mushroomed the readmission problem.
So now as we begin to think about global payment, we're back to sort of thinking about, how do we adequately adjust risk? I've yet to meet the provider who doesn't think they're caring for a sicker set of patients. And so risk adjustment is incredibly central to any of this.
I think the real challenge here is that, one, we're working outside the data. We can begin to look at, for example in bundled payment, what does 30-day utilization look like following discharge? But trying to get the appropriate rates for the hospital system, for the physicians in the bundle, and then the post-acute providers as well, is really challenging. And then thinking about how that rate gets divided up.
We can all agree that utilization is too high under the current system. But then thinking about how we actually account for this very different mix of patients across providers is really challenging.
Now imagine that you're trying to risk-adjust an entire set of healthcare services. Imagine it's a dually eligible individual and you're trying to risk adjust all their Medicare and all their Medicaid.
We can all agree there's a lot of inappropriate utilization, some waste that we could eliminate in the system, but trying to figure out what's the appropriate payment rate? I think given the number of services that are in the bundle or in the capitated rate with the complexity of the patients makes this incredibly challenging.
Think about even our current payment systems. If you take home health payment, we have all the outlier payments and complexities and the risk. All of that is so complex. That's just for home healthcare alone. Now think about putting home healthcare in this bundle or in a capitated rate. It's that much more complex for a very sick population mix.