But for more complex procedures, such as hip replacements, using reference pricing could lead to “significant out-of-pocket costs for consumers,” the authors warned. Some employers have already begun using reference pricing for such procedures. For instance, the California Public Employees' Retirement System, or CalPERS, which manages benefits for current and retired state employees, reported in June that it had successfully lowered costs of hip- and knee-replacement surgeries by limiting members to a designated list of facilities that had all agreed to charge less than $30,000.
A coalition of large U.S. employers, including Walmart and Lowe's, recently announced a deal with four centers around the country to send their employees there for hip and knee implant procedures starting Jan. 1. Employees who have their procedures done at those centers will receive full coverage with no deductibles or co-insurance, as well as receiving travel costs.
One way to keep out-of-pocket costs down, the authors say, would be to combine reference pricing with bundled payments, or single payments for all services provided for a particular condition. Such an approach would extend financial risk to providers as well as patients, while also encouraging cautious use of services, according to the report.
“For providers, pairing reference pricing with bundled payment creates accountability for defined outcomes (e.g., quality of care metrics) and financial liability for costs above the predetermined price for the bundle,” the authors wrote. “This promotes a focus on delivering only the most appropriate healthcare services within the episode, optimizing patient outcomes and avoiding preventable adverse events that can lead to a need to deliver more care, including readmissions.”
In January, the CMS announced tapped more 450 providers to participate in its Bundled Payments for Care Improvement initiative, developed by the Center for Medicare and Medicaid Innovation, which aims to test the use of episode-based payments as a method of aligning incentives across care settings and improving quality.