The reimbursement system is flawed. At least that's what lawmakers think, and they've been pulling long hours on the Hill to find a solution that actually works. Democrats, Republicans, physicians and insurers have their own plans to wrest health care costs from an escalating trajectory, but the one thing they all demand is greater efficiency. "The big objective of health reform is to bend the curve on health care cost inflation going forward and not add a dime to the deficit," said Tom Enders, managing director of CSC Healthcare Group. "So there's a big question: How is this going to get paid?"

Ready to rethink reimbursement? Our reform round-up breaks the options down.

The Concepts

Bundled Payments

"[Bundled payments] are certainly one thing every reimbursement professional needs to really understand and be focused on how to actually deliver," Enders said.

Similar to DRGs, which combine payments related to a single diagnosis, bundled payments clump all services provided from admission to post-discharge. While physicians and hospitals are used to getting separate payments, they'll now have to divvy the amount. "The idea of bundled payments is to create an incentive for doctors and hospitals to work more closely together than they do now," said Stephen Shortell, PhD, MPH, MBA, dean of the school of public health and professor of health policy and management at University of California at Berkeley.

Payments will be risk-adjusted and take cost of living into account, so amounts will vary. But whatever value the payer decides is what the hospital and physicians will get. If they complete a procedure for less, they'll share the savings; if the procedure is more costly-say, a hospital-acquired condition extends length of stay-the net gain will be less.

Just as providers must coordinate care, coders and reimbursement professionals will have to work together to ensure everyone's on the same page. That's where EHRs and other HIT systems could play a role, said David Jackson, director of marketing, Bloodhound Technologies. "The more things we can do online and the more that's available online, it's better for everybody," he said. "It's better in terms of billing; it's better in terms of coordination of care."

Gainsharing

Launched by the Centers for Medicare and Medicaid Services (CMS), a pilot program for gainsharing is currently underway in 72 hospitals across the nation.

Gainsharing follows the same theory as bundled payments, with set reimbursement for a procedure, but it aims to reduce variation in favor of more effective treatment. Hospitals examine each physician's orders and outcomes and identify which ones save costs without compromising care. Physicians who contribute to lower cost, high quality outcomes earn a piece of the hospital's savings, in the form of a bonus check. "Spending less oftentimes is better care-there's a huge body of evidence that says that," said John Gribbin, president and CEO of CentraState Healthcare System, which is participating in the pilot.

But while it's a simple idea on paper, gainsharing requires time, effort and constant analysis. "It's very labor-intensive; it's very data-intensive," Gribbin said.

Besides collecting the data for such measures, hospital staff has a more direct hand in saving costs. If records aren't available or test results run late, physicians can't do their jobs and savings will drop. Physicians may be getting the checks, but it's up to the staff to make payments possible. "Hospitals are incredibly complex places, and all of our staff have to be working together all the time to make it efficient," Gribbin said. "So, from a logistical standpoint, it probably affects the hospital more than the physicians."

Accountable Care Organizations

A new concept mentioned in several reform bills is the accountable care organization (ACO), in which a large entity, such as an integrated health system or physician-hospital organization, takes responsibility for cost of care over a large number of providers. Under the ACO, patient-centered medical homes would bring caregivers together to coordinate treatment. Providers would still be paid on a fee-for-service schedule, but they'd earn bonus payments for meeting quality standards.

Like bundled payments, ACOs would entail a new approach to reimbursement-but it's unclear how the system would work. With so much attention on team-based care, there's been little lip service on logistics.

Hospital-based and community-based physicians, in particular, will need to align systems to submit claims and avoid double-billing for services. EHRs, therefore, should include networking or interfacing capabilities so providers will be prepared for any coordination down the road. Enders encouraged those involved in reimbursement to participate in medical home discussions and ensure revenue cycle coordination is part of the EHR component. The ACO will also need to establish a "financing entity" to manage payments, Enders said, which could be a new career track for revenue cycle professionals.

Expanding Coverage

Besides cutting costs, reform aims to give more Americans access to health coverage. Fewer uninsured means hospitals will lose less money to charity care, but it also means more people will be visiting doctors and scheduling procedures, which may or may not be a good thing.

The U.S. is already facing a shortage of primary care physicians; even with insurance, patients may not have easy access to preventive care-a key factor in reducing health costs. "We're handing out movie tickets to everybody, but we're not building new theaters," Gribbin said. "What's the logical conclusion of that?"

Providers will have more patients, but they may get less reimbursement for the services they provide. The government will need to find a way to pay for expanded coverage, and that may come through Medicare cuts.

The "E" Word

Much of health reform is in the air, but there's one concrete goal: efficiency. No matter which measures are implemented, coders and revenue cycle staff should anticipate changes to their profession.

As providers adopt low cost, high quality measures, coders will likely see fewer MRIs and duplicate tests and more preventive treatments in their queue, Dr. Shortell said. Professionals should also familiarize themselves with claims data, according to Enders. Better coordination of care will (hopefully) slice readmission rates-and with it, a decent chunk of reimbursement (readmissions count for as much as 5 to 15 percent of hospital revenue, according to Enders). Revenue cycle staff will need to work closely with payers to establish incentive payments to offset any loss, and those well-versed in claims analysis will have an upper-hand.

Whichever measures are implemented, they'll likely roll out through pilots, according to Enders. Professionals should keep an eye on demonstration projects-and if you're feeling proactive, jump in. "I encourage providers to sign up for those as a way to get experience," Enders said. "That's what they're for."

Cheryl McEvoy is an assistant editor with ADVANCE.