Rosenkrantz Andrew B, Hirsch Joshua A, Allen Bibb, Harvey H Benjamin, Nicola Gregory N
Department of Radiology, NYU Langone Medical Center, New York, New York.
Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
J Am Coll Radiol. 2017 Jul;14(7):882-888. doi: 10.1016/j.jacr.2017.01.023. Epub 2017 Mar 11.
The current fee-for-service system for health care reimbursement in the United Stated is argued to encourage fragmented care delivery and a lack of accountability that predisposes to insufficient focus on quality as well as unnecessary or duplicative resource utilization. Episode payment models (EPMs) seek to improve coordination by linking payments for all services related to a patient's condition or procedure, thereby improving quality and efficiency of care. The CMS Innovation Center has implemented a broadening array of EPMs. Early models with relevance to radiologists include Bundled Payment for Care Improvement (involving 48 possible clinical conditions), Comprehensive Care for Joint Replacement (involving knee and hip replacement), and the Oncology Care Model (involving chemotherapy). In July 2016, CMS expanded the range of EPMs through three new models with mandatory hospital participation addressing inpatient and 90-day postdischarge care for acute myocardial infarction, coronary artery bypass graft, and surgical hip and femur fracture treatment. Moreover, some of the EPMs include tracks that allow participating entities to qualify as an Advanced Alternative Payment Model under the Medicare Access and CHIP Reauthorization Act (MACRA), reaping the associated reporting and payment benefits. Even though none of the available EPMs are radiology specific, the models will nevertheless likely influence reimbursements for some radiologists. Thus, radiologists should partner with hospitals and other specialties in care coordination through these episode-based initiatives, thereby having opportunities to apply their imaging expertise to help lower spending while improving quality and overall levels of health.
在美国，当前医疗保健报销的按服务收费系统被认为会鼓励提供碎片化的护理，且缺乏问责制，这易导致对质量关注不足以及不必要或重复的资源利用。按病种付费模式（EPMs）旨在通过将与患者病情或手术相关的所有服务费用联系起来，改善协调，从而提高护理质量和效率。美国医疗保险和医疗补助服务中心（CMS）创新中心已实施了一系列越来越多的按病种付费模式。与放射科医生相关的早期模式包括改善护理捆绑支付（涉及48种可能的临床病症）、关节置换综合护理（涉及膝关节和髋关节置换）以及肿瘤护理模式（涉及化疗）。2016年7月，CMS通过三种新的模式扩大了按病种付费模式的范围，这些新模式要求医院强制参与，涉及急性心肌梗死、冠状动脉搭桥手术以及髋部和股骨骨折手术治疗的住院护理和出院后90天护理。此外，一些按病种付费模式包括相关路径，允许参与实体根据《医疗保险准入与儿童健康保险计划再授权法案》（MACRA）符合高级替代支付模式的资格，从而获得相关的报告和支付福利。尽管现有的按病种付费模式都不是专门针对放射科的，但这些模式仍可能会影响一些放射科医生的报销。因此，放射科医生应通过这些基于病种的举措，与医院及其他专科合作进行护理协调，从而有机会应用其影像专业知识，在提高质量和整体健康水平的同时帮助降低支出。
