Case Study: A Leading Approach to Payment Innovation

Value-Based Fee Structure

A Midwest ASC was operating in a market dominated by a high cost health system that threatened physicians’ ability to remain independent. The existing ASC fee structure was not supportive of clinically appropriate case migration, which resulted in ASCs remaining out-of-network or in partnership with high-cost hospital systems.

Program structure:

Transitioned facility to in-network status via a value-based facility fee schedule

Physician Quality Incentive

For an ASC in the Southeast, physician employment and strict CON laws hindered independent ASC viability. To promote and optimize the use of ASCs for appropriate services, SCA Health worked with a commercial payer to develop an incentive structure for surgeons.

Program structure:

Aligned the underlying economics for surgeons who improved quality and cost-of-care for clinically appropriate outpatient surgeries

Surgical Bundle

To accelerate clinically appropriate case migration in the Midwest, SCA Health implemented a surgical bundle that promotes higher quality care and lower costs, and a streamlined approach to the surgical and recovery processes.

Program structure:

• Create a comprehensive bundle that consolidates physicians’ fees, facility charges and rehabilitation costs
• Promote clinical benefits that include improved quality and patient care; as well as lower costs

Physician Quality Incentive (Surgical Hospital)

In the Mountain West region, two high-cost hospital systems significantly impacted the availability of high quality, lower-cost surgical care. SCA Health worked with a major commercial payer to develop a quality-based value network of surgeons, who are recognized based on clinical outcomes and efficiency.

Program structure:

• Organized current physician partners and organized additional surgeons to participate in the payer’s quality-based network
• Aligned the underlying economics of surgeons who improve quality and cost-of-care for clinically appropriate outpatient surgeries at the more efficient surgical hospital setting

Cost-of-Care Savings

To lower the cost-of-care for surgical procedures, SCA Health worked with a commercial payer to implement an internal efficiency program that shares savings with the patient and payer through a fixed reimbursement structure when lower-cost implants are selected for the commercial payer’s patients.

Program structure:

50 percent of the total shared savings are placed into a shared savings pool