A comprehensive overview of barriers and facilitators in the design and implementation of bundled payment contracts

Abstract

Introduction: Most current healthcare payment methods financially punish providers that deliver high quality, preventive and appropriate care. A healthier population decreases volume, and therefore lowers their revenue. In addition, most current healthcare delivery systems are highly fragmented and providers are paid separately for their services. This forms a major obstacle to the integration of care. Therefore, many countries are now taking steps to transition their provider payment system from traditional volume-based to innovative valuebased payment methods. One of these newer methods in particular has attracted prominence lately: bundled payments. Although its potential to facilitate the integration of care is considered high, there is a lack of studies addressing the complexity in the design and implementation of bundled payment contracts between payers and providers. Due to the complex interactions between a high number of factors on different stakeholder levels, implementation is complicated. Methods and results: We performed a scoping review that aims to identify and categorize the hindering and facilitating factors in the design and implementation of a bundled payment contract. Together with a university librarian we developed a review protocol based on the PRISMA statement. The search was performed on nine scientific databases and, in addition, relevant grey literature (e.g. government and third-party evaluation reports) was included as well. The initial search resulted in 4.035 unique articles. After screening titles, abstracts and full text, 115 articles were included in the final study sample. Two reviewers examined the full text independently and identified and coded the barriers and facilitators described in the literature. Then, in an iterative process, they searched for consensus and collated them into comprehensively defined themes until a saturation point was reached. This saturation was then externally tested in consultation exercises with groups of experts. Eventually, the themes were collated into 54 key factors and considered relevant to the aim of the study. We then constructed a model with two axes in which all factors were plotted. On the vertical axis we used a system-wide perspective that illustrates the interactions between different healthcare stakeholders (government, payers, providers, professionals, patients). On the horizontal axis we used the six phases of a healthcare procurement design- and implementation process (specify, select, contract, identify, deliver and monitor, payment). Based on the high degree of interaction between factors in our model we defined ten dichotomous design considerations that are essential for the successful implementation of a bundled payment contract. Discussion and conclusion: The model shows a comprehensive overview that provides valuable insights for all payers and providers aiming to facilitate the integration of care by designing and implementing a bundled payment contract. It illustrates which factors, on which stakeholder level and in which procurement phase, might influence the process and therefore need to be taken into account. This enables policymakers to change their mindset from thinking of bundled payments as too complex and unfeasible to a challenge that has, although still comprehensive, huge potential to improve healthcare quality and contain costs by facilitating the integration and coordination of care for patients.