Will the Identification and Treatment of Acute Stroke Add Value?
Thomas C. Royer, M.D.
Henry Ford Medical Group, Detroit, Michigan
To be effective today, disease management must assure outcomes that will create value for the patient by raising the quality of care while maintaining or lowering the costs. Quality alone is no longer sufficient to garner support for a treatment plan in the world of managed care. If the treatment is not affordable, its quality will probably not make it saleable or useable by our patients and their families.
The majority of payments for health care in America come from third-party payors--including government for Medicare and Medicaid recipients and insurance companies or HMOs for commercial patients. The decision to cover a particular service is usually based on two criteria: (1) is it nonexperimental, and (2) is it FDA approved? Based on these criteria, the treatment of acute stroke with t-PA should be a reimbursed service. However, the medication and treatment procedure is only one part of the continuum of stroke care. There are numerous steps in the early identification and transport of an acute stroke patient to an appropriate treatment facility. We must persuade third-party payors to understand the importance of each of these interconnected steps and seek funding from them to offset the costs.
As we move from a fee-for-service environment to a capitated HMO payment mechanism for many of our patients, the delivery team members must take the financial risk for providing this service. A capitated payment usually provides for total care for all episodes of disease as well as health maintenance. Consequently, the delivery team must deliver all care in the most cost-effective way so that there will be dollars remaining to cover the identification and treatment of acute stroke when such is required for an HMO patient. It is also important to note that slowly but surely Medicare and Medicaid systems are moving from a fee-for-service payment mechanism to a capitated structure. Therefore, these same challenges will ultimately apply to most of our patients regardless of their health care reimbursement mechanism. The questions explored by the Health Care Systems Panel included:
All disease management processes have costs associated with them that must be covered by some reimbursement process. Designing a treatment process and testing its validity is the important first step toward ensuring this reimbursement. This has been accomplished. Understanding the importance of the treatment process and learning how to incorporate it into our medical practices is the next step. This is the primary goal of this monograph. Recognizing that the medical management process adds value to the patients being cared for by an informal or formal health system, and covering the costs of such, is the final step in assuring the best possible care for the largest number of people in America.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last updated May 17, 2011