Editor's Note: Payment Accountability

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Hospitals and physicians are so accustomed to getting paid every time they stick, cut, radiate, measure, poke, suture, bandage, medicate, and otherwise "do" something to a patient that the thought they will get paid to actually make those patients better is causing predictable gnashing.

Few would ever describe the current system of perverse incentives as anything more than a causal fracture of poor care, disjointed coordination, and misguided payment. If the first tentative steps into a more reasonable world of healthcare payment include the idea that healthcare episodes would be "bundled," then the reformer in all of us should celebrate.

As is often the case when theory meets real life, this transfer of risk from the government payer to provider has caused hospitals to convulse in defense of their complicated mission. How can they be reasonably held accountable for an episode of care for the patient with multiple comorbidities? How does one create the right balanced formula to pay for results gone bad even when all suggested care has been followed?

Hospitals have been girding against the idea that one day they would be held accountable for outcomes, but the new twist in the bundling debate may be that the view of responsibility has been extended into areas outside the traditional end point of inpatient care. As one health system CEO told me, "We are being forced into an area in which we have no expertise." In response, the American Hospital Association has lobbied on what defines bundling—whether you include hospital and physician as a bundle or acute and postacute. The AHA has suggested more demonstration projects and assessment.

Whether "bundling" survives the legislative meat grinder in 2009 is only a pause. At the core is the central covenant of whether those in healthcare feel they can stand behind their work, even as complex, as variable, and as fluid as healthcare inherently is. Whether those in healthcare like it or not, the answer may have to be yes in order to get the system we need. Providers may have to accept the unfair, to assume that risk, as the only way to break the addiction to a payment system that is killing all of us.

Jim Molpus

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