Bundled payment for mental health care: a realist review

Abstract

The shift from volume-based systems to value-based care has driven public and private payers to redesign reimbursement models that stress accountability for care quality and healthcare costs. As the dominant fee-for-service model for reimbursement encourages fragmented care, with little incentive for resource stewardship, coordination or communication across multiple providers, alternative payment models like episode-based, bundled payments have come to the forefront of the international discussion on combating rising healthcare costs. Bundled payment is a single payment for all services related to a specific treatment or condition, possibly spanning multiple providers in multiple settings. Although not a new policy initiative, bundled payments have resurfaced in the current era of health care reform with its advocates arguing that it can curtail health care costs while simultaneously improving quality. Despite the copious discussion on health care payment reform in recent years, there has been little focus on mental health and, with few exceptions, the application of bundled reimbursement models has lagged in mental health compared with other specialties. Based on these findings we aim to provide a realist review of bundled payment initiatives across the world aimed at discerning what works for whom, in what circumstances, in what respects and how. We therefore aim to discuss what are the main characteristics of bundled payment initiatives worldwide; what are their potential advantages and disadvantages for mental health; what are the opportunities, threats and levers of improvement across different system configurations; and what implications these initiatives might have in a national health system such as Italy. In order to do this, we employed a realist approach to evaluation. The first step was to make explicit the programme theory or theories, the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then defined the scope of the review concept mining and framework formulation; searched for and scrutinized the evidence; extracted and synthetized the evidence; and developed the narrative, including hypotheses. We found few examples and theories of bundled payment in mental health, although some notable examples and theories have been described and also a number of programs underway in mental health that will hopefully prove out just how sustainable this pay-for-value approach will be for providers. Bundled payments for mental health, have the potential to substantially improve care coordination among hospital and community services, to encourage integration of physical and mental health providers, could compel systems and payers to focus on well-described critical time windows for mental health patients, such as transition of care from inpatient to outpatient settings or vice versa and generate savings for mental health. Our review enabled the decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively and provided the key elements to design the first bundled payment for severe mental health patient in Italy.