The following are 10 points to remember about bundled payment for stroke care:

1. Since stroke is such a disabling condition, interventions that improve functional status for stroke patients, even modestly, can be very cost-effective.
2. When care is bundled, a single payment covers multiple services (e.g., provider, hospital) related to a defined episode of care within a specific time frame. Bundling of care is a potential way to improve outcomes and reduce costs.
3. In the United States, bundled payment models (aside from diagnosis-related group, which only applies to inpatient care) are not widespread.
4. There have been seven published bundled payment demonstration projects for stroke-like conditions, and only one included stroke care. Four of these projects occurred in the private sector and Medicare implemented three.
5. Of the four private bundled payment projects, two were successful in reducing length of stay and costs. These projects applied to cardiac surgery and coronary artery bypass grafting (CABG). The other two projects, which applied to orthopedic surgery and multiple conditions (six chronic conditions, four surgical procedures, and three acute medical conditions [one of which was stroke]), were unsuccessful due to low volume and difficulty with implementation.
6. The three Medicare projects, which addressed CABG, cataract surgery, and cardiac and orthopedic procedures, were successful in reducing costs.
7. Implementing bundled payments is more difficult when there are multiple partners involved.
8. If stroke care were to be bundled, the time period should include admission through rehabilitation, and include metrics that address secondary prevention.
9. The Affordable Care Act has spurred more efforts to test bundled payment models, and results from these projects will help guide future efforts in this area.
10. Features that are likely associated with success in bundled payments include:
• An electronic information system that can monitor clinical events, quality metrics, and costs.
• Financial incentives, including targets for bonuses that align with the goals of the bundled payment system.
• Sufficient volume of patients.
• Mechanisms for balancing risk between payers and providers.

Keywords: Acute Disease, Cardiac Surgical Procedures, Cataract, Coronary Artery Bypass, Diagnosis-Related Groups, Episode of Care, Health Expenditures, Length of Stay, Medicare, Orthopedic Procedures, Outpatients, Patient Protection and Affordable Care Act, Private Sector, Secondary Prevention, Stroke, Vascular Diseases

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