PHP 310 FINAL
Good care will always require teamwork between multiple types of expertise (T/F)
TRUE
Health IT has have positive business indicators and regulatory environment (T/F)
TRUE
In the UK the Government owns the hospitals. (T/F)
TRUE
In the UK there are no insurance premium, no co-pays, and no fees of any kind. (T/F)
TRUE
Define market justice
What is really mean is market efficiency
Primary care physicians 46% practice in 1 or 2 person practice; only 7% work in organizations or 11 or more MDs (T/F)
TRUE
Private insurance has 80 year history and deep roots in American health culture (T/F)
TRUE
RI has an Office of the Health Insurance Commissioner (T/F)
TRUE
Rates higher than negotiated rates with ESI (T/F)
TRUE
Rates of employer based coverage are slowly declining (T/F)
TRUE
Real and lasting culture change is slow and difficult (T/F)
TRUE
Risk adjustment can be technically complex and expensive (T/F)
TRUE
Separating the financing and delivery systems doesn't work well to control costs. most of the proposed solutions to rising cost involve having the delivery system share financial risk with the financing entities, or at times assume it completely. (T/F)
TRUE
Some of the US's high cost for health care can be attributed to differences in social determinants. (T/F)
TRUE
Some specialists can do Primary Care (e.g., internal medicine and pediatrics) (T/F)
TRUE
States currently with low medicaid coverage will experience the greatest increase in eligibility and enrollment (T/F)
TRUE
Technical vs. Interpersonal Care: One could argue, at least for the care of chronic diseases, that this is an artificial distinction. (T/F)
TRUE
The US research infrastructure is the envy of the world. (T/F)
TRUE
The US spends more money than other countries in the health care system. (T/F)
TRUE
The governance of ACOs must be a recognized, authorized organization. (T/F)
TRUE
The health care is heavily regulated. (T/F)
TRUE
The inefficiencies and less than optimal service quality in office settings is creating opportunities for new markets and new care settings (e.g., urgent care centers and retail clinics) (T/F)
TRUE
There are both shortages in primary care physicians, and also distribution problems (T/F)
TRUE
There are gaps in employer sponsored insurance (ESI) (T/F)
TRUE
There are many different types of hospitals facing many challenges. (T/F)
TRUE
There is consolidation in physician practice, but less in primary care than specialty care (T/F)
TRUE
There is tremendous pressure for hospitals to reduce costs AND improve quality (T/F)
TRUE
There is widespread agreement and excellent data supporting the assertion that social factors are stronger determinants of health than medical care (T/F)
TRUE
Those residing in states without expansion and are near poor are not eligible for Medicaid or for premium subsidies (T/F)
TRUE
Trends in Medicaid enrollment cyclical with the economy (T/F)
TRUE
Typically the goal of insurance is to protect again uncommon or rare, expensive events. (T/F)
TRUE
Usually, the Emergency Department does not have information about patients. (T/F)
TRUE
We have a fragmented, information, and defacto mental health system (T/F)
TRUE
We should have alternative payment models - payments linked to quality and value. (T/F)
TRUE
With hospice you are less likely to be hospitalized and to die in hospital (T/F)
TRUE
health insurance is all about cost shifting (T/F)
TRUE
How much is Cadillac Tax (percent wise) ?
Tax is 40% of the value of the plan that exceeds threshold amounts
What does an AMC teach?
Teaches generations of health care professions with an eye on training the right mix of providers for tomorrow's needs
What is the Providers perspective on quality?
Technical skills, knowledge, training, reputation, how their patients fare
Define Technical interoperability
Technical standards and data models for interfaces - HL7, IHE, FHIR
In France the Health Care System covers every resident and guarantees each the same level of care. (T/F)
True
There are gaps in public insurance (Medicaid) (T/F)
True
In France, there is little interference with Medical Doctor decision making. (T/F)
True.
A lot of things contribute to health other than health care. (T/F)
True. A lot of things contribute to health other than health care.
Define cream skimming or cherry picking
Try to select and insure healthy people, and avoid sick people; get the full premium but not the risk of having to pay much out
How is Interoperability defined in ONC's nationwide roadmap?
"...Systems can exchange and use electronic health information without special effort on the part of the user."
Define ambulatory care:
"Ambul" = walking
Define Fee for Service in Medicaid
-Standard Medicaid delivery system -Providers paid for each unit of service by State
Hospitals can gain or lose up to what percent in 2013?
1%
Describe the history of AHRQ (7)
1. 1989: created as part of the Omnibus Budget Reconciliation Act of 1989, called the Agency for Health Care Policy and Research (AHCPR) 2. part of charge: clinical guideline development 3. 1993-1995: Conflicted with drug and device industries, and with surgeons, particularly back surgeons, who disagreed with evidence about the lack of effect of back surgery for low back pain 4. 1994: Republican control of House and Senate (Gingrich "Contract with America") 5. 1995: budgetary battles and near eliminate of the agency 6. 1997: Dr. John Eisenberg became agency Director 7. 1999: reauthorizing legislation changed name to the Agency for Healthcare Research and Quality (AHRQ), dropped guideline focus
Talk about the large MA study of primary care. (3)
1. 34.5% connected only to a practice 2. 59.3% connected to a specific physician 3. 6.2% neither
What drives the cost of Medicaid? (3)
1. 60% acute care and payments to managed care plans 2. 34% long term services 3. 6% special payments to hospitals serving low-income and uninsured patients
What are the two interrelated trends in Ambulatory care?
1. Because inpatient care is so expensive, payers won't pay for an overnight stay if it isn't medically necessary 2. Hospital-based outpatient care is more expensive than non-hospital based outpatient care
What are determinants of health? (6)
1. Behaviors 2. Social circumstances 3. Environment 4. genetics 5. medical care 6. stress
What are possible solutions to create incentives to cut costs in high spending areas? (4)
1. Bundling and Accountable Care organizations 2. Increase incentives for high value, low cost services: e.g., pay-for-performance 3. Generate and disseminate better data about variations and cost-effectiveness: e.g., public reporting 4. Shared decision making tools
What decision must states make about state exchanges? (2)
1. Decide to set up or not 2. Federal rules, but lots of state discretion
what are threats to historical sources of revenue for AMCs? (3)
1. Decrease in inpatient admissions 2. Migration of services to outpatient settings - often not owned by the AMC 3. Governmental quality/value based payment schemes that disadvantage institutions with complex care -Process-of-care measures -Efficiency - Medicare Spending per Beneficiary -Patient Satisfaction
Describe how state licensure is primary oversight mechanism for hospitals and other health organizations (3)
1. Joint Commission on the Accreditation of Healthcare Organizations (JCAHO or the "Joint Commission" 2. JCAHO certification can satisfy requirements for state licensure: 80% of hospitals choose this route 3. The other 20% choose state mechanisms
What services does Long Term Care Include? (13)
1. Nursing Homes 2. Home Health Care 3. Hospice Care 4. Assisted Living 5. Day Care Programs 6. Case Management 7. Residential Care 8. Adult Foster Care 9. Meals on Wheels 10. Rehabilitation Hospital 11. Rehabilitation Center 12. Physical and Occupational Therapy 12. Personal Care Attendants
What are 3 examples of regulations in health care?
1. physicians 2. Hospitals 3. managed care
What does CQI stand for?
Continuous Quality Improvement
Data connectivity is not simply _____ (3)
Data connectivity is not simply PLUG AND PLAY
Define semantic interperability
Data standardization around common vocabulary required
What decision must states make about Medicaid expansion?
Decide to take up or not
How can value in health care be a research area?
Decision analysis, cost effectiveness analysis
What does an AMC develop?
Develops technology and carries out research that improves lives
Variations can be seen in all dimensions of care, such as what? (2)
Diagnosis treatment
Regulation must evolve as what changes ?
Evolve as society, business, technologies, and needs change
How has regulation in healthcare evolved?
Evolved as the business of health care and has become more complex
What was the objective of the Hospital Compare experiment?
Examine trends in quality of care and racial/ethnic disparities in 6 years after Hospital Compare
Define Cadillac Tax
Excise tax on insurers of employer sponsored plans with aggregate values that exceed $10,200 for individuals and $27,500 for families
Technical requirements are the primary reasons for lack of health information exchange. (T/F)
FALSE. Technical requirements are NOT the primary reasons for lack of health information exchange.
The National Institute for Clinical Excellence decision-making is completely private. (T/F)
FALSE. The decision-making is fully transparent.
FDA requires measures of ____ (1)
FDA requires measures of FUNCTIONING
What are generally agreed upon concepts for ACOs? (3)
Group of providers Joint responsibility for a population of patients Responsibility includes quality improvements and cost reductions
High quality interpersonal care, is required for what?
High quality interpersonal care, at least for chronic care, is required for good technical care to be implemented -Return visits -Medication adherence -Behavioral changes
In the UK the National Health Service pays all ____ (1)
In the UK, the National Health Service pays all BILLS .
Where must accountability occur? (3)
Inpatient Outpatient Across care spectrum
Interdependence, "The most knowledgeable people are also the most ____(1)"
Interdependence, "The most knowledgeable people are also the most CONFLICTED."
Describe economic sustainability: federal over state
Intra-state competition limits state ability to generate revenue
Define Advance Directive
Is a general term used to describe two types of documents - living wills and medical powers of attorney
What is driving variation in preference rates?
It has to be the preferences of the physicians practicing in these communities that is driving these variations in rates
Is Canadian private insurance expensive or inexpensive.
It is inexpensive because it isn't needed for much in Canada
When did the modern NIH begin to take shape?
Just before WWII
Describe 1990's HMOs in 4 bullet points.
Little patient choice Medical doctors feel disempowered, don't like being told what to do Cost focus Under care (stinting)
_____(1) are concentrated in poor performing hospitals.
MINORITIES are concentrated in poor performing hospitals.
Nevada, Florida, New Mexico, and Texas had uninsured rates that are ____ (percent) or higher
Nevada, Florida, New Mexico, and Texas had uninsured rates that are 24% or higher
Define Block grant
Only broad federal parameters -> lots of flexibility for states
Define congress
Passes laws which often are modified and occasionally repealed
People with mental disorders often cannot _____ (1)
People with mental disorders often cannot WORK
Personal health care needs include what?
Physical, mental, emotional, and social concerns related to individual functioning
States must provide what following services in order to receive federal matching funds?
Physician Services Hospital Services (IP and OP) Lab and Xray services EPSDT FQHC and Rural Health Clinic Services Family Planning services Pediatric and Family NP Services Nurse Midwife services Nursing Facility Services > 21 year old HCBS Transport Services Tobacco Cessation
Physician workforce is getting more ______ (3)
Physician workforce is getting more FEMALE AND OLDER
Physicians and hospitals that accept government payment cannot practice _____ (1) as well; so there is not much private practice.
Physicians and hospitals that accept government payment cannot practice PRIVATELY as well; so there is not much private practice
What are the two broad types of Medicare ACOs?
Pioneer ACOs (more risk) Shared Savings ACOs (Less risk)
The Canadian providers are private ____ (1) practice.
Private FFS practice
What is an RN
Registered nurse (2 years training)
Define mandatory spending
Reliant on authorized legislation, not annual appropriation acts -Examples: Medicare, Medicaid
Shewart's observations were _____ (1) in the US
Shewart's observations were IGNORED in the US
$57B in uncompensated care; 75% of this paid for by local, state, federal governments, 25% by providers (T/F)
TRUE
Due process from 5th and 14th amendments required of regulatory action that could result in denial of life, liberty or property. (T/F)
TRUE
EDs in the US are busy and stressed care settings (T/F)
TRUE
Employees don't have to purchase ESI if it offered, cost can be an obstacle (T/F)
TRUE
Even if two insurers use the same payment scheme, the amount paid can vary (T/F)
TRUE
In 1962 FDA inspector Frances Oldham Kelsey receives an award from President John F. Kennedy for blocking sale of thalidomine in the United States (T/F)
TRUE
In the UK most physicians only have one source of payment. (T/F)
TRUE
In the UK, General practitioners are private business people - not government employees. (T/F)
TRUE
In the US price per unit of service is dramatically higher than in other countries (T/F)
TRUE
In the US, in mental health (as in other countries) we under treat some people and over treat others (T/F)
TRUE
Mental disorders are prevalent both in the US and worldwide (T/F)
TRUE
The House recently passed Doc Fix (SGR fix) Bill. (T/F)
TRUE
The Medicaid option to cover childless adults occurred in 2014: 19-65 with 133% FPL through ACA (T/F)
TRUE
The UK has no billing system. (T/F)
TRUE
The majority of NPs are in specialty ambulatory care settings (T/F)
TRUE
We are still unclear on how to do P4P. (T/F)
TRUE
Medical schools and house staff training increasingly teachings principles of what?
Teamwork, root cause analysis
The "value" of the health care we get is, relative to other developed nations, ____ (1)
The "Value" of the health care we get is, relative to other developed nations, LOW
The French have ____ (1) choice of plans; most plans are very similar.
The French have LITTLE choice of plans; most plans are very similar.
Describe MMA of 2003
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Medicare Modernization Act or MMA) Created Part D: prescription drug coverage Rebranded M+C as medicare advantage Increased reimbursement to plans Created regional PPOs (so that beneficiaries in rural areas could benefit) and special needs plans
How many hospitals does the NHS own?
The NHS
The NHS is very ____ (1); no battles with insurance companies about bills
The NHS is very POPULAR; no battles with insurance companies about bills
The NHS owns 2000 hospitals, that is ___ (how many times) as many Hospitals as Hospital Corporation of America (HCA), a for-profit chain.
The NHS owns 2000 hospitals, that is 10 times as many as Hospital Corporation of America (HCA), a for-profit chain
What is the only Health Care payer in the UK?
The National Health Service
The US ____ (overuses/underuses) may diagnostic and treatment modalities that have a strong evidence base.
The US UNDERUSE many diagnostic and treatment modalities that have a strong evidence base
Define quality assurance
The concept of inspection or culling, throw out defective products or "bad apples"
The indirect costs of mental disorders (loss of earnings) are _____ (high/low)
The indirect cost of mental disorders (loss of earnings) are HIGH
The number of hospitals and hospitalizations are ____ (1)
The number of hospitals and hospitalizations are FALLING
READING: Use of mental health services for anxiety, mood, and substances disorder in 17 countries in the WHO world mental health surveys by Philip S. Wang
The number of respondents using any 12-month mental health services (57 [2%; Nigeria] to 1477 [18% USA]) was generally lower in developing than in developed countries, and the proportion receiving services tended to correspond to countries' percentages of gross domestic product spent on health care. Although seriousness of disorder was related to service use, only five (11%; China) to 46 (61% Belgium) of patients with sever disorders received any care in the previous years.
READING: The Effective of Pay-For-Performance In Hospitals: Lessons for Quality Improvement by Rachel M. Werner...
The performance of the hospitals in the project initially improved more than the performance of the control group: More than half of the pay-for-performance hospitals achieved high performance scores, compared to fewer than a third of the control hospitals. However, after give years, the two groups' scores were virtually identical.
The public/private split is very different between countries' health care in developed countries is mostly _____ (private/public), which has implications for policy solutions.
The public/private split is very different; health care in developed countries is mostly PRIVATE, which has implications for policy solutions.
When money is saved by not paying for something, what does NICE do with the money?
The saved money gets spent on something else; it does not go to profit
There is a nursing ____ (1)
There is a nursing SHORTAGE
WELCOME: www. hrsa.gov INTRODUCTIOn
To provide the national leadership, program resources, and services needed to improve access to culturally competent, quality health care. HRSA focuses on uninsured, underserved, and special needs populations in its goals and program activities
What is IPAB's purpose?
To recommend ways to reduce Medicare spending if Medicare per capita growth rates exceed certain targets
WEBSITE: www. ahrq.gov INTRODUCTION
To support, conduction, and disseminate research that improves access to care and the outcomes, quality, cost, and utilization of health care services. Information from AHRQ's research on outcomes, quality, costs, use, and access helps people make more informed decisions and improves the value of the health care services they receive.
What does TQM stand for?
Total Quality Management
What can vary in an ACO? (2)
Variety of provider configurations Variety of payment models
Define Living Wills (sometimes called medical directives)
are written instructions for care in the event that a person is not able to make medical decisions for him or herself. Currently, 47 states and the District of Columbia have laws authorizing living wills. Massachusetts, Michigan and New York do not
Adverse selection arise because of what?
asymmetric information
What did the Import Drugs Act of 1848 ban?
banned food and drug adulteration
Medication costs are waived for whom? (3)
children people over 60 The chronically ill
Define single risk pool
claims experiences of all enrollees in individual plans pooled; reduces risk that sicker people will pay higher premiums
Define rate making
deciding what to charge people with different risks
What was the goal of the Hill -Burton construction funding (1946)
expansions of hospitals
In health care in the US, regulation and over sight can have what 3 components?
federal state private
Who is eligible for medicaid expansion?
half of those who would be eligible are under 35 35% between the ages of 35-54 Four in five uninsured adults not living with dependent children Mix of race/ethnicity: -White Only - 55% -Hispanic - 18% -Black/African-American - 20% More than half who could gain coverage are male
Define hospital consolidations
integrated delivery systems -Lifespan: RIH, Hasbro, Miriam, Newport, Bradley -Care New England: Women and Infants, Kent, Butler
Define medical power of attorney (sometimes called a health care power of attorney)
is a document that appoints a particular person (health care proxy or health care agent) to make health care decisions for a patient who is unable to do so for him- or herself (not just during a terminal illness) All 50 states and the District of Columbia have laws recognizing health care powers of attorney. Currently 28 states and the District of Columbia specify the types of decisions that health care proxies can make.
Physician connected patients are more likely than practice connected patients to get what?
mammography, cervical cancer screening, colorectal cancer screening, recommended diabetes care, and recommended coronary disease care
READING: Sensipar Story
medicare pays for kidney dialysis: very costly Erythropoietin story: anemia drug -Free-for-service payment mechanism -Some is good, too much is harmful -Bundling * effectively reversed overuse Sensipar: combats bone disease -Excluded from bundling in 2010 -now again in 2013 Inserted into "fiscal cliff" legislation by Senate finance committee -Max Baucus (Democrat, Montana) -Orrin Hatch (Republican, Utah) Increases Medicare costs ($500M) Lobbying by interest groups: 74 Amgen lobbyists Campaign financing Bipartisan Science and drug development Payment mechanisms: FFS and bundling Role of interest group, $, and lobbying Politics and health care Every dollar cut = a dollar of income lost for someone
Define consolidation
mergers and integration of health systems
Who is in charge of the coordination of discipline in regulation?
national Practitioner Database (NPDB) maintained by HRSA which is part of HHS
Define quaternary care
pediatric heart surgery or BMT
Alternative payment methods are needed that create incentives for what? (2)
quality value
What does misuse of preference-sensitive care refers to?
refers to situations in which there are significant tradeoffs among the available options. Treatment choices should be based on the patients' own values (such as the choice between mastectomy and lumpectomy for early-stage breast cancer); but often they are not
Define medical loss ratio
requirement that 80% of premium dollars in individual market be spent on care and quality improvement
Define executive branch
responsible for most of the implementation and regulation of health care
Define courts
rule on civil, criminal and occasionally constitutional matters related to health care
A different of 1-2% may matter to what type of hospital?
safety-net hospitals
Define categorical grants
specific criteria -> less flexibility for the states
The ACA does a number of things to promote ______ (2)
the ACA does a number of things to promote PRIMARY CARE
What percent of the Medicare population is part of a minority group?
~20% (8-10 million)
How many people does medicaid cover?
~68 million individuals
When is risk adjustment critical?
Critical in public reporting and pay-for-performance
Define inpatient care
At least one overnight stay
Where is MinuteClinic located in?
CVS
Define load or loading fees
Costs over and above the actuarially fair premium cost
When was the National Health Service formed?
In 1948
Define true patient-centric interoperability.
"Data follows the patient without special effort on the part of the patient."
What is the guiding principle according to HITECH Act?
"Data follows the patient."
READING: IOM report: Unequal Treatment: Confronting Disparities in Health Care by Institute of Medicine
"Disparities in the health care delivered to racial and ethnic minorities are real and are associated with worse outcomes in many cases which is unacceptable." -Alan Nelson, retired physician, former president of the American Medical Association and chair of the committee that wrote the Institution of Medicine report, "Unequal Treatment: Confronting Racial and Disparities in Health Care"
Describe Lynn Ho, MD (Micropractice)
"I am just adoring CurrentCare!" ENROLLMENT "I am checking every patient who comes in tot see if they are enrolled and enrolling them on the spot, if not enrolled." LABS "A patient with leukemia wanted his CBC from RIH (they send consult notes, but it takes a few days). I pulled it up in CurrentCare and was able to share this with the patient in a timely fashion. "When specialists call me up for labs I've ordered, I say to their staff: 'Enroll in CurrentCare and you can pull these off the website yourselves!'"
Define manual rating
"Manual" comes from use of rate manuals from pre-computer era Age, gender, occupation, location, health status used to predict costs -> sicker people pay more More commonly used in the "individual market"
"Safety Net" hospitals serve the ____ (1)
"Safety net" hospitals serve the POOR
"Value" is difficult to define for hospitals and perhaps even more difficult to ____ (1)
"Value" is difficult to define for hospitals and perhaps even more difficult to INCENTIVIZE
What is the retainer free of concierge medicine?
$1000-$5000
What are some cost-reduction feature of the ACA? (3)
$716B from Medicare over 10 years Independent Payment Advisory Board (IPAB) Tax on "Cadillac plans"
What is the HHS worth money wise?
$967 Billion dollars
Define ADLs
(Activities of Daily Living) The most commonly used measure of disability. ADLs determine whether an individual needs assistance to perform basic activities, such as eating, bathing, dressing, toileting, or getting into or out of bed or chair
Define IADLs
(Instrumental Activities of Daily Living) A person's ability to perform household and social tasks, such as home maintenance, cooking, shopping, and managing money
What does the ACA say about how child up to age 26 can be covered under their parents' policies?
(a) IN GENERAL - A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage. (b) REGULATIONS - The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a) (c) RULE OF CONSTRUCTION - Nothing in this section shall be constructed to modify the definition of 'dependent' as used in the Internal Revenue Code of 1986 with respect to the tax treatment of the cost of coverage
In economics, what is an externality?
(aka transaction spillover) is a cost or benefit not transmitted through prices that is incurred by a party who did not agree to the action causing the cost or benefit. The cost of an externality is a negative externality, or external cost, while the benefit of an externality is a positive externality, or external benefit
Define managed care for medicaid
-Medicaid services provides from an organization under contract with the state -MCOs receive monthly payment from state -Many states requiring enrollment in MCO
What 4 categories of low income persons (with income cut-offs that vary by state) does Medicaid cover?
1. Children 2. Parents 3. Pregnant women 4. Disabilities
How does the Doc Fix Bill harmonizes merit-based incentive payment system? (4)
1. 4% max penalty/bonus in 2019 and 9% in 2022 2. EMR adoption and health information exchange (25%) 3. Quality and Resource Utilization (30% each) 4. Clinical Practice Improvement (15%)
Who are the uninsured? (7)
1. 47M people in 2010 2. Recession and high unemployment rates worsened the problem 3. Disproportionately poor 4. Usually from working families 5. More likely to be non-white 6. Tremendous state-to-state variation 7. Cost is the most commonly reported reason
What is the Technology challenge for AMCs? (3)
1. "Arms race" mentality for acquisition of new technology 2. High-end equipment is expensive to purchase and maintain and often requires extensive training 3. Reimbursement may not offset the increased cost of the technology
What are some issues with measuring outcomes? 93)
1. "Hard," objective, outcomes like death rates are often irrelevant (i.e., in any situation where mortality is rare) 2. Functional outcomes - Objective measures: stress test, 6 minute walk -Self-reported functioning -Good measures exist, but they are less intuitive 3. Risk adjustment is necessary
What is the pragmatic argument for state regulation? (3)
1. "Laboratories of democracy" 2. Local approaches to meet local needs 3. Existing state infrastructure
Technical definitions of quality (3)
1. "Quality is the extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." 2. "Quality and safety are ultimately determined by the degree to which health care improves important patient outcomes." 3. "Characteristics associated with excellence, including safety, effectiveness, patient control, timeliness, efficiency, and equity."
What are some facts about campus suicides? (5)
1. #2 cause of death among college students 2. Over 1,100 suicides/year on college campuses 3. 4/5 young adults who commit suicide show warning signs before hand 4. 90% of young adults who commit suicide have a diagnosable mental diagnosis, usually depression or substance abuse 5. Only 15% of suicide victims were in treatment at the time or their death
Describe the graph: Quarterly All-Cause 30 Day Readmission Rate CurrentCare Alerts vs. No Alerts (2)
1. $1.8 Million Lower Readmission costs in the Alert Group in 2013 2. $24 million reduction if extrapolated to all admissions in the state
Describe dual eligible spending (4)
1. $128.7 billion spent on Dual eligible (2008) -39% of all Medicaid expenditures -Aged represent 62% of spending 2. 69% expenditures for long term care services 3. Cost sharing for medicare services and premiums account for 1/4 spending 4. $16,087 average per capita -$28,000 per year for 85+
Describe the Milbank Memorial Fund (4)
1. 105 year old operating foundations 2. National scope 3. "Improving Population Health by connecting leaders and decision makers with the best evidence and experience." 4. Three priorities -Be a source for evidence and experience in response to state requests -Build state health policy capacity -Increase impact of Milbank Quarterly
Describe Federal insurance regulations (pre-ACA) (4)
1. 1973 HMO Act 2. 1974 Employee Retirement Income Security Act (ERISA) -Exemption of self-insured employers from state regulation 3. 1986 Consolidated Omnibus Reconciliation Act (COBRA) -Continuation of coverage option for families who lose employer health benefits 4. 1996 Health Insurance portability and Accountability Act (HIPAA) -Federal "floor" limiting coverage denials
Describe the 3 bullet points describing ACO utilization and cost benchmark concept
1. 3 year prior utilization history (Parts A and B spending), weighted toward most recent year 2. Spending projections will use national data and will go out 3 years 3. Shared savings only start if you exceed a certain amount of savings (MSR or minimum savings rate)
What are the three levels of NCQA certification?
1. 35-59 points and all must pass elements 2. 60-84 points and all must pass elements 3. 85-100 points and all must pass elements
What is the political philosophy for federal regulation? (3)
1. 50 different strategies -> harder to make a national strategy -Issue of national/multi -state companies 2. Citizenship is a national and not regional or local concept -Problem of disparities among states 3. Federal responsibility to "promote the general welfare" -Local allocation/policy decisions may be guided by politics (this is true for national decisions too)
Describe how we have started a transformative change in alternative payment models - payments linked to quality and value? (2)
1. 50% of Medicare FFS payments under APM by the end of 2018 2. Payments linked to quality and value to reason 85% by 2016
Clinic characteristics in hospital based ambulatory care (5)
1. 55% General Medicine 2. 14% Surgery 3. 11% Substance Abuse/other 4. 11% Pediatrics 5. 9% ob/gyn
What is the workload or demands on PCPs (4)
1. 56% of visits to physicians offices are for primary care, but only 37% (287,000) of physicians are PCPs 2. Patients are older, have more chronic illnesses, and more care needs 3. Estimated time needed to provide evidence based chronic care: 10.6 hours per day 4. Estimated time needed to provide evidence based prevention: 7.4 hours per day
Who is driving the cost of Medicaid? (3)
1. 67% of spending attributed to elderly and disabled who account for 1/4 of total enrollees 2. Growth in number of enrollees and rising health care costs 3. Per Capita spending -Disabled: $14,500 -Elderly: $12,500 -Adult : $2,500 -Children: $2,100
What are the provider types in hospital based ambulatory care? (2)
1. 74% saw physician 2. 18% saw NP/PA; 14% only saw NP/PA
What is the Office type in outpatient offices (4)
1. 87% private practice 2. 6% public health clinics or urgent care centers 3. 3% community health center 4. 4% other
Describe stats associated with Urgent Care Centers (5)
1. 9,000 urgent care centers in the US; growing by 300-400 per year 2. Average visits per week = 357 3. 85% open 7 days/week 4. 69% of patients wait 20 minutes or less to be seen; 3% wait more than 40 minutes 5. 94% have at least 1 full time physician on staff
Describe the operation and clinical efficiencies in HIMSS adoption Model Stage 7: UPMC (7)
1. 94% of all orders directly into EMR - reducing the potential for human error 2. Eliminates time-consuming processes such as the search for paper records 3. Eliminates the need to ask for the same information from the patient or parent. 4. Mobile, wireless computers allows nurses, physicians to spend less time charting at the nurse's station and more time at the patient's bedside. 5. Gives caregivers immediate access to lab and radiology reports as well as online access to medication formularies and medical references 6. Provides information needed for regulatory and compliance standards 7. The entire EHR is securely available at the bedside and from anywhere in the world
Describe the Financial ROI in HIMSS Adoption Model Stage 7: Kaiser Permanante (3)
1. 95% decrease in dictation costs documented by one Kaiser region resulting from EMR use 2. Enterprise-wise cost-savings due to dramatic decrease in print expenses. One region save $1.4 million in printing costs on annual outpatient forms alone 3. 54% reduction or archival storage space translated into a $200,000 savings in just one year
What are the provider type for outpatient offices? (2)
1. 95% physician 2. 6% NP/PA
Describe Hospice (4)
1. A cluster of comprehensive services for the dying 2. "Method" of care 3. Interdisciplinary Team and patient/family unit of care 4. Includes: -Pain and symptom management -Emotional and spiritual support (patient AND family) -Bereavement support (for family)
What is driving the evolution of quality measures? (3)
1. AHRQ: collecting and disseminating data 2. BOTH private and public payers 3. New private organizations that have developed to meet the needs of payers, often formed by purchasers
How is there better cost control in MH than general medical sector of health care (3)
1. About 1/4 (23%) of total costs are for drugs 2. Use of outpatient care 3. Use of community and informal care
What needs to be improved in the health care system? (5)
1. Access 2. Cost 3. Quality 4. Patient experience 5. Provider experience
What are the 6 ways EHRs improve quality?
1. Access to accurate and complete information 2. Support for clinical decision making (reminders, alerts, safeguards, increased efficiency) 3. Reduction of errors, patient safety (Information can be shared, Automatic of prescribing) 4. time and cost savings 5. Patient-centeredness 6. Public health advantages
Describe the National geographic distribution of primary care physicians (4)
1. Access to primary care varies widely between rural and urban areas 2. 21% of US population lives in rural areas, but only 10% of doctors practice in those areas 3. 65M people in the US live in areas designated as Primary Care Health Professional Shortage Areas 4. 16,000 additional PCPs needed in these areas
Hospital Compare has quality indicator for what 3 conditions?
1. Acute myocardial infarction (AMI) 2. Congestive heart failure 3. Pneumonia
What are CMS's 3 responsibilities?
1. Administer Medicare - CMS contracts with private companies (Fiscal Intermediaries under part A and Carried under Part B) to process and pay claims 2. Administer Medicaid and CHIP - This duty is assigned to state agencies who receive funding support from the Federal Government 3. Regulate all laboratory testing on humans
What are the 3 things required for Health Care Transformation?
1. Adoption and Use of an Electron Health Record (EHR) - To Drive Efficiency, Reduce Waste and Improve Quality 2. Health Information Exchange with other Providers - So Data Follows the Patient, and Drives Efficiency and Quality with network effect 3. Knowledge- and Data-driven Learning System - Analytics to Drive Population Health, and Precision and Personalized medicine
What are the 9 Areas of Disadvantage for US?
1. Adverse birth outcomes 2. Injuries and homicides 3. Adolescent pregnancy and sexually transmitted infections 4. HIV and AIDS 5. Drug related mortality 6. Obesity and diabetes 7. Heart disease 8. Chronic lung disease 9. Disability
What are the 9 areas of disadvantage for US ?
1. Adverse birth outcomes 2. Injuries and homicides 3. Adolescent pregnancy and sexually transmitted infections 4. HIV and AIDs 5. Drug related mortality 6. Obesity and diabetes 7. Heart disease 8. Chronic lung disease 9. Disability
Describe the Medicaid and Health Care reform (4)
1. Affordable Care Act was passed and signed into law in March 2010 -Enacted January 1, 2014 2. Requires most US citizens and legal residents to have health insurance 3. Expansion of Medicaid to all non-Medicaid eligible individuals under age 65 with incomes up to 133% FPL 4. Federal government to cover 100% of states cost 2014-2016 and decreasing to 90% in 2020 and thereafter
How do HDHPs work? (3)
1. All costs up to the amount of the deductable paid out of pocket 2. Once deductable amount reached, the insurance kicks in (though there can be copay and coninsurances) 3. One the out-of-pocket maximum is reached, the enrollee pays nothing
Explain simplicity as an advantage of measuring technical process. (3)
1. All women between 50 and 75 should have a mammogram every 2 years 2. All diabetics should be screened yearly for diabetic retinopathy 3. All patients who have had a heart attack should be on daily aspirin (absent counterindications)
Describe Intraoperative Magnetic Resonance (MR) (5)
1. Allows for imaging during an operation 2. Less than 5% of time the machine is used during the day if dedicated to the operating room 3. Limited opportunity for other uses of the MRI 4. No additional payment for use of the technology 5. Very expensive technology that will be used by a small number of cases
What are ACA's 10 essential health benefits
1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services include behavioral health treatment 6. prescription drugs 7. Rehabilitative and habilitiative services and devices 8. laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including vision and dental care
"Joint" means endorsed by what 4 main physician groups interested in primary care?
1. American Academy of Family Physicians 2. American Academy of Pediatrics 3. American College of Physicians 4. American Osteopathic Association
The Joint Commission on Accreditation of Health Organizations (JCAHO) is organized and funded by whom? (5)
1. American College of Surgeons 2. American Medical Association 3. American Dent Association 4. American Hospital Association 5. American College of physicians
Explain the quality indicator: Pnemonia (7)
1. Antibiotic within 6 hours of arrival 2. Antibiotic selection 3. Blood culture within 24 hours (ICU) 4. Blood culture before first antibiotic dose 5. Smoking cessation counseling 6. Pneumococcal vaccination 7. Influenza vaccination
Describe managed Care Organization (MCO) (4)
1. Approximately 70% of Medicaid enrollees receive some or all of services through MCO 2. MCO paid on capitation basis 3. Ability to structure and deliver a network of providers -Ensure Medicaid recipients have a choice in providers 4. Majority of enrollees are children and non-disabled adults -States pushing for mandatory enrollment of elderly and disabled
Explain the Quality indicator: Acute myocardial infarction. (6)
1. Aspirin on arrival 2. Aspirin at discharge 3. Beta-blocker at discharge 4. ACE-I or ARB in left ventricular systolic dysfunction 5. Smoking cessation counseling 6. PCI within 90 minutes
Describe state-licensed health insuring organizations or "fully insured" plans (5)
1. BCBS, Aetna, United Healthcare 2. Employer pays a premium for each employee, and the plan assumes full insurance risk for employee 3. Tend to be smaller employers, 3-199 employee range 4. 45% of the private insurance market 5. Regulated by states
How do we counterbalance moral hazard? (3)
1. Balance or tension 2. no insurance or poor insurance: little protection against financial losses 3. Too much or poorly structured insurance: unnecessary or wasteful utilization
Why must hospitals maintain all the expensive services and technology? (2)
1. Be properly accredited and licensed 2. Attract various insurers, patients AND physicians
Describe Meaningful Use Stage 3 (6)
1. CMS recently published stage 3 rules for public comment 2. Goes into effect in 2017 3. Reinforced Triple Aim 4. Reduces Complexity of Reporting 5. Promotes Interoperability and Health Information Exchange 6. Aligns Quality Reporting for: EMR incentive program, Hospital inpatient quality reporting, and physician quality reporting system
Describe Private, for-profit hospitals (3)
1. Can distribute profits to share holders 2. Must pay all taxes 3. More flexibility to raise revenue and capital from share holders
What are micro-level solutions to primary care panel sizes? (2)
1. Care teams involving delegation of non-MD tasks to others 2. Idea of practicing at the top of your license
What are some of the variety of additional services included in concierge medicine? (4)
1. Cell phone access to MD 24/7 2. Same day visits 3. longer visits 4. PCP accompanies you to specialty visits
Explain Federal regulation through medicare (3)
1. Certification of participation required -Can come through JCAHO certification 2. EMTALA (1986): hospitals that participate in Medicare must provide appropriate emergency care 3. Clinical Laboratory Improvement Amendments (CLIA 1988): Quality standards for medicare
How has the federal power and authority grown over time, creating conflict? (2)
1. Challenge of the ACA in the Supreme Court 2. Firestorm about the ACA and contraception
What are some significant internal challenges to PCMH? (4)
1. Changing daily activities 2. Changing how providers in PCMHs communicate with each other 3. Integrating new people and new roles into primary care practices (e.g. care coordinators) 4. Requires new skills
How do Urgent Care Centers compare with emergency room? (4)
1. Cheaper source of care (3-4x cheaper) 2. Often shorter wait times 3. Often lower copay for insurance than ER 4. Perhaps inappropriate for children under 2 if no pediatric expertise
Where do you find process measures? (3)
1. Claim databases (if it is something that is reimbursed) - also called "administrative data" 2. Medical records (e.g. smoking cessation discussions, examining the feet of diabetic patients) 3. medical records can be incomplete and if not electronic can be difficult to review
Describe Retail clinics (4)
1. Clinics located in retail stores -Grocery stores -Drugstores -"Big box" stores such as Wal-Mart 2. Convenient, walk-in care for minor problems like colds and prevention (e.g., flu shots) 3. Usually staffed by non-physicians 4. Night time and weekend hours
What is some powers shared by both the state and national government? (6)
1. Collect taxes 2. Regulate banks 3. Establish and administer a judiciary 4. Borrow money 5. Provide for common good 6. Make and enforce laws
How did Mergers pick up in the 1990s? (2)
1. Combine some administration roles 2. Increased bargaining power with private insurers
What are some societal considerations about health care (5)
1. Communicable diseases 2. Cost shifting (negative financial externality) 3. Improper and inefficient care delivery; misuse of services 4. Paternalism: irrational decisions, free riders 5. Job lock: fear of becoming uninsured prevents people from changing jobs
Describe self-funded employee health benefit plans (4)
1. Company insures itself rather than purchasing insurance 2. Contract with third party to administer the benefits 3. Tend to be large employers, often with employees in multiple states 4. NOT regulated by states; regulated by federal government under a law called ERISA
How are outpatient clinics now a source of profit for hospitals? (4)
1. Compete with private physicians for privately insured patients 2. Cross-referral with hospital inpatient facilities 3. Send non-urgent ED visitors to ambulatory care center 4. Better manage patients under managed care (can discharge)
What is political and economic competition argument for state regulation? (2)
1. Competition -> better performance 2. Ability to move to somewhere more in line with policy preferences -Individuals/businesses -"Threat of exist" can make policies more responsible to local needs
What is the political and economic competition argument for federal regulation? (3)
1. Competition will produce race to bottom 2. Issues of inequity 3. Can everyone "vote with their feet"?
What is the legal basis of regulatory power? (3)
1. Congress passes laws 2. Agencies in executive branch are authorized or empowered by those laws to develop regulations that implement those laws 3. Agencies are authorized to take executive legislative and judicial types of actions in the course of implementation
Describe coordination/integration in PCMH (2)
1. Coordination across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services) 2. Care is facilitated by registries, information technology, health information exchanges and other means
Regulation generally focuses on what 3 inter-related domains of health care?
1. Cost 2. Quality 3. Access
What are some other effects of Medicaid expansion? (2)
1. Coverage for the homeless population, who tend to be frequent users of the Emergency room -More consistent treatment for conditions such as alcoholism, drug addiction, chronic pain, and depress -Shift in burden of care from ER to doctor's offices Prevention of homelessness as a result of illness or medical debt
Describe Medicaid Expansion Eligibility and states (2)
1. Currently, few states cover non-disabled, non-pregnant parents up to 133% FPL in Medicaid -Typically, Children covered through CHIP and parents left uninsured 2. 18 states, prior to ACA, provide comprehensive Medicaid coverage to parents at or above 100% FPL ($18,530 in 2011)
What are some consequences of being uninsured? (4)
1. Decreased access to outpatient and preventive care 2. Decreased access to drug treatments 3. Increased rates of avoidable hospitalizations 4. Financial problems
How can markets "fail"? (4)
1. Development of monopoly or oligopoly power 2. Collective action or public good: e.g. highways or national defense 3. Inadequate information: e.g. food labeling, drug or device quality, or hospital quality 4. Unseen externalities: e.g. water pollution, global warming, or cost-shifting in health insurance
Explain the quality indicator: Congestive heart failure. (4)
1. Discharge instruction 2. Left ventricular function assessment 3. ACE-I/ARB in LVSD Smoking cessation counseling
What are 2 ways that we can integrate health information exchange into workflow at care delivery?
1. Doctor seeing the patient 2. Checking up on the patient after patient visiting other providers
What are some additional medicaid populations? (3)
1. Dual eligible enrollees 2. Disproportionate Share Hospitals (DSH) 3. SCHIP
Describe the regulatory system of health care (2)
1. Flexible, evolving public-private partnership 2. In some cases we are seeing innovations to provide data to help consumers be "smarter" and thus make markets work better
Describe how futile disease modifying care often continues at the cost of a lower quality of life (5)
1. Due to lack of needed provider-patient-family discussions regarding prognosis and end-of-life care options 2. Due to lack of advance directives or to advance directives that aren't honored 3. Due also to out fragmented healthcare system and lack of "case management" 4. Due to system (financial) incentives - The "choice" people must between medicare hospice and other medicare benefits -The financial benefits of continuing care (Example: Chemotherapy within a week or two of death) 5. Also, culture of care community seems related to care intensity
Explain how agencies require specialized knowledge, expertise, and resources. (2)
1. E.g., state legislatures create licensure requirements for physicians, and create a mechanism in the form of medical boards, but then leave the task of creating and enforcing the standards to the boards 2. Legislation doesn't try to address/resolve technical issues, but creates mechanisms to do so
How can we improve care and documentation of preferences (3)
1. Early discussions regarding condition and what to expect -- upon diagnosis and ongoing 2. Fair reimbursement for healthcare providers to having end-of-life discussion with patients 3. use MOLST (in RI) to ensure patient directives are followed
Why grants? (5)
1. Economic efficiency 2. Easier for federal government to redistribute resources 3. Economic stabilization: "Automatic stabilizer" 4. Way for federal government to influence state or local policies 5. Allows for state or local experiments and innovation
What happened when many hospitals closed or downsized under PPS? (3)
1. Efficient hospitals could do well under PPS 2. Inefficient hospitals could easily lose money 3. Rural hospitals hit hard
Talk about Medicaid's history (4)
1. Enacted in 1965 2. Jointly funded by federal and state governments - Federally defined core benefits and populations -States define optional groups and benefits to cover -State financial contributions vary 2. Originally, entitlement program for low-income families receive cash assistance 3. Today, coverage expanded to others who meet certain criteria
What are the Six NCQA standards?
1. Enhance access and continuity 2. Identify and manage patient populations 3. Plan and manage care 4. Provide self-care and community support 5. Track and coordinate care 6. Measure and improve performance
Define Health Savings Accounts: HSAs (4)
1. Enrollees and/or employers can contribute pre-tax money to HSA 2. Can be invested like IRA funds, and any earnings are non-taxed 3. It can accumulate from year to year 4. Can only be used for qualifying health expenses
History of private plans in medicare
1. Enrollment in private plans started in 1970s -HMO act of 1973) 2. Between 1993 and 1999 enrollment increased from 1.8 to 6.9 million because of favorable plan reimbursement 3. Mostly group and staff model HMOs, with some IPAs 4. Balanced Budget Act (BBA) of 1997 created Medicare + Choice -PPOs -Private FFS plans -High deductible plans with Medical Savings Accounts
What are some of the powers of state government? (8)
1. Establish local government 2. Regulate intrastate commerce 3. Public education - schools 4. Conduct elections 5. Provide for common good - protecting health, safety/morals 6. regulations for marriage 7. Professional licensure 8. All powers not delegated to the national government or denied to the states per US constitution
Describe quality and safety in ensured in PCMH (4)
1. Evidence-based medicine and clinical decision-support tools guide decision making 2. Physicians engage in performance measurement and improvement activities 3. Information technology supports patient care, performance measurement, patient education, and enhanced communication 4. Patients and families participate in quality improvement activities at the practice level
Describe Medicaid Expansion (3)
1. Expand Medicaid eligibility to all individuals < 138% of the Federal Poverty level (FPL) 2. Uniform minimum Medicaid eligibility standard across states 3. Currently... -29 states and DC have expended -7 are still considering it -15 are not considering it
What are some future challenges for health care regulation? (2)
1. External: increasing complexity of issues and problems faced by the US: toxic waste, globalization, terrorism, new infectious diseases (Ebola) 2. Internal: Increasing complexity of financing and delivery systems in health care, and serious cost problems
Primary care practitioners are whom? (6)
1. Family phyisicians 2. general internists 3. geriatricians 4. General pediatricians 5. Nurse practitioners 6. Physician assistants
What is the government role in primary care? (2)
1. Federal government involvement in primary care -Community health centers -Sites for military personnel and veterans -Prison health care -Indian Health Services clinics 2. Relatively little state government involvement in primary care
Name and define the two types of government (public, funded by tax dollars) hospitals
1. Federal: Veterans Affairs (VA), Indian Health Service (IHS), military, prisons 2. State/Local: Psychiatric, city, county-run hospitals
What are the benefits of medicaid expansion?
1. Federally required to cover certain mandatory benefits 2. Established and administered by each state -Determines type, amount, duration, and scope of services 3. States also permitted to cover other services designated as "optional" -Many "optional" considered essential i.e. prescription drugs
Why do people visit the ED and how does it vary by age and sex? (3)
1. Females under 15: top 3 diagnoses are upper respiratory infections, ear infections, viruses 2. Females 15-64: abdominal pain, complications of pregnancy, chest pain 3. Males 15-64 open wound, contusion, chest pain
How did PPS increase consolidation?
1. Fewer stand-alone hospitals, more hospitals in health systems 2. Economies of scale 3. More market share -> more bargaining power
Describe solvency in regulation of health insurance (3)
1. Financial standard setting 2. Monitor compliance, financial condition 3. Limit risk taking
Under Donabedian's Model what falls under outcome?
Acute recovery Restoration of function Survival Efficiency
Define Symptoms (6)
1. Focus on whole organism 2. Physical symptoms such as pain or itching 3. Emotional or psychological symptoms such as frustration, anxiety, fear 4. Somatization and hypochondriasis 5. Complicated relationship between biological variables and symptoms 6. Subjective; cultural component; stigma
How does the ACA change private insurance (5)
1. Forbids denial of coverage (for pre existing conditions, cancer, sickness of any kind) 2. Can adjust premiums by age, geography, smoking and family composition 3. Caps on annual out of pocket spending 4. No cost sharing for preventive services 5. No lifetime limits
Talk about the primary care workforce (2)
1. From 1965 to 1992 MDs per capita increased from 115 to 190 per 100,000, but it was mostly specialists Primary care to population ratio increased by 14%, specialty ratio increased by 120%
Describe workforce management in terms of federal oversight and regulation. (4)
1. Funding of medical schools 2. Grants and loans for medical training 3. Reimbursement of hospitals for residency and fellowship training through Medicare: DME and IME 4. Physician compensation and the RBRVS
What is the pitch for the Edwards and Medtronic devices? (4)
1. Future of cardiac surgery is through minimally invasive procedures 2. Rewards will come to those who are early adopters of the new technology 3. Promise of significant down stream revenue 4. "Halo effect" will increase the value of all cardiac services
Describe Certification of Need (CON) programs (1974) (3)
1. Goal was contraction 2. Federal legislation requiring CONs lapsed in 1986 3. Today 36 states require CONs
What are some of the forms of regulation? (4)
1. Government imposed legal restrictions 2. Self-regulation by a trade organization 3. Social regulation (social norms) 4. Market regulation
What is primary care associated with? (6)
1. Greater use of preventive services 2. Less use of Emergency Departments 3. Higher care quality using Medicare data 4. Lower care costs using Medicare data 5. Other data show equal quality of care for diabetes, hypertension, and back pain 6. Higher overall satisfaction with care
Describe high "acuity" care (4)
1. Growth in the proportion of facilities providing tracheostomy care 2. Growth in the proportion of facilities without tube fed residents 3. growth in proportion of homes with 10%+ tube red residents 4. Many SNFs now "mini-hospitals"
What are factors in long-term care growth (6)
1. Growth of older population [MORE old people] 2. Increased longevity of the elderly 3. Medical technology has prolonged life for previously "fatal" conditions 4. PPS for in-patient care reduced length of hospital stay, promoting post-acute care 5. Desire to keep people out of hospitals 6. Desire to keep people out of nursing homes (home care)
What are some of the types of consequences or ways to induce behavior change? (6)
1. Hassle and costs 2. Taxes 3. Fines 4. Public embarrassment 5. Initiated administrative or legal actions 6. Revocation of license, e.g. of a provider, hospital, nursing home, etc.
Why don't markets work well in health care? (2)
1. Health care is complicated, and you can't comparison shop or rely on you experience 2. Even doctors have conflicts of interest because they can get paid for "selling" you services that may not help, or may hurt, and that you may not have the knowledge refuse (again, the principal-agent problem)
What is the pragmatic argument for federal regulation? (2)
1. Health has national benefits -Poor health has national costs 2. Federal government better able to adapt during recessions -Procyclical state policies (balanced budgets)
How is BCBS provider driven? (3)
1. Health insurance in Europe consumer driven 2. In US, provider driven 3. Thesis: control of this major source of insurance guaranteed that payments would remain high and that cost control would have a less important role
Describe US vs. Southern Easter Underwriters Association (1944), McCarran- Fergusan Act (1945) (2)
1. Health insurance markets could be regulated by states 2. State-regulated markets exempt from federal antitrust laws
of the 12% admitted to the hospital, what were the leading diagnoses for those admitted? (4)
1. Heart disease (6.3%) 2. Chest pain (5.7%) 3. Pneumonia (3.5%) 4. (Cerebrovascular disease (stroke, 3.0%)
What are some issues for the FDA? (7)
1. Herbal supplements: what is food and what is a drug? 2. Dietary Supplement Health and Education Act of 1994: supplements are more like foods 3. Speed of drug approval: tricky balance 4. Direct-to-consumer advertising and internet marketing 5. Off-label prescribing 6. Re-importation of prescription medications -US is the only industrialized country that does not directly regulate drug prices -Brand name drugs are more expensive here then in, say, Canada -Another balancing act; access vs. safety 7. Drug development is costly, in part because of the FDA; but drugs (mostly) trusted, also because of the FDA
How has employer based insurance distinguished between physical and mental health in coverage rules? (2)
1. Higher copays for MH 2. Limits on inpatient days and visits
What are some examples of federal power in health regulation? (2)
1. Hill-Burton Act (1946) 2. Department of Health and Human Services (1980)
What are the three approaches to end-of-life care?
1. Hospice care -Home in Community -Inpatient Hospice -Nursing Home -Assisted Living Facility 2. Palliative care 3. Disease Modifying Care (with and without PC) -Nursing Home -Hospital Intensive Care and Treatment -Home with family (perhaps Home Health Care or Outpatient Care)
Describe the Hill-Burton Act. (3)
1. Provided federal grants and guaranteed loans to states for hospital construction 2. Goal of 4.5 beds per 1000 people 3. Very successful; allowed even small, remote communities to have their own hospitals
What are the different types of Ambulatory care settings? (9)
1. Hospital emergency departments (EDs) 2. Hospital-based outpatient departments (OPDs) 3. Outpatient offices; physician private practices 4. Community Health Centers 5. Free-standing specialty care settings -Ambulatory surgery centers (ASCs) -Imaging centers 6. Urgent Care Centers 7. Retail clinics 8. Concierge medicine 9. Complimentary and Alternative Medicine
What facilities need licensure? (3)
1. Hospitals 2. Nursing homes 3. Clinics
Describe reimbursements for the medtronic and edwards trials (2)
1. Hospitals are reimbursed by DRG on a per stay basis 2. Reimbursement is basically the same under both procedures (TAVR and traditional Aortic Valve replacement)
Define Overall Quality of Life (4)
1. Idea of how happy one is with their life overall 2. May be strongly related to the economy, religious beliefs, health of others, etc. 3. Relationship to functional status may be surprisingly weak 4. Case of quadraparesis
How do states play a key role in the ACA? (4)
1. Implementation 2. Obstruction 3. Opportunities 4. Challenges
Describe meaningful use of "Certified EMRs" (5)
1. Improving quality, safety, efficiency, and reducing health disparities 2. Engage patients and families in their health 3. Improve care coordination 4. Improve population and public health 5. Ensure adequate privacy and security protection for PHI
What is the triple aim to creative transformative care?
1. Improving the patient experience of care (including quality and satisfaction) 2. Improving the health of populations 3. Reducing the per capita cost of health care
Describe growth in Hospice use (2)
1. In 2000, 23% of older adults received hospice (much variation across US states) -26.7% dying in community received hospice -13.8% dying in nursing homes received hospice 2. In 2012, 46.7% of Medicare beneficiaries who died had any hospice -Growth has resulted in more non-cancer patients receiving hospice resulting in longer lengths of stay (Bimodal distribution - Many stays very short and very long)
How should we solve the problem of geographic maldistribution for primary care physicians? (4)
1. Increase funding of the national health service corps 2. Adapt medical school admission policies to favor those likely to return to rural practice 3. Increase numbers of under-represented minorities in medical schools 4. Increase federal grants for primary care training that provide incentives to practice in underserved areas
What can be some quality challenges with Electron Health records? (3)
1. Increased errors (Poorly designed system interfaces, Lack of end-user training, Inaccuracy of patient information, Alert fatigue) 2. Risk of patient privacy violations 3. Overdependence on technology (EHR downtime, less time spent with patients)
Describe the first IPA (3)
1. Independent Practice Association 2. 1954: medical society in San Joaquin County CA worried about Kaiser plans moving in, undercutting prices and taking their business 3. Set up San Joaquin Foundation to contract with employers AND with providers -Monthly capitation fee -Foundation would pay doctors a discounted FFS rate and do utilization review
Name 3 quality focused organizations
1. Institute for Health Care Improvement (IHI) 2. Massachusetts Health Quality Partnership (MHQP) 3. Pacific Business Group on Health (PBGH)
What are some additional issues with primary care physicians? (5)
1. Insurance related access problems 2. After hours access 3. Same day scheduling ("open access") 4. Email and telephone visits 5. Delegation of non-professional tasks
Describe HealtheWay (2)
1. Integration of CurrentCare with HealtheWay ongoing (2015) 2. Bi-directional exchange of CCDs for Continuity of Care of veterans seeking care outside of VA system
What are the 9 Hospital EMR components?
1. Lab Information System (LIS) 2. Pharmacy Information System 3. Radiology Information System 4. Cardiology Information System 5. Clinical Data Repository 6. Clinical Decision Support - Drug/Drug interactions 7. Electronic Medication Administration Record 8. Nursing documentation 9. Clinical documentation
Describe the stats associated with St. Luke's Medical Center (6)
1. Licensed beds: 864 2. Employees: 4,193 3. Active medical staff: 570 4. Average daily census: 558 5. Annual admissions: 30,024 6. Home of the Texas heart Institute
Describe how we estimate who will need LTC and for how long (3)
1. Long term care needs often begin as medical problems which, in turn, compromise functioning, physical and/or mental 2. Some people will die quickly and NEVER need long term care 3. Others will acquire a need for LTC and will need it for a long time
What does overcrowding in the ED lead to? (4)
1. Long waits for inpatient beds 2. Ambulance diversions 3. Errors 4. Adverse outcomes
Who is covered under Medicaid? (5)
1. Low income pregnant women, children, and parents 2. Children with Special Health Care Needs 3. Low Income Adults with Disabilities 4. Low income elderly 5. Low income childless adults in states opting for Medicaid expansion
Describe access to care for medicaid patients (2)
1. Low rates may cause some physician offices to not accept Medicaid patients 2. mix of patients needed in order to serve decent volume of Medicaid
Studies have documented the receipt of palliative care (PC) is associated with what? (2)
1. Lower costs for hospital patients 2. Lower acute care utilization (hospital and ER use and hospital deaths) for patients with cancer
How can we finance long term care in the future? (4)
1. Major increases in the size of the elderly population, notwithstanding a dropping percentage at each age group using nursing home 2. Health Care costs, even long term care, continue to rise quicker than real GDP 3. While real GDP growth somewhat higher than historical rates could pay growing pension liabilities 4. Health care cost increases MUST slow to pay for future long term care costs
What are some of the National governments powers? (9)
1. Make treaties 2. Establish and regulate postal system 3. Regulate foreign and interstate commerce 4. Tax imports/exports 5. Declare war 6. Maintain military 7. Coin money 8. Protect copyright/patents 9. Make all laws "necessary and proper" to meet responsibilities per the US constitution
How can TQM/CQI be applied to medicine? (3)
1. Malcolm Baldridge National Quality Award mid 1980s 2. Acceleration of application to health care between 9185 and 1995 3. "Bad apples" vs. poorly designed and complex systems
Who determines the eligibility of Medicaid? (2)
1. Mandatory Eligibility groups set at Federal Level -"Categorically needy": families and children, SSI recipients, pregnant women, and Medicaid beneficiaries meeting income requirements 2. Optional eligibility groups determined by each state -Expansion of mandatory groups -States will vary with income eligibility threshold or age restrictions for some groups -Medically Needy: individuals who spend all income on health care and qualify for Medicaid via income eligibility
Describe the MA health care environment in the MA AQC Experience. (3 points)
1. Mature managed care environment 2. Established networks 3. Universal coverage in MA since 2006
Describe Provision and financing of health services (5)
1. Medicaid -Managed care 2. Public hospitals, clinics 3. Insurance for state workers/retirees 4. Health coverage expansion -Oregon Health Experiment -Massachusetts 5. Prescription drug purchase
What does the super court decision on the individual mandate mean? (4)
1. Medicaid expansion provision intact, BUT enforcement authority is restricted 2. State can now decide whether or not to expand Medicaid program 3. Expansions will increase coverage and reduce uninsured 4. Federal government will pay a very high share of new Medicare costs
What are potential reasons why medicaid rates are low. (4)
1. Medicaid rates set by states Budget allocated to Medicaid program -Set amount of dollars already set aside. If a state wants to cover more individuals and services with same amount of money, pay lower price per unit 2. Reimbursement to hospitals not as low History of serving the poor and have teaching obligations more political power to negotiate higher rates 3. Medicaid MCOs pay closer to Medicare and other private rates 4. Lower reimbursement rate claim may be deceiving
Describe workforce education and training in health care (3)
1. Medical education 2. State medical schools 3. Education for other professionals: nurses, social workers
What are HHS's duties? (11)
1. Medicare (health insurance for elderly and disabled Americans) and Medicaid (health insurance for low-income people) 2. Medical and social science research 3. Preventing outbreak of infectious disease, including immunization services 4. Assuring food and drug safety 5. Financial assistance and services for low income families 6. Improving maternal and infant health 7. Head State (pre-school education and services) 8. Preventing child abuse and domestic violence 9. Substance abuse treatment and prevention 10. Services for older Americans, including home-delivered meals 11. Comprehensive health services for Native Americans
Describe the relationship between ACA and primary care (7)
1. Medicare 10% increase in primary care reimbursement rates, 2011-2016 ($3.5 billion) 2. Medicaid reimbursement for primary care increased to at least medicare levels, 2013 - 2014 ($8.4 billion) 3. 15-20M (?) more people insured, with preventive and primary care coverage, leading to less uncompensated care 4. Medicare and Medicaid patient-centered medical home pilots 5. Grants/contracts to support medical homes through... -Community Health Teams increasing access to coordinated care -Community-based collaborative care networks for low-income populations -Primary Care Extension Center program providing technical assistance to primary care providers 6. Scholarships, loan repayment, and training demonstration programs to invest in primary care physicians, midlevel providers and community providers 7. $11 billion for Federally Qualified Health Centers, 2011-2015, to serve 15 million more patients by 2015
When someone is treated for severe aortic stenosis in patient there is a high risk of surgical valve replacement where two devices can be used. What are the two devices?
1. Medtronic: CoreValve: Self expandable 2. Edwards: Sapien XT Valve: Balloon pump
Name 2 mental health parity legislation
1. Mental Health Parity Act of 1996 2. Mental Health Parity and Addiction Equity Act of 2008
Describe the spectrum of scientific rigor: strong to weak (6)
1. Meta analysis of randomized trials 2. Individual randomized clinical trials 3. Observational studies 4. Case reports 5. Conventional wisdom 6. "In my experience..."
What are the 3 kinds of quality problems?
1. Misuse: errors, mistakes 2. Underuse: not doing things that you should 3. Overuse: doing more than you should
Define Biological and Physiological Variables (6)
1. Molecular and genetic factors 2. Function of cells, organs, and organ systems 3. Diagnoses such as HIV/AIDS, diabetes, lung cancer 4. Laboratory values such as temperature, white blood count, serum glucose level 5. Exam findings such as weakness on one side of the body, a skin rash, or a heart murmur 6. Mental diagnosis like panic disorder
The 15-member board of the IPAB is appointed by who?
Appointed by the President and confirmed by the Senate
What does medicaid expansion offer? (4)
1. More federal Medicaid funds -Federal government pays 100% of coverage costs through 2016 2. Great access to care for poor -Increased eligibility for those with FPL < 133% 3. Reduces outlays for uncompensated care -Increase in numbers insured -Physicians and Hospitals 4. Reduces financial risk for lowest-income Americans -Financial hardship due to medical bills reduced
Describe the Institute of Medicine study on the causes and consequences of Geographic variation in Medicare spending reported. (2)
1. Most of the "explained" regional variation in overall Medicare FFS spending is attributable to variation in post-acute provided 2. Post-acute care in the SNF, HHA, IRF, LTACH, re-hospitalization and outpatient care that occurs in the 90 days AFTER hospitalization
What are SCHIP covered services? (2)
1. Must provide benchmark coverage, benchmark-equivalent coverage, or Secretary-approved coverage -Modeled after private insurance 2. Stand alone programs typically do not cover a number of Medicaid covered services -These services could include Vision, Dental, Durable Medical Equipment, Mental Health Therapies, or personal care services
What are examples of organizations that review and certify measurement tools. (2)
1. NCQA (National Committee on Quality Assurance) 2. NQF (National Quality Forum)
Describe Articles of Confederation (2)
1. National government was extremely weak 2. States had own navies, currencies, etc.
Describe elements of compromise in regulation? (3)
1. National industry requires some national oversight -Physicians are mobile -Drugs sold nationwide -Insurers and other health care concerns have national scope -infectious diseases, bioterrorism, environmental hazards have national scope -Is health insurance national... it is, under the commerce clause of the Constitution, "interstate commerce" 2. State-level regulation -Closer to the provision of care -Deep understanding of local issues and regional practices -Sophistication about local and regional needs -Likely will be more knowledgeable about how to deal with things like restaurant hygiene, drinking water contamination, toxic spills, local hospital practices, and medical marijuana 3. Private professional organizations -Deep subject matter expertise -Commitment to the health of the profession -JCAHO, NCQA, LCME, and ACGME all play important roles that it would be hard for "external" regulators to duplicate -Concern about regulatory "capture"
Describe the US constitution (3)
1. Need for stronger national authority 2. Need counterbalanced by fear: strong national government as "new monarchy" (Antifederalist view) -Push for weak national government, institutional barriers to inhibit government action 3. Convention did not resolve these issues -> support for each view in the document
What are the two types of hospitals in public control?
1. Non-community hospital (~13%) -VA: serves veterans of armed services -Institutional hospitals: prisons, universities -Long-stay hospitals 2. Community Hospital (~21%) -Facilities are available to the general public -Usually provides short stays -Excludes federal hospitals
Name and define the two types of non-government (private) hospitals
1. Not-for-profit/Voluntary: Exempt from taxes 2. For-profit chains: Owned by stock holders
What can cause problems at an ED besides overcrowding? (3)
1. Nursing shortages 2. Physician shortages: surgeons and specialty care physicians related to legal liability 3. Uncompensated care
Cost sharing balancing act (4)
1. On the one hand it works to reduce utilization 2. On the other hand it does nothing to insure that patients make the right decisions about what utilization to forego 3. Population impact (RAND HIE) vs. individual impact (case) 4. Current trend: increase patient cost sharing
How can PCMHs impact the physician work life? (5)
1. One-on-one vs. team care 2. Participant/leader in team care 3. Interdisciplinary teams that might include nurses, patient educators, pharmacists, care coordinators, and others 4. Enhanced coordination and collaboration with other care settings 5. Patients/families as partners
What implemented systems are implemented to enhance access in PCMHs? (3)
1. Open scheduling (facilitating same day appointments) 2. Expanded hours: evenings and weekends 3. New options for communication between patients, their personal physician, and practice staff (e.g., email, patient portals)
Describe Safety hospital (2)
1. Operate on negative or low operating margins 2. Benefits the most from DSH and uncompensated care payments
Describe interest group politics (2)
1. Out system encourages self-interested groups of every conceivable type to play in the free market of ideas related to health care -Media set up to accentuate conflict -Internet, 24-hour news shows, blogs 2. "This process poses a challenge for health specialists: Groups pushing their own interests will stand up and oppose even the most unambiguous scientific finds."
Describe dual eligible enrollment (3)
1. Over 9 million Medicare beneficiaries enrolled in Medicaid 2. More than 60% were elderly (65+) and remaining duals are younger individuals with disabilities 3. Account for 15% of all Medicaid enrollees -Significant variation across states
Describe the HMO act of 1973 and how it stimulated growth of HMOs (2)
1. Over ruled some state laws 2. First direct federal intervention in health insurance
What are the attributes of palliative care? (4)
1. Pain and symptom management 2. may or may not be done in conjunction with life-prolonging or curative treatment 3. Addresses emotional and spiritual issues 4. Palliative care programs and/or consultation services in hospitals, outpatient settings and NHs -Often provided by a team
Describe the HITECH Act (Health IT for Economic and Clinical health). (4)
1. Part of ARRA, passed in Feburary 2009 2. Provided $29 Billion in incentive payments for meaningful use of EMR by Medicare and medicaid providers 3. Incentive payments until 2015; payment reduction penalties in 2015 4. Pass Meaningful use measures and report clinical quality measures
Describe the licensing board disciplinary processes (4)
1. Usually private until decisions made, and even then aren't widely publicized 2. Boards made up of physicians 3. State to state variation in rigor of enforcement 4. Actions usually for egregious behavior
Describe the Pure Food and Drug Act of 1906 (5)
1. Passed in response to scandals about harm caused by 2 popular cold remedies (patent medications) 2. Upton Sinclair's book The Jungle about dangerous and unsanitary conditions in meat packing industry 3. Prohibitions again "adulteration and misbranding of foods and drugs in interstate commerce." 4. Required food ingredients be listed on packages 5. For drugs, required that dangerous ingredients such as alcohol, heroin, and cocaine be listed
When doing a risk adjustment what should you statistically adjust for? (6)
1. Patient age 2. Patient gender 3. Previous disease 4. insurance 5. Income 6. Social and family support
How can a patient be engaged with health information exchange? (2)
1. Patient reported data 2. Personal Health record (PHR)
What are some of the factors explaining slower 30-year growth in MH costs? (5)
1. Payer mix: more state and local payers who face balanced budget restrictions 2. Private insurance and Medicare have required higher level of cost sharing for MH than for general medical services 3. Managed Behavioral Health Care has been successful in moderating cost growth 4. De-institutionalization: inpatient psych beds fell from 500K to 200K between 1970 and 2000 Low tech care: visits and medications
How is TQM/CQI seen in Medicare? (2)
1. Peer Review Organizations (PROs), created in 1982 to review outlier cases in Medicare program 2. Quality Improvement Organization (QIOs), created in 1992 to improve care of all patients in Medicare program
What are the principles of PCMHs (7)
1. Personal physician 2. Physician directed medical practice 3. Whole person orientation 4. Care is coordinated and/or integrated 5. Quality and safety ensured 6. Enhanced access 7. Payment reform
What are the dimensions of function status? (4)
1. Physical 2. Emotional 3. Role 4. Social
Describe provider group consolidation (4)
1. Physician Hospital Organization (PHOs) 2. Accountable Care Organization (ACOs) 3. Factors: economies of scale, negotiating power 4. Changes in financing -> changes in delivery system
What professionals need licensure?
1. Physicians 2. Nurses 3. Social workers
What are some promotions of public health? (5)
1. Population health 2. Disease control and prevention 3. Sanitation 4. Environmental protection 5. Bioterrorism
What are the 10 CAM therapies most commonly used within the past 12 months measured in terms of the percentage of U.S. adults were...
1. Prayer specifically for one's own health (43%) 2. Prayer by others for one's own health (24.4%) 3. Natural product (18.9%) 4. Deep breathing exercises (11.6%) 5. Participation in prayer group for one's own health (9.6%) 6. Meditation (7.6%) 7. Chiropractic care (7.5%) 8. yoga (5.1%) 9. Massage (5%) 10. Diet-based therapies (3.5%)
Describe preference sensitive care (2)
1. Preference-sensitive care comprises treatments that involve significant tradeoffs affecting the patient's quality and/or length of life 2. Decisions about these interventions - whether to have them or not, which ones to have - ought to reflect patients' personal values and preferences, and out to be made only after patients have enough information to make an informed choice
Describe cost sharing (3)
1. Premium cost sharing, deductables, copays, and coinsurances 2. attempt to counterbalance the natural tendency to unnecessary utilization by requiring payment at the point of service 3. Motivate patients to be smart shoppers or to have "skin in the game"
Describe consumer protection in regulation of health insurance (3)
1. Prevention of fraud 2. Regulate of product structure 3. Market conduct
What are 3 essential characteristic of primary care?
1. Primary Care Physicians (PCPs) receive all the problems patients bring 2. Have the skills to manage most of them 3. Know when to appropriately involve specialists
Describe the transformation of US nursing Homes (5)
1. Prior to Medicare/Medicaid Nursing Homes were "Homes for the Aged" 2. Nursing homes built rapidly: 1960s and 70s 3. De-institutionalization of mental hospitals 4. Deflection of cognitively impaired from mental hospital to nursing home 5. Emergence of Nursing homes as a locus of skilled, rehabilitative services and not just custodial care
How does MA work? (3)
1. Private plans are not "Medicare" 2. Required to provide all covered benefits, so it covers all part A and B costs, and all urgent and emergent care 3. Can vary benefit design as long as actuarially equivalent to "traditional Medicare" -Benefit design: e.g., cost-sharing, restrictions in provider network, how referrals work Does not cover hospice, but if you need hospice and have MA it will be covered by FFS Medicare May offer extra services such as vision, hearing, dental, wellness programs Premiums: participants pay their regular Part B premium + another monthly plan premium Its managed care (mostly): so you have to follow plan rules about things like referrals Many MA plans (about half) include part D coverage You don't need and can't buy supplemental coverage to cover deductibles, copays and coinsurance if you have MA -Those things are all part of the "benefit design" In some plans there is an annual cap for out of pocket costs for Part A and B services
Describe the NCQA (5)
1. Private regulatory entity 2. Created by plans to regulate plans 3. has become a trusted entity 4. Taking a leadership role in quality measurement and reporting 5. Producing information so that markets can work
How are RUC turn into RVUs? (4)
1. Proceedings are private and proprietary, with secret ballots 2. In a zero-sum redistribution game, decisions are political 3. The RUC is the primary advisor to CMS for RVUs -CMS has implemented 95% of the RUC's recommendations 4. Growing compensation gap between cognitive and proceduralist specialties
We need to reinvent primary care practice so it does what? (2)
1. Produces better results for patients 2. Is a higher quality work environment for providers
What are the required processes for a ACO operation? (4)
1. Promote evidence based medicine 2. Ensure beneficiary engagement 3. Report internally on quality and cost 4. Coordinate care
What are problems with multi-payer systems?
1. Provider confusion and costs: fifty different sets of rules, benefits, payment rates that are privately negotiated or publicly set 2. Consumer confusion: different rules and different benefits 3. barriers to provider innovation - too many payers to negotiate with
What are the 3 core principles of ACOs?
1. Provider led group with strong primary care base is collectively responsible for quality and costs across the continuum of care for a population 2. Payments linked to quality improvements that also reduce costs 3. Measurement that supports quality improvement and shows that cost improvements are not from stinting on needed care.
What are some challenges to LTC? (4)
1. Public perception of poor quality 2. Regulation and enforcement 3. Client/Family awareness of services 4. Services often needed in a crisis or at a point of stress; must decide quickly with little information or capacity to absorb it
Describe Patient Safety and Quality in HIMSS Adoption Model Stage 7: Kaiser Permanante (4)
1. Reduced the rate of medication errors by 57% one hospital site using barcode scanning linked to CPOE and electronic medication administration 2. Trimmed by 12% outpatient lab utilization two years after the implementation of Kaiser Permanente HealthConnect, illustrating that reduction in duplicate tests 3. Provided patients with test results within two days instead of a week or longer 4. Doctor proficiency increased anywhere from 11-39% and the more proficient doctors also reported less time spent documenting charts
Describe government payments and the ACA (3)
1. Reductions in market-based updates to provider payments 2. Reductions in payments to hospitals for care delivered to uninsured 3. Medicare's "Value-Based Purchasing" (VBP) programs to pay providers based on quality
Describe payment reforms for PCMH (4)
1. Reflect work/thought that falls outside of the face-to-face visit 2. Pay for coordination of care both within a given practice and between consultants and other resources 3. Support adoption and use of health information technology for quality improvement 4. Support enhanced communication access such as secure e-mail and telephone consultation
What are the 2 regulatory federal powers in health regulation?
1. Regulation of commerce between states -1906: Pure Food and Drug Act -> Food and Drug Administration (FDA) creation 2. Funding for general welfare
Describe the growth in Rehab and Sub-acute units (4)
1. Related to HMO penetration, competition and strategy to serve medicare patients 2. Related to greater competition in NH market 3. Non-profit facilities most likely to have unit 4. Located in somewhat larger facilities
Describe the Emergency Medical Treatment and Labor Act (4)
1. Requires hospitals and ambulances to provide care to anyone needing it regardless of ability to pay, citizenship, and legal status 2. Functional "safety net" 3. Provides no money to accomplish this; classic "unfunded mandate" 4. Counteract "dumping" of uninsured or unprofitable patients
What are three legs of the traditional AMC three legged stool?
1. Research 2. patient care 3. Education
What is the concept of a carve-out? (2)
1. Responsibility for behavioral health services separate from general medical services 2. Separate provider networks, coverage rules, administrative services
Satisfaction with care literature (3)
1. Review of the literature examining the relationship of interpersonal continuity of care to patient satisfaction (1966-2002) 2. 22 original articles 3. 19 of the 22 reported higher satisfaction when interpersonal continuity was present
What were some challenges for hospitals? (3)
1. Rising demand and constrained capacity -Medicare and Medicaid payment shortfalls -Decreased access to capital -Shortages of workers, including nurses 2. Rapidly rising input costs 3. Regulatory burden
Describe some of American cultural values (3)
1. Rugged individualism and individual freedom 2. Suspicion and distrust of government in general, and more specifically of national government's power and authority 3. Faith in markets not in governments
What is the process of regulation?(2)
1. Rules issued by agencies are similar to statutes... even though they are not issues by legislatures 2. Adjudications have force similar to court rulings... even though they aren't issued by judges or courts
Describe the Financial ROI in HIMSS Adoption Model Stage 7: UPMC (5)
1. Serious medication errors have been reduced by 92% 2. 99.5% of all results are entered directly online, 0.5% are scanned paper 3. The reduction in transcription costs saves $42,800 per year for a single note type 4. 60% decrease in medication safety events at Children's Hospital from 2003-2009 5. Administration to Documentation time in patient's charts decreased by 80%
When measuring interpersonal care what should you ask the patients? (3)
1. Service quality: office and telephone wait times 2. Communication quality: Information exchange about medications, diagnostic testings, diagnosis, prognosis 3. More complex concepts: trust, respect, overall satisfaction with care, willingness to recommend
What are 9 basic points about LTC?
1. Services sick and frail people; "Care" is as important as "cure" 2. "Functional health" is a key concept; ADLs and IADLs 3. Initially, most of the LTC continuum was custodial -- caring for persons as they steadily approached death 4. Services provided as a "continuum of care" 5. The objective is to have a range of services which are combined into client-specific packages 6. One of the major goals it to keep the person as independent as possible 7. Services are not provided by a single agency. Ability to link services is crucial for "continuity of care"; Case management is important 8. Many of the individual services are not necessarily long-term in nature. It is the combination that makes a LTC "system" 9. LTC interfaces with more aspects of life than does acute care
Describe long-term care (5)
1. Services that are delivered over extended periods of time (such as over 90 days) 2. Can include a hospital episode, but not as the primary service 3. A system of care, not just a single service 4. Can be rehabilitative OR custodial services 5. For younger persons too, not just the elderly
Talk about Walter Shewart at Western Electric (1930s) (4)
1. Shewart introduced idea that any production process, when examined using statistical methods, had a predictable and constant number of errors 2. Error rate is a function of the production process or system 3. Don't over react to individual defects, analyze and fix the production system that created them 4. Shift the whole curve upward
Describe some recent trends for hospitals? (4)
1. Shift from inpatient to outpatient setting 2. Fewer hospital beds 3. Fewer hospital stays on a population basis 4. Shorter length of stay
What are some problems with cost sharing? (4)
1. Shopping for medical care is not like shopping for groceries; different information asymmetry problem (providers know more than patients) 2. Medicaid co-pay example 3. Poor decisions (i.e., decisions that are not in the self-interest of the medical shopper) are probably common 4. Soumerai studies from 1980s on what medications people stopped taking when Medicaid medication payment strategy changed
Describe the Medical Device Amendments of 1976 (2)
1. Significant expansion of FDA authority Rules 2. Rules for testing and approval of devices that are parallel to those for drugs
Explain this theme: innovation if good... but can be very expensive (4)
1. Significant pressure to participate in both trials 2. Competition between cardiologists and surgeons resulted in many physicians wanting to be included in the trials 3. 4 teams (2 for CoreValve; 2 Sapien) complete training for participate 4. Preliminary financial analyses suggest a $20,000 loss for each case
Describe the implications of expanded nursing home use for PAC (3)
1. Since hospital PPS, implicit policy has been to expand use of nursing homes - Rapid post-acute discharge -In lieu of hospitalization in managed care -as place to die 2. Rise of assisted living and home care means NH admissions later and sick 3. Medicaid rates have grown but not kept up with this expanding role
How did the ACA encourage consolidation? (4)
1. Slowing of payment increases for inpatient stays 2. Penalties for readmissions 3. Emphasis on prevention 4. Accountable Care Organizations
What are some significant challenges relating key external parties in PCMH (4)
1. Specialists 2. Hospitals 3. Rehabilitation and skilled nursing facilities 4. Home health practitioners
What are the four distinct sectors (providers) in the mental health care system?
1. Specialty mental health sector 2. General medical/primary care sector 3. Human services sector: social welfare, criminal justice, education, religious services 4. Voluntary support sector: supports groups (AA, Al-Anon, NAMI Rhode Island)
Describe the Resource-based relative value scale update committee (RUC) (3)
1. Sponsored and run by American Medical Association 2. Recommends RVUs for each of >7000 medical services 3. 26 voting members, most appointed by specialty societies -Generalists: >50% of visits; only 3 (11%) on RUC
What are the 3 levels of regulation in the US?
1. State 2. Federal 3. Private
How is the government involved in virtually every domain of regulation but yet a private sector? (3)
1. State governments have responsibility for professional licensing, but they give physicians permission to deign and implement the process 2. State governments have responsibility for hospitals and institutional licensing, but JCAHO actually does it 3. Employer based insurance and tax expenditures
Describe SCHIP cost sharing (3)
1. State option to impose cost sharing and/or premiums 2. Total cost sharing cannot exceed 5% annual family income 3. Children with income < 150% FPL -Cannot be charged more than $16 month for premium -Cannot be charged more than $5 for services
What are some confrontations to regulation? (4)
1. State-federal balance: supreme court decisions on ACA 2. Population vs. individual health 3. Acute vs. chronic disease 4. Public vs. private sector role
Describe SCHIP funding (3)
1. States receive enhanced match rate [65% minimum], but funds capped 2. Total enrollment, 2011: 7.9 million nationwide 3. Total spending, 2009: 10.6 billion -7.5 billion Federally funded -3.1 billion state funded
Describe the problem of shared powers and ambiguity (2)
1. Strong national government/fear of same 2. Federalism allows for shifts in power and for shared power --> ambiguity
What does the NCQA measure? (3)
1. Structural features of HMOs: how providers selected, size of provider network 2. Patient satisfaction type measures: ease of enrollment, responsiveness to enrollee inquiries 3. Health employer data information set (HEDIS): clinical performance -Preventive care: e.g. immunizations - Screening: e.g. mammography -Measures of disease management: e.g. proper diabetes care
Desfine and explain Avedis Donabedians 3 elements in the Donabedian's model
1. Structure: physical and organizational resources contributing to healthcare delivery 2. Process: Activities that constitute care delivery 3. Outcome: Results of care processes; recovery, restoration of function, and survival
What are research priorities for palliative care policy initiatives (5)
1. Studies that create a roadmap for scaling successful implementation and dissemination of proven models of care 2. Novel financing models for health care delivery 3. Quality of care metrics and integration into payment and accreditation/regulatory models 4. Workforce development in geriatrics and palliative care 5. Current and future hospice benefit structure and practice
How is the patient's perspective on quality? (3)
1. Subjective outcomes: experience of care; being treated with respect, dignity, courtesy 2. Objective outcomes: (reassurance, BP control, survival) 3. Other object outcomes: functional outcomes, safety
Describe Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in terms of Private regulation (4)
1. Surveys every 3 years 2. Formerly very process oriented: look at many things including completeness of medical records, minutes of medical staff committees, quality assurance and improvement processes, operating room procedures, etc. 3. Last 10 years: focus on outcomes and quality improvement 4. JCAHO surveys not considered "friendly visits" by most hospitals
Describe the exchanges and premium subsidies in the Medicaid expansion? (4)
1. Target is the near poor, those not Medicaid eligible after Medicaid expansion 2. Use private insurance plans to accomplish this 3. New market places for individuals and small businesses 4. Level playing field for private insurers to compete
Describe the tax credits in exchanges and premium subsidies? (4)
1. Tax credits: 250-400% FPL 2. Tax credits and cost subsidies for those with incomes from 138% to 250% FPL -400% FPL is $46,680 for individual and $95,400 for family of 4 (2013 numbers) 3. Sliding scale 4. Requirement to buy insurance is waived if you have to pay >8% of income after accounting for employer contributions and tax credits
When measuring interpersonal care how do you ask patients about care? (3)
1. Telephone surveys 2. Mail surveys 3. Internet surveys
Describe concurrent Hospice and Disease Modifying Care (3)
1. The Accountable Care Act required CMS to conduct a demonstration of Medicare Concurrent Care -Not yet initiation -Perhaps fear of "death panels" accusation 2. The Veterans Administration (VA) does allow for concurrent care -Study now underway to evaluate it 3. Aetna insurance company has reimbursed for concurrent care with very favorable outcomes
Describe innovative models/study in nursing homes (2)
1. The OPTIMISTIC CMS-funded - A comprehensive program, building on evidence-based strategies, to collaborate with 19 central Indiana nursing facilities to improve the quality of care of long stay nursing facility residents and reduce hospitalization 2. Palliative care consults in nursing homes (PI: Miller, SC) -Have gained an understanding of how nursing home residents' receipt of PC consults in associated with end of life hospital/ER use for -By identifying an algorithm to identify PC consults using claims data attempts to make this type of research easier
Describe accessible care (3)
1. The ease with which a patient can initiate an interaction with a physician 2. Interaction could be a visit, phone call, or increasingly an email interaction 3. Also refers to efforts to eliminate barriers posed by geography administrative issues, financing, culture, and language
Using the Institute of Medicine Report, 2002 what are some Evidence that shows disparities exist? (5)
1. The evidence is "overwhelming" 2. Disparities exist even when insurance status, income, age, and severity of conditions are comparable 3. Minorities are less likely than whites to receive needed services 4. Disparities contribute to worse outcomes in many cases 5. Differences in treating heart disease, cancer, and HIV infection partly contribute to higher death rates for minorities
How does quality assurance try to find the source of mistakes? (2)
1. The person working on the assembly line at the time of error 2. The physician, pharmacist, or nurse who makes an error
Describe whole person orientation in PCMH (2)
1. The personal physician is responsible for providing all the patient's health care needs and organizes needed referrals 2. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care
What is the role of the interest group in America? (2)
1. Theory -Politicians alleged incapable of acting decisively in public interest -Interest groups and private interests fill void to advance private agendas 2. Potential consequence: Policy making responds to financial resource of interest groups and re-election need of politicians not to objective public and social needs
What are examples of market failures (3)
1. Theory of externalities -Water pollution -Erin Brockovitch (CA powerplant) -Carbon taxes 2. Orphan drugs: no company will ever develop drugs with small markets if there is no chance of recovering their investment 3. drug safety: why we have FDA
Describe fragmented politics in US (5)
1. Theory of fragmented political power -Checks and balances -Separation of powers -Federalism 2. President's agenda may not be adopted 3. States can pursue their own agendas 4. Many opportunities to block legislation 5. Parties weak by international standards
What are the implications of people getting older and LTC being used more (2)
1. Today's elderly can expect to be disabled for 4 years and receive LTC for 2.7 years -One in three will have at least 5 years of difficulty -One in five will have at least 5 years of care 2. There is considerable variation among demographic groups is expected years of disability and LTC -Women will be disabled 1.5 years longer than men and will receive more of each type of care -persons divorced or separated are disabled longest but spend a large share of that time without care
What is the problem with a primary care physicians panel size? (2)
1. Too many patients; too few PCPs 2. PCP needs a panel size of 2000 patients to survive economically
Describe Urgent Care Centers (5)
1. Treat patients who have illness/injury that requires immediate care but not require ED -Should be treated within 24 hours 2. Unscheduled, walk-basis 3. Extended hours -fills in the gap after private offices are closed 4. More services than primary care practice -X-ray, defibrilator, oxygen, lab capabilities 5. Can be free-standing or within hospitals
Describe social justice: federal over state (2)
1. Treatment of vulnerable populations 2. Equality
What is an effective use of Board of Trustees (3)
1. Understand the issues 2. Back up Management 3. Manage the cocktail party chatter
What happens to states that opt out of Medicaid expansion? (4)
1. Uninsured with income 100-133% FPL eligible for federal subsidies in the exchange 2. Residents paying taxes that support health care benefits in other states 3. Uninsured with income <100% FPL not eligible for subsidy 4. State experiences a net increase in spending during the short term due to more spending on uncompensated care -Reallocation of state funds to hospitals due to reduced DSH
What is the summary of arguments for primary care? (3)
1. Value proposition: can be improved with a more primary care oriented health care system 2. NB: specialty care is critical - the issue is how do we get the proportions right 3. Does the primary care have its act together? not yet!
Describe institutional capacity/feasibility: federal over state (2)
1. Variable state capacities 2. Balanced budget requirements, other limitations to state capacities
Describe tensions over turf for doctors (4)
1. Vascular surgeons vs. cardiologists 2. Orthopedic surgeons vs. neurosurgeons 3. generalists (primary care) vs. specialists 4. Doctors vs. nurses
How can ED visit rates vary by patient characteristics? (3)
1. Visit rate for nursing home residents was 4x that of those living at home 2. Visit for homeless was twice that of those with homes 3. Visit rate for blacks twice of that of whites
Who implemented Shewart's observations in Japan's industry after WWII? (2)
1. W. Edwards Deming 2. Joseph M Juran
What are 2 key points about moral hazard?
1. When we have insurance we behave differently in ways that may produce utilization than when we do not 2. when we have insurance we are more likely to utilize health services than when we do not, and the more insurance we have the more we are likely to use
What are the two parts of the value proposition?
1. cost 2. quality
Medicaid program evolved from entitlement for the poor to health coverage for many more groups include whom? (4)
1. elders 2. Disabled 3. pregnant women 4. children
Economic regulation involves what two things in hospitals?
1. hospital supply 2. rates
How is "data hoarding" a critical and pervasive problem? (3)
1. large hospital systems consolidating more hospitals and practices 2. Flawed thinking that everyone adopting Epic solves the problem 3. Vendors charging recurring fee for data to leave/enter EMRs
Describe non-ownership classifications (6)
1. length of stay Short stay (<=30 days) Long stay (>30 days) -Long-term rehab, chronic ventilator patients 2. Teaching vs. non-teaching 3. Number of beds 4. Urban vs. rural 5. General vs. specialty -Psychiatric, tuberculosis, children's, rehabilitation 6. Safety net, Disproportionate Share Hospitals
What 3 conditions should primary care understand?
1. living conditions 2. family dynamics 3. cultural background
In the context of our poor "value" health care system, arguably this is the kind of care that is needed, particularly given that our population is increasingly what? (4)
1. older 2. chronically ill 3. obese 4. diverse: racially, ethnically, religiously, culturally, linguistically
Describe the theme: Data follows the patient (4)
1. patient should not chase and aggregate data from multiple sources 2. Systems interoperability necessary but not sufficient 3. Patient authorizes the HIE to collect, aggregate and deliver data 4. Patient-mediated exchange should be the last resort, not primary means
What does Hospital OPDs include what services? (4)
1. primary care 2. cancer center 3. ambulatory surgery center 4. diagnostic services
Hospitals can gain or lose up to what percent in 2014?
1.25%
What are some of the key reasons for high costs and low quality in health care? (3)
1.Care delivery in silos vs. care continuum 2. Fee for Service vs. payment for value 3. Cost and Quality Transparency
What are macro-level solutions to primary care panel size? (4)
1.Increase PCP supply 2.Reduce PCP-specialty income differences 3. Change the way graduate medical education is funded to train more PCPs 4. Expand NP training
How many people visit the Emergency Department (data from 2007)
116.8 million visits in 2007 (~300M people in US) 39.4 visits per 100 persons
What percent of health care revenue is spent collecting bills?
12%
Describe what 12% means in context with shared savings
12% = Shared Savings which is split between CMS and the ACO according to various formulas: generally between 50 and 65% goes to the ACO ... DEPENDING on the quality scores
What percent of ED visits are by the uninsured?
15.3%
Of the top 24 universities in the world, how many does the US have?
18
Describe History of HRSA (5)
1935: Social Security Act Title V authorizes general health grants to States by the Public Health Service 1973: Health Services Administration and Health Resources Administration established 1982: Health resources and services administration (HRSA) created by merging Health Services Administration and Health Resource Administration 1990: Ryan White Comprehensive AIDS Resource Emergency (CARE) Act begins providing support for people with HIV/AIDS 2010: ACA increases funding to Community Health Centers ($11 billion)
When did the National Cancer Institute (NCI) form?
1937
When did the NCI campus in Bethesda open?
1940
Canada has had National Health Insurance since when?
1961
Describe CMS History (8)
1965: Medicare and Medicaid enacted 1972: medicare extended to those with ESRD 1973: HMO Act passed 1980: Medigap (a private plan) brought under federal oversight 1982: Quality oversight expanded to include Peer Review Organizations (PROs), which in 1992 because Quality Improvement Organizations (QIOs) 1985: The Emergency Medical Treatment and Labor Act (EMTALA) 1997: Balanced Budget Act of 1997 (BBA) - State Children's Health Insurance Program (SCHIP) was created 2003: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA), created Part D (Medicare drug coverage) and created Medicare Advantage
When was the Prospective Payment System (PPS) passed?
1983
When was NICE originally set up (year)?
1999
Private Insurance history
19th century Europe - Voluntary benefit funds -Set up by guilds and industries -Pay monthly premium and get assistance when ill Metropolitan Life and Prudential -10-25 cents/wk along with life insurance -Paid for funeral and final illness expenses -Premiums collected weakly; administrative expense great
Hospitals can gain or lose up to what percent in 2017?
2%
In 2000, what fraction of first-year residents in primary care were IMGs
2/5
UK's administrative costs are what percent of America's costs?
20%
READING: The Patient-Centered Medical Home Movement by Eric B Larson
2002 to efforts to improve access, change reimbursement models, increase productivity -> physicians didn't like it 2006 pilot to decrease panel size and increase visit length -> better response Unclear how this will roll out to other clinics They conclude that primary care is complex and difficult, and change is hard (even in an organization like theirs)
When was Hospital Compare initiated?
2005
When will Cadillac Tax come into affect?
2018
In 2005 and 2006, what percent of office visits were to international medical graduates (IMGs)
25%
How can state health departments fund local agencies?
3,000 local (county, city, district, region...) public health departments
READING: The Long-Term Effect of Premier Pay for Performance on Patient Outcomes by Ashish K. Jha...
30 day mortality
Describe the quality measures in an ACO.
33 measures in 4 domains Patient/caregiver experience (7 measures) Care coordination/patient safety ( 6 measures) Preventive health (8 measures) At-risk population -Diabetes (1 measure and 1 composite consisting of five measures) -Hypertension ( 1 measure ) - Heart failure (1 measure) Coronary Artery Disease ( 1 composite consisting of 2 measures)
In the IRS rule is overturned how many states would lose subsidies?
34 states
Updates about medicaid expansion
48% of people eligible for Medicaid reside in states not expanding the program Applications for Medicaid increased 15% faster than what is usually received in an average month Medicaid enrollment outpacing enrollment in private insurance
Describe how the Texas Medical Center is the largest in the world
54 Member Institutions including: -25 agencies of government -24 private not-for-profit health institutions -14 Hospitals -4 Medical Schools -6 Nursing Schools -3 Public health organizations -2 pharmacy programs 106,000 employees 20,000 Physicians, scientists, researchers and other advanced degree professionals in the life sciences 6,800 patient beds 7.2 million visits annually Great than 18,000 international patients
What percent of IMGS were in primary care specialties, compared with 46.2% of US medical students
57%
What percent of UK doctors are generalists?
60% of Medical doctors are generalists
Outside of metropolitan areas what percent of IMGs, compared with 39.8% of US graduates, practices in areas with primary care shortages?
67.8%
Explain the experiment where patients' race affected clinical decision-making
720 physicians shown a recorded interview from a hypothetical patient about their chest pain; given other data Asked to make a recommendation about cardiac testing
Describe AAMC 400 Major Teaching Hospitals and Health Systems (5)
79% of all level-one trauma centers 68% of all burn care unit beds 37% of neonatal ICUs 59% of pediatric ICUs 37% of all hospital charity care nationwide
What percent of drugs are provided at no cost in the UK?
85% of drugs are provided at no cost.
CMS is what percent of HHS budget?
88%
What percent of the French buy supplemental health insurance to pay for things sickness funds don't pay for (like Medigap)?
90% of French buy supplemental insurance to pay for things sickness funds don't pay for.
What is Health (WHO definition)?
A complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity (WHO), 1948
Due to MD services exceeding the target of the Balanced Budget Act of 1997 what has happened?
A deficit has built up in the $200-300 billion range
Define co-pay
A fixed amount that the insured person has to pay at the time a service is provided
READING: Can Medical Students Afford to Choose Primary Care? An Economic Analysis of Physician Education Debt Repayment by James A. Youngclaus CONCLUSIONS
A primary care career remains financially viable for medical school graduates within median levels of education debt
Define NICE.
A special health authority, to reduce variation in the availability and quality of NHS treatments and care.
Define federalism.
A system of government with both a central authority and autonomous constituent jurisdiction
Define Basic EHR system
A system that has all of the following functionalities: patient history and demographics, patient problem lists, physician clinical notes, comprehensive list of patients' medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically
READING: Professionalism, Regulation, and the Market: Impact on Accountability for Quality of Care by L. Gregory Pawlson
ACCOUNTABILITY Physicians and physician organizations Hospitals Insurers COMPETITION, CONSUMERISM, AND MARKET FORCES Consumerism slow to arrive to health care Ratings in new magazines and websites Increasing public interest in accountability
ACO operations have a wide _____ (2) for required processes.
ACO operations have a wide IMPLEMENTATION LATITUDE for required processes.
Define ACOs (technical definition).
ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely. It will share in the savings it achieves for the Medicare program.
ACOs are intentionally a ____ (1) model; Pioneer ACO's can move to full capitation in year 3.
ACOs are intentially a TRANSITIONAL model; Pioneer ACOs can move to full capitation in year 3
ACOs are not a single, well-defined _____ (1)
ACOs are not a single, well-defined ENTITY
What are some of the future intelligent alerting to improve quality that might be in place?
ANALYTICS FILTERS A1C > 9 and previous A1C < 9 PATIENT PANEL GENERATION A1C > 9 and A1C < 9 in last 6 months TIME BASED NOTIFICATION Last A1C >= 7 and no lab in the last 3 months Patient had 2 or 3+ ED visits or inpatient admissions in past 6 months MEDICATION RECONCILIATION AND ADHERENCE For high-risk meds, alert PCP that patient discharged on new medication in same class of medication as patient was on before patient discharged with community acquired pneumonia and does not fill and prescription for an antibiotics within 1 or 2 days of discharge
Is the MA AQC experiment working?
AQC experiment seems to be working
How much money is being spent to install/replace Hospital Information Systems?
About $100 million
About what fractions of Canadians have private insurance?
About 2/3 have it
How many people are served in the French Health Care system?
About 61 Million people are served.
Define quality
Abstract, multi-faceted concept that related to the improvement of patient health outcomes
What does AMC stand for?
Academic Medical Center
Without insurance what is compromised?
Access to care is compromise, cost to individuals is increased, and quality suffers
Insurers pay hospitals according to what?
According to various payment system schemes (FFS, per episode...)
What does ACO stand for?
Accountable Care Organizations
What is the goal of the PCMH?
Achieve the triple aim -Improving the experience of care -Improving the health of populations -Reducing per capita costs of health care
Outcome measurement, to be fair, should take account of or adjust for what?
Adjust for patient characteristics related to their baseline risks for the outcome in question
Define modified community rating
Adjustments allowed for family coverage, geography, age and tobacco use No adjustments permitted for pre-existing conditions, occupation, gender, duration of coverage, credit, worthiness 3:1 ratio of highest to lowest premium in 21-64 age group allowed
How are bills handled with the Carte Vitale?
After a visit, bill sent with a single key stroke, and payment comes in three days.
What does AHRQ stand for?
Agency for Healthcare Research and Quality
Define Health information exchange
Aggregate (collect and combine) data from multiple sources to create comprehensive patient record
Alignment of economic/financial incentives is probably _____ (1) but not sufficient to transform to a value-based health care system in the US
Alignment of economic/financial incentives is probably NECESSARY but not sufficient to transform to a value-based health care system
Federalism is a allocation of power and responsibility between whom?
Allocation of power and responsibilities between state and national government
Who was Joseph Mengele, MD?
Also know as the "Angel of Death" Did medical experiments on prisoners at Auschwitz Escaped to South America, "Wolfgang Gerhard" Died in 1979
Alternative Quality Contract there is ____ (1) capitation
Alternative Quality Contract there is a GLOBAL capitation
Alternative Quality contract is _____ (1) driven
Alternative Quality contract is INSURER driver
Alternative quality contract is already _____ (1), established HMO network
Alternative quality contract is already EXISTING, established HMO network
How can state regulate insurance markets?
Although this regulation is a state power, there are federal boundaries on this power
What does ARRA stand for?
American Recovery and Reinvestment Act: Stimulus Bill
Describe the woodwork effect
Argument for many states not participating in expansion Phenomenon that occurs when an expansion of public program eligibility takes place), and individuals who were already eligible for coverage but who had previously not enrolled choose to sign up Refers to those individuals already eligible for Medicaid under pre-ACA law, but have not enrolled in program States will only receive FMAP for these individuals pre-ACA
Define Premium
Amount you pay to purchase insurance Comes out of your paycheck if you have employer based insurance -The full premium consists of the part you pay, and that comes out of your paycheck + the part the employer pays and that you never see Monthly bill if you have individual insurance
Define an Academic health center
An academic health center has an owned or affiliated hospital (s), a medical school and at least one other of these schools: pharmacy, veterinary medicine, Public health, dentistry, graduate studies, nursing, allied health, optometry
CHART: NCQA PCMH Growth 2008-2013 RESULTS TO DATE
Anecdotal reports of dramatic improvements Formal, peer reviewed, evaluations are accumulating slowly Results mixed so far
Define Comprehensive care
Any health problem at any stage of life cycle
Define delivery
Anything and everything related to the delivery of any type of medical care
READING: The Disruptive Innovation of Price Transparency in Health Care by Uwe E. Reinhardt
As a consequence, the often advanced idea that American patients should have "more skin in the game" through higher cost sharing, inducing them to shop around for cost-effective health care, so far has been about as sensible as blindfolding shoppers entering a department store in the hope that insure they can and will then shop smartly for the merchandise they seek. So far the application of this idea in practice has been as silly as it has been cruel
As costs rise issues related to _____ (1) will only become more prominent and complex
As costs rise issues related to REGULATION will only become more prominent and complex
Define system
As you know well by now, there is no system-ness, nothing system-like, about health care delivery
What is one of the main things the ACA does?
Attempt to resolve the problem of lack of insurance and poor access: understand what the gaps in insurance are in the US and how the ACA addresses them
What are other countries that use federalism?
Australia, Brazil, Canada are other examples of government systems with elements of federalism - but they look very different
Define High Deductable Health plans
Authorized under the Medicare Modernization Act of 2003 Sometimes called "consumer-driven health plans" Often combined with a Health Savings Account (HSA); people with an HSA must also have a HDHP
Define Experience rating
Based on premium on previous cost experience Also called risk rating More common in "large group" insurance market Different employer pay different rates
The beneficiary assignment and notification of ACOs is based on what?
Based on primary care service utilization
In April 2013, after becoming established in primary legislation, what did NICE become?
Became a Non Departmental Public Body (NDPB) and placed themselves on a solid statutory footing as set out in the Health and Social Care Act of 2012. They took the responsibility for developing guidance and quality standards in social care.
Because the onset of mental disorders is generally in childhood or early adulthood, the impact of the disability is _____ (1)
Because the onset of mental disorders is generally in childhood or early adulthood, the impact of the disability is LIFELONG
WEBSITE: Centers for Medicare and Medicaid services (CMS)
Before assuming leadership of CMS, Dr. Berwick was President and Chief Executive Officer of the Institute for Healthcare Improvement, Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School.
After merging with the Health Development Agency in 2005, what did NICE begin to develop?
Began developing public health guidance to help prevent ill health and promote healthier lifestyles
Define benefit period
Begins when a person is admitted to a hospitals and ends 60 days after discharge from a hospital or a skilled nursing facility
Beneficiary assignment and notification of ACOs is a prospective _____ (1), and a restrospective _____(1)
Beneficiary assignment and notification of ACOs is a prospective ASSIGNMENT, retrospective RECONCILATION
What are some innovative healthcare models
Blog by Susan Block, Vicki Jackson, and Thomas Lee (2/19/14): Care Delivery and Coordination in the Accountable Care Environment Partners Health System (PHS; Boston) integrated palliative care into a recently created Accountable Care Organization (ACO) -Integrated, coordinated care across the continuum -Uniform standards for PC -Pay for performance initiatives to expand PC access, advance care planning, and MOLST implementation -Investment in generalist PC training throughout system -Other Have had "remarkably few barriers" Biggest barrier is small number of well-trained PC clinicians which limits expansion Also, struggle to obtain balance between traditional, fee-for-service approaches and accountable care
Both payment and quality of work life issues contribute to primary care _____ (1) problems
Both payment and quality of work life issues contribute to primary care PIPELINE problems
What are other names for concierge Medicine (3)
Boutique medicine, retainer-based medicine, and innovation medical practice design
Broadly targeted efforts to improve quality may reduce some _____ (1) in care
Broadly targeted efforts to improve quality may reduce some DISPARITIES in care
What is the ACO concept built on?
Built on previous concepts including HMOs capitation, integrated delivery systems, PCMHs, pay for performance
READING: English NHS Embarks on Controversial and Risky Market-Style Reforms in Health Care by Martin Roland, D.M., and Rebecca Rosen, M.D.
But they also include new arrangements for accountability, fundamental changes to the structure of the NHS, and a shift in the responsibility for paying for health services to groups of capitated physicians.
By 2020 the ______ (2) rate in the coverage gap will be reduced to 25% (from 100%).
By 2020 the COINSURANCE RATE in the coverage gap will be reduced to 25% (from 100%)
What happens when the government stops paying for Medicaid expansion (2)
By 2020, state will be responsible for 10% of costs Argument that 10% Medicaid costs still significantly less than cost of uncompensated care
By looking at the 3 kinds of quality problems there is a relationship to Donabedian's framework: this approach of understanding quality looks at _____ (1)
By looking at the 3 kinds of quality problems there is a relationship to Donabedian's framework: this approach of understanding quality looks at PROCESSES
By most measures of quality and health system performance, the US _____ (overperforms/underperforms) compared with other developed countries
By most measures of quality and health system performance, the US UNDERPERFORMS compared with other developed countries
How is privacy concerns and misperceptions a barrier to health IT?
Congress does not support a national health identifier
READING: Correlations among measures of quality in HIV care in the United States: cross sectional study by. Ira B. Wilson
CASE: Cervical cancer screening in women with HIV care Chain of events that has to happen in order for this relatively simple event to occur Single weak link breaks the chain Thus the emphasis on teamwork and systems
Describe the future of DSH
CBO estimates a 2% decline over the next 5 years for DSH payments ACA reduces the number of uninsured per state DSH reductions do not reflect a direct reduction in uncompensated care costs -Hospitals with high volumes of undocumented immigrants -Gaps between cost of care and what providers paid in Medicaid
READING: The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care by Elliott S. Fisher
CONCLUSIONS: Medicare enrollees in high-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.
READING: The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care by Elliott s. Fisher
CONCLUSIONS: Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern and practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions
READING: Performance Differences in Year 1 of Pioneer Accountable Care Organizations by J. Michael McWilliams...
CONCLUSIONS: Year 1 of the Pioneer ACO program was associated with modest reduction in Medicare spending. Savings were greater for ACOs with higher baseline spending than for those with lower baseline spending and were unrelated to withdrawal from the program.
Describe HMO Act of 1973
CONTEXT -Medicare and Medicaid created in 1965 -Medical care expanding quickly, and costs rising dramatically -1970: 33 HMOs with 3M enrollees -Government wanted to improve access and efficiency, because it appeared that HMOs saved money Established the term Health Maintenance Organization (HMO)0, coined by Paul Ellwood Set criteria that plans had to meet to be "federally qualified" Provided capital to qualified HMOs (NB: public money to private entities) -$145M in grants -$219M in loans Employers mandated to offer prepaid group practices as an option where they were available Recognized IPAs as a type of HMO, with requirements to offer them also where available Preempted restrictive states
Who are the payers in France's Health Care System?
Caisses d'assurance maladie or sickness insurance funds
What does Palliative care call for focus?
Call for focus on quality of life and other outcomes -Much research underway or completed by not yet published
France's payers cannot deny a ____ (1); have to pay doctors in a week and reimburse co-pays in a month
Can't deny a CLAIM; have to pay doctors in a week and reimburse co-pays in a month.
Canada has a ____ (1) system; 10 provinces and 3 territories; each with their own Plan
Canada has a DECENTRALIZED system: 10 provinces and 3 territories; each with their own Plan
Care has been moving to the ____ (1) setting for 20 years, and this will continue
Care has been moving to the AMBULATORY setting for 20 years, and this will continue
Define continuous care
Care over time by an individual or team, and timely communication of health information (e.g., events, risks, advice, patient preferences)
Define supply sensitive care
Care whose frequency of use is not determined by well-articulated medical theory, much less by scientific evidence
Carte Vitale is ____ (1); no privacy breaches.
Carte Vitale is ENCRYPTED; no privacy breaches
What does risk adjustment cause a drive for?
Causes a drive for standardization
Why has the fee reductions, spoken about in the Balanced Budget Act, been blocked by Congress seventeen times?
Congress has two choices. 1. Let SGR mechanism work, resulting in massive fee reductions, and probably Medicare patients can't get needed services 2. Repeal the SGR and replace it with something better and sustainable; but no agreement on what this might be; poisonous health politics
Describe cost sharing in medicaid
Children, pregnant women, and other vulnerable groups exempt from any cost sharing States have option to charge premiums and to establish OOP requirements -Maximum OOP limited -Individuals who fall in higher income spectrum of Medicaid eligibility more likely to have cost sharing -Cost effective measures taken by States (example: Use of generic drugs; RI Example of RIte Share and terminating eligibility for some groups
Why Join MA?
Choice of plan types now, for the most part, very good (except for rural areas) -HMOs (group, staff, and IPA) -Preferred Provider Organizations (local and regional) -Private Fee-for-service plans -High-deductible plans linked to medical savings accounts -special needs plans Unlike FFS Medicare, there are out of pocket cost limits Out of pocket costs are, in general, lower Less hassle with payments
What did Thatcher privatize in the UK? (4) What did he not privatize?
Coal mines rail roads telephones water supply NOT health care
READING: Complementary and Alternative Medicine Use Among Adults: United States, 2002 INTRODUCTION
Complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, therapies, and products that are not presently considered to be part of the conventional medicine.
Define tertiary care
Complex, institution based, highly specialized
What are the 3 branches of government?
Congress Courts Executive branch
What is the hospice rating and processes for Family ratings/reports/unmet needs
Consistently better with hospice and within hospice not differential by dementia diagnosis
What was the supreme courts decision on: is the mandate a permissible exercise of Congressional powers?
Constitutional exercise of Congressional power to tax
What are tradeoffs in non ED settings?
Convenience vs. detailed patient knowledge; potentially poor communication with primary care providers
Cost has historically been the most important driver of _____ (1)
Cost has historically been the most important driver of REGULATION
What is the biggest drive of regulation?
Cost increases, with quality and access generally taking a secondary role
Costs are dramatically _____ (higher/lower) in the US than in other developed countries.
Costs are dramatically HIGHER in the US than in other developed countries
Costs for mental health are disproportionately borne by the _____ (1) sector (Medicaid and other State/Local)
Costs for mental health are disproportionately borne by the PUBLIC sector (Medicaid and other State/Local)
Part D of Medicare will do what to the coverage gap (doughnut hole)?
Coverage gap will gradually be closed.
What does Canadian National Health Insurance cover? (4)
Covers all medical and psychiatric care, inpatient and outpatient
In Canada what does private insurance cover?
Covers things not covered by government such as viagra/cialis or botox
What are some HEDIS indicators? (Two Diabetes indicators and Two Cardiovascular indicators)
DIABETES LDL below 130 HgA1c controlled below 9.0% CARDIOVASCULAR LDL < 130 after MI Blood pressure < 140/90
_____ (1) are replacing other kinds of care for mental disorders
DRUGS are replacing other kinds of care for mental disorders
READING: How and why US Health Care Differs From that of other OECD Countries by Victor R. Fuchs
Deep historical distrust of government Reluctance to achieve more equal outcomes through redistributive public policy US political system makes it possible for special interests to have more impact
What is the Payer's perspective on quality?
Different payers answer to different communities; value proposition, efficiency
Describe iatrogenic disease
Disease caused by physicians and or medical care -To err is human: building a safer health system (IOM, 2000) -"Adverse events" responsible for 44,000 to 98,000 deaths per year -1/3 to 2/3 attributed to medical errors -2-4% of all deaths -Loss of life expectancy of 4-8 months
Explain Accessibility under the Canada Health Act (1984)
Doctors must treat everyone for the same fee
How can you think of value as a ration? (formula)
Dollars per unit of quality
What do symptoms drive?
Drive care seeking and care costs
Describe Drugs and healthcare Products (3)
Drugs, devices, and other products are the tools needed for modern care Rapid technological change Key drivers of cost increases
_____ (1) should be a dimension of quality.
EQUITY should be a dimension of quality.
_____ (1) incentives (e.g., public reporting) may widen gaps in care
EXTERNAL incentives (e.g., public reporting) may widen gaps in care
Describe a personal physician in a PCMH setting
Each patient has an ongoing relationship with a personal physician trained to provide first contact, and continuous and comprehensive care
How do non-profit hospitals earn tax-exempt status
Earn tax-exempt status by providing public good and not distributing profits to individuals -Regulated by IRS and state designated office -Exempt from most federal, state and local taxes (income, sales, and property)
READING: Who Patient Safety Research By WHO
Every year, tens of millions of patients worldwide suffer disabling injuries or death due to unsafe medical care. Nearly one in ten patients is harmed while receiving health care in well-funded and technology advanced hospital settings. We know much less, however, about the burden of unsafe care in non-hospital settings, where the majority of health care if delivered globally. Even more importantly, we have very little evidence about the burden of unsafe care in developing countries where there may be greater risk of patient harm due to the limitations of infrastructures, technology and resources.
How is Health IT more than just IT?
Ecosystem of Clinical Applications and Information Sharing enabling Healthcare Workflow
What was the focus of Medtronic and Edwards trials?
Efficacy and safety in extremely sick patients (not eligible for traditional aortic value replacement)
What does EMR stand for?
Electronic Medical Records
Emergency care not free: you get ___ (1)
Emergency care not free: you get BILLED
Employer-based insurance has a history that reaches back to _____ (1) and is deeply embedded in our tax code and in management-union relationships AMA is a powerful and savvy interest group
Employer-based insurance has a history that reached back to WWII and is deeply embedded in our tax code and in management-union relationships AMA is a powerful and savvy interest group
When was SCHIP enacted?
Enacted in 1997 to provide coverage for uninsured low-income children no eligible for Medicaid -Reauthorized in 2009
What does ESRD stand for?
End stage renal (kidney) disease
Who are usually dual enrollees?
Enrollees typically the elderly or younger persons with disabilities
It is very hard to predict when a person will die, especially when what?
Especially those with noncancer terminal illnesses (such as Alzheimer's disease) -Big barrier to hospice referral -Much oversight by Medicare/OIG in regard to long length of stay and admitting patients "too early"
The estimate cost to "fix" the Balanced Budget Act blocked reduced fees was at a all time ___ (high/low) last year because of low medical inflation
Estimated cost to "fix" at an all time LOW last year because of low medical inflation
Every encounter with Healthcare System makes us wonder if Healthcare IT is in _____ (1) age
Every encounter with Healthcare System makes us wonder if healthcare IT is in the STONE age
Explain Universality under the Canada Health Act (1984).
Every resident must have the same access to treatments and drugs
Every health care system _____ (1): supply side vs. demand side
Every system RATIONS: supply side vs. demand side
What medical expenses are not covered in the UK? (4)
Eyeglasses Contacts Dentures Dental Bills
The 3 triple aims are the same as access, quality, and cost (T/F)
FALSE. 3 Triple Aims are NOT the same as access, quality, and cost
A new patient safety discipline has yet to be developed. (T/F)
FALSE. A new patient safety discipline has developed
Medicaid costs continue to drop with 1/4 of those enrolled accounting for the majority of costs. (T/F)
FALSE. Costs continue to rise with 1/4 of those enrolled accounting for the majority of costs
Even in developed countries SMI's are treated well (T/F)
FALSE. Even in developed countries SMIs are poorly treated
HMOs have only financial features. (T/F)
FALSE. HMOs have BOTH financing and delivery system features
In Duke, there are 900 beds, and 900 billing clerks. (T/F)
FALSE. In Duke, there are 900 beds, and 1300 billing clerks
The NHS is the smallest employer in Europe. (T/F)
FALSE. Largest employer in Europe.
Medicaid expansion is at the discretion of the federal government (T/F)
FALSE. Medicaid Expansion at discretion of states
Non-profit organizations do not make profits. (T/F)
FALSE. Non-profit organizations DO make profits
Overall the supply of physicians is not keeping up with demand (T/F)
FALSE. Overall the supply of physicians is probably keeping even with demand
P4P has not be well tested. (T/F)
FALSE. P4P has been well tested in the last decade, and the jury is still out
In an ACO, patients do not have freedom of choice of providers. (T/F)
FALSE. Patients have complete freedom of choice of providers (NOT like typical HMO)
In France, Sickness funds are not like government entities. (T/F)
FALSE. Sickness funds are more like government entities.
In the UK there are both bills, and billing offices. (T/F)
FALSE. There are no bills, and no billing offices in the UK.
There is a pipeline for primary care (T/F)
FALSE. There is not much of a pipeline
ACOs government does not need a Taxpayer ID. (T/F)
FALSE. They MUST have a taxpayer ID
Physicians at St. Lucks Medical Center did not want to participate in the Medtronic and Edwards trials. (T/F)
FALSE. They did want to participate
The uninsured have been increasingly using the ED as a place to get primary care. (T/F)
FALSE. They have NOT been using it more. The percent of ED visits for uninsured persons from 1996 to 2004 was steady at 15-16% (there is no data yet on 2007-2011)
US administrative costs are low. (T/F)
FALSE. US administrative costs are high.
Federal vs. state argument about this question: is the mandate a permissible exercise of Congressional powers?
FEDERAL ARGUMENT Health care market unique Decision to not purchase insurance by many people affects this market -> need for regulation STATE ARGUMENT Mandate complex someone to do an involuntary act -> submit to Commerce Clause regulation -> overreach
What would be a hybrid version of an ACO?
FFS payment system with later sharing of savings (if there are any)
STUDY: Whitehall study (Michael Marmot)
FIRST WHITEHALL STUDY (1967) 18,000 men British Civil Service Mortality related to civil service grade SECOND WHITEHALL STUDY (1985) Civil servants between 35 and 55 years old 2/3 men, 1/3 women Still underway
What are the arguments for and against block grants?
FOR More predictable federal spending on Medicaid States have new cost control incentives Lower cost burden to states AGAINST Reduction in people, services covered Hard to measure performance Decreased accountability
Describe funding and administration for Medicaid
FUNDING: Categorical grant -Joint federal and state funding -% contributed by state varies across states ADMINISTRATION State, under federal guidelines -Examples of required services: inpatient and outpatient hospital, nursing homes -Examples of restricted services: abortion 1977 Hyde Amendment) -Federal eligibility criteria
Under Donabedian's Model what falls under structure?
Facilities Equipment Staffing Qualifications Licensing Accreditation
Describe FMAP
Federal Medical Assistance Percentage (FMAP) FMAP is an example of an intergovernmental revenue transfer of federal funds to the states Determined annually based on per capita income Lower than average per capita income results in states receiving increased federal funds for Medicaid "Matching" percentage -Cost to state and cost to federal government -State responsible for defined percentage of Medicaid costs -FMAP ranges from 50% to 76%
Describe expansion spending
Federal government responsible for 100% of Medicaid costs for expansion populations through 2016 Majority of new spending falls on the Federal Government Total spending due to increased enrollment and services provided will increase by 13% Total spending projected to increase by $464.7 billion 95% of total spending by Federal government Federal government responsible for paying to cover people who are newly eligible for Medicaid through 2016 -State share increases incrementally 2017-2020 HOWEVER, states will only receive their usual FMAP for individuals previously eligible for Medicaid
In Canada who sets most of the health care rules?
Federal government sets most of the rules
Explain DSH payments
Federal payments for hospital with high Medicaid/low income patient volume -$11.3 billion distributed in 2011 from Federal -> state -DSH payments differ per uninsured person in each state State decides threshold of Medicaid/low-income patient level and services provided to receive DSH funds
Define DSH payments
Federal payments to hospitals with high Medicaid/low income patient volume
What is Part A financed by?
Financed primarily by payroll tax (1.45% each from employer and employee, total 2.9%) Payroll taxes deposited in the Hospital Insurance Trust Fund or Part A Trust Fund ACA increases payroll tax by 0.9 percent points to 2.35% for higher income individuals (>$200,000) and couples ($250,000); took effect in 2013 Tax note -Progressive taxation: higher incomes pay higher percentage of income, as with income taxes Regressive taxation: higher incomes pay lower percentage of income
What does quality assurance focus on?
Focus on the "tail" of a distribution that does not meet standards
For high technology services (cardiac, catheterizations, MRIs, CT scans, kidney dialysis), the US does more of them AND unit costs are _____ (lower/higher)
For high technology services (cardiac, catheterizations, MRIs, CT scans, kidney dialysis), the US does more of them AND unit costs are HIGHER
For most services (hospitals, outpatient visits, medications) the US does NOT do more of them, it is that unit costs are _____ (higher/lower)
For most services (hospitals, outpatient visits, medications) the US does NOT do more of them, it is that unit costs are HIGHER
France has ____ (1), ____(1), and _____ (3) hospitals. (3 types)
France has PUBLIC, PRIVATE, and NOT-FOR-PROFIT hospitals.
French physicians are mostly in ____ (1) practice.
French physicians are mostly in PRIVATE practice.
French provider reimbursements are ___ (low or high) compared to the US?
French provider reimbursements are LOW compared to the US.
In 1944 Public health Service Act, building on the NCI model funded what?
Funded private scientists more broadly
How are general practitioners paid in the UK?
General practitioners are paid by capitation in the UK
What does Carte Vitale, by being digit, get rid of?
Gets rid of all paper medical records.
With who does the French government negotiate with on behalf of the sickness funds (3)?
Government negotiates on behalf of the sickness funds with doctors, hospitals, and drug companies.
In France, the Government negotiates on behalf of the what?
Government negotiates on behalf of the sickness funds.
How does the UK government pay for health care?
Government pays for healthcare through taxes.
Greatest eligibility change would be experienced by adults living in states currently that have restricted _____ (1) (Arkansas, Alabama, etc)
Greatest eligibility change would be experienced by adults living in states currently that have restricted ELIGIBILITY (Arkansas, Alabama, etc)
What is the Secretary of HHS required to implement (concerning IPAB)?
HHS is required to implement the Board's recommendations unless Congress enacts alternative proposals that achieve the same level of savings, with new deadlines and procedures for Congressional deliberations.
HITECH also funded state-wide _____ (1), but only a dozen were successful
HITECH also funded state-wide HIEs, but only a dozen were successful
Define Phocomelia
Hands or feet attached close to trunk
Health IT needs to have a secure and _____ (1) infrastructure.
Health IT needs to have a secure and PRIVATE infrastructure
Health care costs do have a large impact on our national ____ (1) outlooks (e.g., deficits)
Health care costs do have a large impact on our national FISCAL outlooks (e.g., deficits)
In the end, what is Health Care always about?
Health care is always, in the end, about people who need care.
Health care organizations can and should collect quality of care information by ____ (1).
Health care organization can and should collect quality of care information by RACE
Health care quality has evolved from a quality assurance approach to a _____ (2) approach
Health care quality has evolved from a quality assurance approach to a QUALITY IMPROVEMENT approach
Health information exchange should ensure ____ (1)
Health information exchange should ensure COMPLETENESS
Describe the history of Medicare
Health insurance for the aged and disabled Passed in 1965, Title XVIII of Social Security Act Expanded federal authority to regulate health care providers Administered by Executive Branch -Health and Human services (HHS) -CMS: Center for Medicare and Medicaid services (formerly the Health Care Financing Administration) 1930s: Removed from SSA (1935), AMA opposition 1940s: Truman endorses a bill for national health insurance, AMA opposition 1950s: little interest during Eisenhower presidency 1960s: Kennedys proposal for health care for the elderly passes the House but fails in the Senate 1960s: Johnson, following his landslide victory, wins passage of Medicare and Medicaid in 1965
Health plans do not report _____ (1) performance for different racial/ethnic groups.
Health plans do not report HEDIS performance for different racial/ethnic groups
Healthcare IT is a critical ____ (1) of change in healthcare
Healthcare IT is a critical ENABLER of change in health
What do healthcare leaders need to do in order to make healthcare IT a reality?
Healthcare leaders - Providers, Payers, Employers, State - need to recognize and support health information exchange
Describe FFS in 5 bullet points.
High cost No financial incentives for integration No incentives for quality Volume focus Excessive utilization
High fraction of health care costs are paid ____ (3)
High fraction of health care costs are paid OUT OF POCKET
READING: Where Americans Get Acute Care: Increasingly, It's Not At Their Doctor's Office by Stephen R. Pitts
Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care - treatment for newly arising problems - are made to patients' personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent) -Busy primary care offices -Difficulty providing after hours and weekend care -Patient-Centered Medical Home and other measures in the ACA may help improve access to office care -Discussion of Accountable Care Organizations (ACos) and retail clinics
Historically, health insurance in the US has been ____ (2), in both the private and public sectors
Historically, health insurance in the US has been ENTIRELY VOLUNTARY, in both the private and public sectors
Describe FFS
Historically, physicians paid usual, customary and reasonable rate (UCR)
define medicare part A
Hospital Insurance Program covers inpatient hospital services, skilled nursing facilities, home and health and hospice care
What are some examples of delivery?
Hospitals Doctors Nurses of all kinds All other health professionals (e.g., pharmacists, chiropractors, physical therapists, home health aids, etc.) Complementary and alternative medicine (CAM) providers Many other things
Hospitals account for what percent of healthcare costs?
Hospitals account for 30% of healthcare costs: we cannot solve the healthcare cost problem without reducing hospital costs
State licensure is primary oversight mechanisms for what? (2)
Hospitals and other health organizations
Hospitals are very important to local ____ (1) and the US economy
Hospitals are very important to local ECONOMIES and the US economy
READING: Public Reporting and Pay for Performance in Hospital Quality Improvement by Peter K. Lindenauer... CONCLUSION
Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.
Define Prospective Payment System (PPS)
Hospitals received a predetermined fixed rate of reimbursement for each hospitalization based in diagnosis-related groups (DRGs)
Hospitals treat patients who are covered by different _____ (1)
Hospitals treat patients who are covered by different INSURERS
READING: Bodenheimer, Berenson, and Rudolf (2007)
How are prices set under FFS? RBRVS: Resource Based Relative Value Scale CPT (Current Procedural Terminology) codes describe what you do -Evaluation and Management services (E&M): history, physical examination, and medical decision-making -Procedural services: e.g., colonscopy, cardiac ultrasound Why is the income gap widening? 1. The volume of procedures, particularly imaging, is increasing more rapidly than the volume of office visits -Changes in imaging reimbursement since 2007 have slowed this growth 2. Specialists are overrepresented on the Relative Value Scale Update Committee (RUC) which advises CMS on revisions to reimbursements 4. Private insurers make this worse, by reimbursing specialists at larger percentages and primary care providers at smaller percentages compared with Medicare rates
ACOs try to simultaneous change what? (2)
How care is paid for and how it is delivered
What are the origins of errors in the health care system? (3)
Human factors Medical complexity System failures
READING: Trends in Quality of Care and Racial Disparities for Enrollees in Medicare Managed Care by Amal N. Trivedi
INITIAL FINDINGS: 1. Quality of care improved dramatically for both white and black enrollees, but still suboptimal 2. Racial disparities decreased for seven of nine HEDIS measures 3. For two outcome measures, racial disparities were unchanged
Define IPA
IPA is a separate organization from the insurer (health plan) IPA creates a provider network by contracting with solo, and group practices physicians contract with IPA, not the HMO IPA takes capitation dollars from the HMO, and creates a variety of risk sharing relationships with providers
What is one common element in P4P methods?
Identify processes or outcomes that you want to create incentives around, and then develop a reimbursement system that aligns with these goals
Take home message for PCMH
Important, promising new model; not simple to implement; no magic bullet
Describe history of AMA and Medicare/Medicaid
In 1920 stated it opposition "to the institution of any plan embodying the system of compulsory [medical] insurance ... controlled or regulated by any state or the federal government." Social Security Act (1935) contained a single sentence about studying health insurance... which because of an AMA letter writing campaign had to be dropped for fear it would entire bill 1948 Truman health insurance program -AMA sad that supporters of the plan included "all who seriously believe in a Socialistic state. Every left-wing organization in America... [and] the Communist party." -PR campaign warning that it would erode the quality of medical care, overcrowd hospitals, and reduce incentives for physicians to provide quality care -Pushed voluntary (not compulsory) insurance as the "American way" Medicare/Medicaid did finally pass in 1965 Physicians are professions who has a social contract with patients BUT, the AMA in the US also behaves as an interest group with its own agenda Long history as a powerful player in health care politics even though only 29% of physicians are members
Describe Blue Cross (hospitals) history
In 1929 Baylor University Hospital Arrangement with Dallas school teachers 21 days of hospital care for $6 per year Prepayment idea spread during Great Depression because of low occupancy rates Next: plans sponsored by groups of hospitals American Hospital Association (founded 1898) supported and the coordinated these groups Plans united into Blue Cross network By 1946, 43 Blue cross plans with 20 M enrollees
In hospitals and outpatient settings, _____ (2) was seen as less aggressive care
In hospitals and outpatient settings PALLIATIVE CARE was seen as less aggressive care
In hospitals, there are ____ (number) administrative persons per bed.
In hospitals, there are 1.5 administrative persons per bed.
In 1997 US federal government required mandatory reporting by health plans of _____ (1) measures
In 1997 US federal government required mandatory reporting by health plans of HEDIS measures
Describe problems with Medicare+Choice
In 1999, approximately 12% of plans made public their intention to withdraw with M+C and 15% planned to reduce services As of January 2001, 934,000 people, or 1 of every 6 M+C enrollees, lost their coverage From 1999 to 2003, M+C enrollment and the number of plans offering coverage declined sharply But BBA also cut plan reimbursement and by 2003 enrollment fell to 5.3 million BBA of 1997 did reduce costs, but at the cost of creased access
Give an example on how France's Health Care is inexpensive for both the single person and employer.
In 2007, a single French person making $20K a year, only paid $12.25 per month. The employer's share was $208 per month.
READING: Medical Bankruptcy in the United States, 2007: Results of a National Study by David U Himmelstien
In 2009, illness and medical bills contributed to 52.9% of Massachusetts bankruptcies, versus 59.3% of bankruptcies in the state in 2007 and 62.1% nationally in 2007. Between 2007 and 2009, total bankruptcy fillings in Massachusetts increased 51% an increase that was somewhat less than the national norm CONCLUSION: Massachusetts' health reform has not decreased the number of medical bankruptcies, although the medical bankruptcy rate in the state was lower than the national rate both before and after reform.
In 2010 David Cameron imposed cuts everywhere, but _____ (increased/decreased) health care spending
In 2010, David Cameron imposed cuts everywhere, but INCREASED health care spending
In ACOs there no ____ (1); they are not an HMO
In ACOs there are no RESTRICTION; they are not an HMO
In Canada is it ____ (legal/illegal) to pay privately for services covered by the government.
In Canada it is ILLEGAL to pay privately for services covered by the government
In Canada there are long ____ (1) for non-urgent specialty care.
In Canada there are long WAITS for non-urgent specialty care
In Canada, individuals are responsible for ____ (1); but at prices the government can bid down
In Canada, individuals are responsible for DRUGS; but at prices the government can bid down
In Canada, patients have _____ (1) access
In Canada, patients have UNIVERSAL access
In Canada there are no co-pays for ____ (1)
In Canada, there are no co-pays for VISITS
In France the government bargains directly with ____ (1) manufacturers.
In France the government bargains directly with DRUG manufacturers.
In France, doctors belong to a ____ (1) union; pickets and strikes.
In France, doctors belong to a LABOR union; pickets and strikes.
In primary care ____ (1) far exceeds supply
In primary care DEMAND far exceeds supply
In the UK administrative costs are far ____ (less/more) than in the US.
In the UK administrative costs are far LESS than US
In the UK generalists are ____ (1): referrals are needed to see specialists
In the UK generalists are GATEKEEPERS: referrals to specialists are needed
In the UK patients are generally very ____ (satisfied/unsatisfied) with service)
In the UK patients are generally very SATISFIED with service
How much does medication cost in the UK?
In the UK prescriptions are $10
In the UK generalists make about ____ (twice/triple/etc.) as much as specialists.
In the UK, generalists make about TWICE as much as specialists.
In the US we have a high cost, and often low ____ (1), health care system
In the US we have a high cost, and often low QUALITY, health care system
In the US, there are fewer elderly, fewer smokers, but more _____ (1)
In the US, there are fewer elderly, fewer smokers, but more OBESITY
In the health IT information gap, information does not _____ (1)
In the health IT information gap information does not FLOW
In the last 30 years the science related to quality has rapidly _____ (1)
In the last 30 years the science related to quality has rapidly ADVANCED
In the minority medicare group there is documented _____ (1) disparities.
In the minority medicare group there is documented RACIAL disparities.
What does "mental health" usually include?
Includes mental health and substance abuse disorders
Income and social security taxes are ____ (higher/lower) in the UK than in the US.
Income and social security taxes are HIGHER in the UK
Incomes of French physicians are about ____ (fraction) of US doctors.
Incomes are about *1/3* of US doctors.
Describe Medicare Modernization Act of 2003
Increased payments to plans Introduced a bidding process (starting 2006) -Plan submits a bid -if bid > benchmark then beneficiaries have to pay the extra amount in their premium -If bid < benchmark then CMS and plan split the savings (called rebated) and plan must spend their share on extra benefits (like reduced copayments) -Payments are risk adjusted
What does IPAB stand for?
Independent Payment Advisory Board
Historically who do hospital outpatient clinics primarily service?
Indigents in city/county hospitals: Important part of the "safety net"
Define dual eligible beneficiaries
Individuals for Medicare and Medicaid benefits -"Dual Enrollees" -Typically very low income and among sickest and poorest individuals
What is care in silos vs. care continuum a key reason for high costs and low quality?
Inefficient processes Lack of care transitions and coordination (Whole-person Care)
Define PPO
Insurer negotiates a discounted FFS rate with "preferred providers" Enrollees can see proferred providers (for a lower co pay) or non-preferred providers (for a higher co pay)
Define Regulator
Is a private entity, founded and funded by the industry
Define managed care
Is an organized approach to delivering a comprehensive array of health care services through efficient management of services needed by the members and negotiation of prices or payment arrangement with providers
Define episode bunding
Is capitating care for an episode of care such as cardiac bypass surgery or a total knee replacement
Define administrative law
Is the body of law that regulates the operation and procedures of government agencies
What do state licensing boards issue and renew?
Issue and renew licenses and enforce basic standards of practice
Why is an AMC considered an economic engine?
It employs thousands of staff and creates original products or technologies that benefit millions of people worldwide
The goal of health care follows what?
It follows that the ultimate goal of quality measurement and quality improvement is to improve health outcomes
It was very _____ (1) to participate in the device trails for severe aortic stenosis.
It was very COMPETITIVE to participate in the device trials for severe aortic stenosis
If HHS was an economy, what would its rank be and who would it be bigger than?
It would be ranked 16. It would be bigger than the Netherlands who has an economy of $779 Billion
Joint Commission For Accreditation of Healthcare Organizations (JCAHO) now use ____ (1) approaches
Joint Commission for Accreditation of Healthcare Organization (JCAHO) now use QI approaches
What are some important HEDIS indicators for Cardiovascular?
LDL <130 after MI Blood pressure < 140/90
What are some important HEDIS indicators for Diabetes?
LDL below 130 HgA1c controlled below 9.0%
Classification of Employer Sponsored Insurance (ESI; sometimes Employer based Insurance or EBI)
Large group: generally >= 200 employees Small group: Generally < 200 employees
READING: Association Between participation in a multiple medical home intervention and changes in quality, utilization, and costs of care by Mark W. Friedberg
Large: 32 interventions and 29 control practices and 120K patients Multipayer: 6 payers involved Duration: 3 years Evaluation included -Structural changes -Quality improvements -Utilization and cost outcomes RESULTS: Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs. 71.7% by year 3, p<0.001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention. CONCLUSION AND RELEVANCE A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement ACCOMPANYING EDITORIAL "One size does not fit all" Think of PCHM interventions as a high cost technology Focus should be on high risk, high cost subset of patients with multiple chronic conditions
What should we note about administrative bureaucracies?
Leadership turns over but staff remains in place
What are some characteristics of France's payers? (3 excluding nonprofit)
Legally private entities Cannot refuse to cover you (no pre-existing conditions) Employment based: employer and employee shared
What is an LPN?
Licensed practical nurse (1 year training)
Why would 34 states lose their subsidies if the IRS rule was overturned?
Likely to drop insurance coverage But DSH payments already reduced since the number of insured was expected to increase...
Lots of money is spent ____ (3), and increasingly from traditional insurance, on Complementary and Alternative medicine (CAM)
Lots of money is spent OUT OF POCKET, and increasingly from traditional insurance on Complementary and Alternative Medicine (CAM)
READING: Variation in the use of Cardiac procedures after acute myocardial infarction by Edward Guadagnoli
METHODS: We studied patients covered by Medicare who were 65 to 79 years of age and were admitted to 478 hospitals with acute myocardial infarction during 1990 in New York (1852 patients) where the rate of use of cardiac procedures is low, and in Texas (1837 patients), where the rate of use of such procedures is high. We compared the patterns of treatment of clinically similar groups of patients in the two states. We also compared mortality rates and measures of the health-related quality of life. CONCLUSIONS: Physicians in Texas were more likely to perform angiography than physicians in New York for patients whose conditions allowed more discretion in the use of cardiac procedures. On average, there appears to be no advantage with respect to mortality or health-related quality of life to perform the procedures at the higher rate used in Texas.
READING: WHO patient safety by WHO (Chapter 3. Patient Safety)
MORTALITY Number of Americans who die each year from medical errors (1999 est.)...44,000-98,000 PREVALENCE Rate of selected hospital-acquired conditions (2010 est.)... 145 per 1,000 hospital admissions Adverse drug reactions during hospital admissions (annual est.)... 49 per 1,000 hospital admissions Rate of adverse drug events among Medicare beneficiaries in ambulatory settings... 50 per 1,000 person-years COST Cost attributable to medical errors (2008)... $19.5 billion Total cost per error (2008)... $13,000 Annual cost attributable to surgical errors (2008)... $1.5 billion
What did the Certification of Need (CON) programs (1974) do?
Made it so that hospitals had to get permission to build or expand
Who is not eligible for medicaid?
Major left out/option populations for states no expanding Medicaid ADULTS -Low income adults - option -Low income childless adults - option -Low income working adults make up majority of uninsured ELIGIBLE, BUT NOT ENROLLED IMMIGRANTS -5 year wait for legal immigrants -No coverage for undocumented or temporary residence
Majority of costs falls onto _____ (2) during first few years of Medicaid expansion
Majority of costs falls onto FEDERAL GOVERNMENT during few few years of Medicaid expansion
Many processes contribute to any ____ (1): think of hospitalization for heart attack or treatment of lung cancer
Many processes contribute to any OUTCOME: think of hospitalization for heart attack or treatment of lung cancer
What are some "optional" benefits medicaid expansion
Many services vital for managing chronic conditions or disability Account for 1/3 of Medicaid Spending
READING: Krugman article (NYT, July, 2009), which is a summary of Arrow Article (1963)
Markets don't work well in health care because... -You can't know (in general) if or when you will need care, and when you do it is very expensive -Therefore you need insurance, but not insurance companies make money by NOT paying for health care, so their interests may not be aligned with yours (principal-agent problem) -The gamesmanship of trying to cover people who won't need care, and denying claims is expensive
READING: Mackey article (WSJ)
Markets would work IF: -remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs) -Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits -Repeal all states laws which prevent insurance companies from competing across state lines - repeal government mandates regarding what insurance companies must cover Move "toward less government control and more individual empowerment"
Describe financing in Medicaid
Medicaid accounts for the single biggest category of state government expenses: 22% of state budgets Where does the money come from ? -Taxes (Income taxes, general sales taxes) -Intergovernmental Revenue (Federal transfers to states) -Charges and Miscellaneous Revenue
Medicaid also excludes near poor who do not qualify for _____ (1)
Medicaid also excludes near poor who do not qualify for MEDICAID
Medicaid coverage was expanded to children in 1997 through _____ (1)
Medicaid coverage was expanded to children in 1997 through SCHIP
Why are people dual enrollees
Medicaid fills in gaps of Medicare benefit package -One quarter of Medicaid spending for duals goes toward medicare premiums and cost-sharing for Medicare services
Medicaid leaves out low income adults without ____ (2)
Medicaid leaves out low income adults without DEPENDENT CHILDREN
Define medicare part c
Medicare Advantage program allows enrollment in private insurance plans
What is an entitlement?
Medicare is a federal entitlement program Categorical programs: benefit targeted at a category of person Guaranteed services provided to all recipients in the category who meet eligibility criteria Entitlement programs funded automatically; not dependent on annual appropriations
Define Medigap
Medigap is private insurance Largely because of a variety of problems/scandals in Medigap over time it is become highly regulated Covers out of pocket payments for Medicare services Over 9 M beneficiaries have Medigap policies There standardized types of Medigap that can be sold my private insurers
Define moral hazard
Moral hazard occurs when a party insulated from financial risk behaves differently than it would behave if it were fully exposed to the financial risk
READING: Not NICE by Jeffrey H. Anderson
More exactly, we're heading toward a nation-defining fork in the road. In one direction lies repeal; in the other, rationed care. In one direction, liberty, in the other, consolidated power.
Why are they reducing DSH payments?
More people would be insured... so less need for DSH $
Mental disorders are generally _____ (1) diagnosed and ____ (1) treated, though this is slowly changing
Mental disorders are generally UNDER diagnosed and UNDER treated, though this is slowly changing
Mental disorders result in tremendous ____ (1)
Mental disorders result in tremendous DISABILITY
What does MSR stand for?
Minimum savings rate
What are the medical expenditures like in Hospice?
Mixed, and few studies estimate separately for those with dementia However, fewer hospitalizations and more long stays don't equate to lower expenditures We found for persons with short NH stays there were fewer expenditures
What does larger risk pools produce?
More actuarial stability and less business risk
CHARTS: Baicher and Chandra
More primary care providers is associated with higher quality and lower costs More specialty providers is associated with lower quality and higher costs
How many people does the NHS employ?
More than a million employees.
What is the most accepted quality measure?
Most accepted quality measures are measures of technical processes.
Access, Cost, and Quality are a framework to think about what?
Most health care and health policy issues
Most of the HHS budget is ____ (1) (entitlements)
Most of the HHS budget is MANDATORY (entitlements)
Most sites chose either the Edwards or _____ (1) trial
Most sites chose either the Edwards or MEDTRONIC trial
Most sites were limited to one cardiologist/cardiac surgeon team to try Medtronic and ______ (1)
Most sites were limited to one cardiologist/cardiac surgeon team to try Medtronic and EDWARDS
What is the hospice ratings and processes for symptom management/processes of care
Mostly better and less aggressive with hospice
What is the ideal future state of ACOs? (4)
Mostly capitated care Primary care and PCMHs at the center of care system (but integrated with specialists, hospitals, long term care, etc.) Quality measurement to prevent under care Choice: tight vs. loose networks (not clear how this will work out)
What is a possible example of an information gap?
My PCP is not talking to the specialist and vice versa
Explain the Supreme Courts Decision on the Individual mandate
NATIONAL FEDERATION OF INDEPENDENT BUSINESS V. SEBELIUS Consideration of the constitutionality of two major provisions of ACA: individual mandate and Medicaid Expansion Decision read on final day of 2011-2012 term DECISION "Medicaid Expansion is Unconstitutionally Coercive of States because States lacked adequate notice to voluntarily consent and the Secretary could withhold all existing Medicaid funds; the appropriate remedy is to circumscribe the Secretary's enforcement authority."
NICE's guidance and other recommendations are made by _____ (1) committees.
NICE's guidance and other recommendations are made by INDEPENDENT committees
France's payers are _____ (1); no incentive to "make a profit"
NONPROFIT; no incentives to "make a profit"
What does NHS stand for?
National Health Service
How is cost control accomplished in the UK?
National Institute for Clinical Excellence (NICE)
What does NICE stand for?
National Institution for Clinical Excellence
Describe the tax subsidy for health insurance
National War Labor Board ruled in 1943 that employer and employee contributions to insurance did not count as wages, and that workers' health benefits were not taxable IRS issued tax exclusion ruling in 1954 "Tax Expenditure": this is an enormous public subsidy of private, employer-based insurance; estimated currently at over $260 B annually
What happens for individuals living in states without Medicaid expansion?
Near poor left without access to medicaid and without eligibility for tax subsidies to purchase private insurance
What do data interperability and continuity of care need to support? (4)
Needed to support value-based payment models, reduce duplication, ensure timely interventions, and improve quality
What does NDA stand for?
New Drug Application
READING: The $16,819 Pay Gap for Newly Trained Physicians: The Unexplained Trend of Men Earning More than Women by Anthony T. Lo
New York State during 1999-2008, we found a significant gender gap that cannot be explained by specialty choice, practice setting, work hours, or other characteristics.
Define integrate care in medicaid
New delivery system model focusing on care coordination and a reduction in administrative burden
What two services do not require co-pays in France?
No co-pays for those with chronic illness. No co-pays for pregnant women during last 5 months of pregnancy and for the first 4 months after delivery.
Status of Louisiana who is not expanding Medicaid
No though of expansion or development of legislation to implement expansion On Feb. 6, 2013, Gov. Bobby Jindal (R) reiterated his opposition to expanding Medicaid in Louisiana. In an op-ed for the Washington Post, Jindal argued that the expansion would cost his state $1 billion over the first 10 years. The Louisiana Senate in May 2013 rejected an amendment that would permit state voters to decide on Medicaid expansion, effectively ending any possibility for action on the issue before the Legislature recessed for the year.
What does NDPB stand for?
Non Departmental Public Body
Non-profit hospitals often _____ (1) very similarly to "for-profit" hospitals in markets
Non-profit hospitals often BEHAVE very similarly to for-profit hospitals in markets
Wait times in the UK are quite long for what type of services? (2)
Non-urgent consultations Elective services
Not all employees are eligible (mean of 79%), i.e., new or part times employees may not be ____ (1)
Not all employees are eligible (mean of 79%), i.e., new or part time employees may not be ELIGIBLE
Not all firms offer employee sponsored insurance (ESI), it is ____ (1)
Not all firms offer employee sponsored insurance (ESI), it is VOLUNTARY
Nurses report significant rates of ______ (3)
Nurses report significant rates of STRESS AND BURNOUT
What are some practitioners that are sometimes included with primary care?
Nurses, pharmacists, health educators, medical assisstants
Describe the modest annual fee increases of the bill signed on April 16th
O.5% increase through 2019 Stable at 2019 level through 2026
Describe the Regulation Case Study
October 22, 2009 a state health department fined a hospital $150,000 for operating on the wrong finger - "Time out" protocols were not followed it was the 5th such "wrong sided surgery" at that hospital since January 2007 Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and the state Dept. of Health (DOH) disagreed about how the hospital should be asked to respond DOH required that the hospital... -Adopt the statewide protocol for safety checklists, surgical marking, and develop a plan to revise protocols and update staff -Shut down surgery for a day and conduct mandatory training and review of surgical procedures -Install audio and video equipment in every ER and, with patient consent, review 2 surgical events each year for each surgeon -Prepare a summary of every surgical error from 2005 to the present, and send it to 4 government and accrediting agencies August 4, 2010 a small piece of drill bit broke off and was left in a patient's scalp during neurosurgery It was discovered the day after surgery and removed without incident The hospital suspended the surgeon and apologized to the patient The event was reported to the DOH on August 6 On Tuesday October 14, 2010 the DOH fined the hospital $300,000 for the drill bit incident for failure to follow its own policies, which require x-rays whenever equipment is not accounted for This was their 3rd fine for surgical errors On Oct 15, 2010 a surgical instrument was discovered in the abdomen of a patient who had had surgery 3 months prior The Director of the DOH said that he was out of ideas other than to impose another fine, "They've got to figure out how to get the staff to follow the policies." Against the recommendations of the Director of the DOH, CMS ordered a survey to determine whether they would keep their certificate of participation (COP) The hospital passed the survey
Primary care definition is in terms of what?
Of the functions that primary provides, not who provides
What does an AMC offer?
Offers unique care not available anywhere else in the region
Why are reimbursement rates so low for medicaid?
On average, pay 58% of Medicare rates -5 cents for every dollar -When comparing to Private insurance reimbursement rates, Medicaid pays much less -Specialty services are reimbursed at a much more reasonable level ACA provides an increase for Medicaid up to Medicare rates for primary care for the next two years -In RI that means a physician will receive almost double the rate he/she is currently receiving
One of the reasons that the "value" of the health care we get in the US is, relative to other developed nations, low, is that we have too much specialty care and not enough ____ (2)
One of the reasons that the "value" of the health care we get in the US is, relative to other developed nations, low, is that we have too much specialty care and not enough PRIMARY CARE
How is the ACA federal, but leaves many decisions to the states?
Opportunities and challenges resulting from this
What are the domains of focus in P4P? (3)
Outpatient and inpatient Potentially others
Was there quality or disparity change in Beta-Blocker Use after Myocardial Infarction?
Overall quality improved and disparity decreased
Was there quality or disparity change in Diabetes: LDL screening?
Overall quality improved and disparity decreased
Was there quality or disparity change in Cholesterol Management After Acute Coronary Event: LDL < 130?
Overall quality improved by disparity increased
Was there quality or disparity change in Controlled Diabetes (HbA1c <9.0%)?
Overall quality improved by disparity unchanged
Where is overuse of supply-sensitive care particularly apparent?
Overuse of supply-sensitive care is particularly apparent in the management of chronic illness (such as admitting patients with chronic conditions such as diabetes to the hospital, rather than treating them as outpatients)
PCPs can only be in ____ (a number) ACO.
PCPs can only be in ONE ACO.
What problem is ACOs trying to solve and what is its solution?
PROBLEM: We want to move away from FFS. We also want to improve quality and decrease costs. SOLUTION: Make simultaneous changes in financing and delivery systems
What are the pros and cons of Concierge Controversy?
PROS -Why not allow people pay more to get more? -Physicians argue that it allows them to practice the kind of medicine that they think is right CONS -2 tier medicine -Better care for the wealthy -Takes physicians away from those who need them
What is an assertion about our poor health system?
Part of the reason we have this dilemma is that health care in the US is specialty driven, not primary driven
What did hospital shortage lead to?
Passage of the Hospitals Survey and Construction Act or the Hill-Burton Act in 1946
How are patients notified of beneficiary assignment and notification in an ACO?
Patients are notified by signs in facility
Why is Cost and Quality transparency a key reason for high costs and low quality?
Patients don't see the premium money going into the system Patients don't know efficient and effective providers
What are the 6 goals of Accountable Care Organizations?
Patients engaged Care integrated and coordinated Incentives of PCPs, specialists, hospitals aligned Focus on quality Focus on populations Lower cost
What are some modern medicine and safety problems? (3)
Patients: complex, chronic illnesses Hospitals: can be dangerous places Treatments: often highly effective, but with risks
Why should we have a pay for performance system?
Pay for quality and outcomes, not for volume
Define capitation
Payer (insurers) pay a fixed monthly amount to providers "Capitation" literally means payment per head Providers have to pay for patients' care from this amount The opposite extreme from paying for each good and service one at a time
Explain comprehensiveness under the Canada Health Act (1984)
Payment for all "medically necessary" services
Payments policies are complex and the process of setting prices is dominated by ____ (1)
Payment policies are complex and the process of setting prices is dominated by SPECIALISTS
Define accountable care
Physicians and the systems they work in are responsible to patients, families and communities for the delivery of ... -Quality care -Patient satisfaction -Efficient use of resources -Ethical behavior
How are physicians paid in France (what type of payment method)? How are prices decided upon?
Physicians paid by Fee-for-service; detailed national price list determines price for each service.
Describe value pluralism: state over federal
Polarizing issues, no national consensus -> reflection in local policy
Define preference sensitive care
Preference-sensitive care comprises treatments that involve significant tradeoffs affecting the patient's quality and/or length of life.
How come health care premiums are not counted as taxable income
Premiums paid by an employer to purchase employee health insurance do not count as income Any portion of the premium the employee pays is not taxed These dollars are excluded from both income tax and payroll taxes or FICA (Federal Income Contribution Act), which is what goes to pay for Social Security and Medicaid "Tax expenditure" is the amount of tax dollars that the government does does not get in revenue because of this Totals about $250B, which is about the same amount of money as we spend on the whole Medicare program It has a regressive effect (higher income people benefit more) Only applies to ESI (not individual market)
Define HMO
Prepaid group plans and IPAs are types of HMOs... and there are other varieties
Define medicare part D
Prescription drug benefit
What is the role of medical care?
Preventive and clinical services responsible for... 30 years in improvement in life expectancy seen between 1900 and 1950 -5-5.5 years attributed to improvements in medical care 7 to 7.5 years to increase between 1950 and 1995 -About half attributed to improvements in medical care
Define primary care based on the 1996 Institute of Medicine (IOM) Report)
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community
Primary care physicians get paid significantly _____ (more/less) than specialists
Primary care physicians get paid significantly LESS than specialists
Define national Committee on Quality Assurance (NCQA), 1990
Private accreditation organization created by the managed care industry to supervise quality
Who funded NCI?
Private scientists funded NCI
About how many concierge services are there?
Probably only 1000 or so in the country; probably don't have a huge impact (yet)
What is US federalism a product of?
Product of reconciling need for greater authority with mistrust of single sovereign
Describe the 2015 Ryan "Path to Prosperity" Plan
Proposed changes to health system -Repeal Medicaid expansion undertaken by the ACA -Convert Medicaid from a categorical to a block grant -Merge Children's Hospital into the Medicaid program
Private Sector ACOs have a lot of experimentation with what? (5)
Providers patients governance patient attribution Payment models
The governing body (board of directors) of an ACO is composed of what two groups?
Providers: 75% of the control Beneficiaries
What do DSH provide?
Provides financial relief for hospitals that serve the poor -"Safety Net" Hospitals
What does an academic medical center provide?
Provides patients and the community with health care for everyday needs and the most specialized services for complex diseases, illnesses and injuries
Explain public administration under the Canada Health Act (1984).
Provincial health systems must be not-for-profit
Explain Portability under the Canada Health Act (1984)
Provincial plan must pay for services in other provinces
By 1980, the US had reached what goal?
Reached its goal of 4.5 community hospital beds per 1000 population
Name the 5 features of the Canada Health Act (1984).
Public Administration Comprehensiveness Universality Portability Accessibility
READING: Guns and Suicide in the United States by Matthew Miller
Public health vs. 2nd amendment perspectives Many suicide attempts are impulsive Whether a suicide attempt is successful depends on the lethality of the attempt Guns are highly lethal Idea that someone who really wants to commit suicide will find a way, and that guns in the environment do not matter, is not supported by this evidence 2 parts of suicide prevention (public health approach) -Treating underlying causes such as depression -Reducing access to lethal means
READING: To Err is Human by the Institute of Medicine
Published in 1999 44,000 to 98,000 preventable deaths in the US annually due to errors in hospital care 7000 due to medication errors Similar efforts to quantify adverse events all over the world System focus
Can adults be covered under SCHIP?
Purchase coverage for parents using a waiver After reauthorization in 2009 pregnant women can be covered by state option States can submit a demonstration waiver to cover SCHIP parents
Describe Patty Kelly-Flis, Director of Quality
QUALITY REPORTING (HEDIS, CTC, FEDERAL, RIPCPC) "I regularly review our cardiac and diabetic patient databases. If a patient has old LDL/A1C results, then I go into CurrentCare. I am quite often able to see lab reports ordered by other providers. POST-HOSPITALIZATION "Getting labs from CurrentCare can be faster than getting hospital records."
Quality improvement methods successfully used in industry are increasingly being applied to _____ (2) ... but changing complex systems is hard
Quality improvement methods successfully used in industry are increasingly being applied to HEALTH CARE... but changing complex systems is hard
Quality of evidence about process-outcome links _____(1)
Quality of evidence about process-outcome links VARY
After Hospital Compare what happened to quality?
Quality of hospital care improved substantially after Hospital Compare
TRENDS: Does US spend more and get less?
RESULTS: US has dramatically higher costs than other nations but the utilization for most things (high tech stuff is the exception) isn't dramatically higher
How are Medicare Physician Fees determined? (formula)
RVU x Conversion Factor = Physician fee
READING: The Quality of Health Care Delivered to Adults in the United States by Elizabeth A. McGlynn
Random sample of adults in 12 communities Phone call followed by request to review medical records Review of the medical records for adherence to standards of care for multiple conditions
What does Evidence Based medicine do?
Ranking the quality and generalizability of evidence
Where would Medicare's VBP be redistributed to?
Redistributed payments from those hospitals underperforming to those performing well
Define value based insurance design (VBID)
Reduce or eliminate co-pays for critical medicals or other services Evidence mixed on effectiveness
Define Evidence Based medicine
Refers to a set of methods, developed in the last 20 years, that are used to evaluate and summarize the information in published literature
Primary care is attracting FMGs reflecting what?
Reflecting that it is a lower demand, lower status segment of the market
Why is Fee For Service vs. Payment for Value a key reason for high costs and low quality?
Regardless of quality Regardless of outcomes Rewards quantity
Define Regulation
Regulation is "controlling human or societal behavior by rules or restrictions."
Regulation is _____ (1) and there are many forms.
Regulation is NECESSARY and there are many forms
Regulation is not _____(1), the federal bureaucracy is constantly in evolution as the problems that face the country change
Regulation is not STATIC, the federal bureaucracy is constantly in evolution as the problems that face the country change
Regulatory power has ____ (1) role in US system of laws
Regulator power has UNIQUE role in US system of laws
For any process measure there are practical issues related to what?
Related to the cost, convenience, and validity of the measurement process
What does RVU stand for?
Relative Value
The fact that hospitals must maintain all the expensive services and technology puts them at a competitive cost disadvantage relative to what?
Relative to free-standing, single focus ambulatory facilities, including even surgical centers or imaging centers
Define Discretionary spending
Reliant on annual appropriation acts -Examples: Department of Labor Training and Employment Services, FAA Grants -in-Aid for Airports
How is insurance mostly regulated by states?
Remember that self-insured companies, often with employees in many states, come under the aegis of ERISA, 1974
Define guaranteed renewability
Renewable at the policyholder's discretion Exceptions nonpayment or lay payment of premiums, for an act of fraud by the policy holder, or for the other limited reasons
Define guaranteed issue
Require insurers to accept all applicants in individual and group markets, regardless of health states, occupation, or other risk factors
What does understanding value and producing value require?
Require that we understand and measure quality
What did Thalidomide resurface?
Resurfaced because it is an inhibitor of TNAa, has anti inflammatory effect
READING: The Geographic Distribution, Ownership, Prices, and Scope of Practice at Retail Clinics by Rena Rudavsky CONCLUSION
Retail clinics are positioned to provide immunizations and care for simple acute conditions for a substantial segment of the urban U.S. population -42 operators, 982 clinics, 22 states -Most in 5 states: FL, CA, TX, MN, IL -Almost all took private insurance and Medicare FFS -29% of the total US population and 36% of the US urban population live within 10 minutes by car of a retail clinic
READING: Visits to Retail Clinics Grew Fourfold from 2007 to 2009, Although Their Share of Overall Outpatient Visits Remains Low by Ateev Mehrotra ABSTRACT
Retail clinics have rapidly become a fixture of the US health care delivery landscape. We studied visits to retail clinics and found that they increased fourfold from 2007 to 2009, with an estimated 5.97 million retail clinic visits in 2009 alone.
What did the bill signed on April 16th do? (3)
Rewards high preforming providers Supports alternative payment models Modest annual fee increases
Give an example of how FMAP works...
Rhode Island FY 2012 FMAP 52% For every dollar spent, RI is reimbursed 52 cents by the federal government In FY 2010, FMAP was 63% incdicating a 63 cent federal reimbursement for every state dollar spent
Describe the 1946 Administrative Procedures Act
Road map for administrative decision making; can't be "arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with law."
How does technology have a role in the patient safety movement?
Role of technology such as electronic medical records and computerized physician order entry
How is there a spectrum or severity in the problem of mental illness?
Rough patch for a normal person or a mental health diagnosis
______ (2) are stronger determinants of health than medical care.
SOCIAL FACTORS are stronger determinants of health than medical care.
_____ (1) and Smaller practices are lagging behind at using EMRs
SPECIALIST and smaller practices are lagging behind at using EMRs
Shewart's observations were _____ (1) to the US in industry gradually starting in the 1960s
Shewart's observations were RE-IMPORTED to the US in industry gradually starting in the 1960s
Define secondary care
Short term, can be outpatient, may have technological focus
What hospitals are at a great disadvantage under the current VBP system than other hospitals?
Safety-net hospitals
Safety-net hospitals operate on _____ (4)
Safety-net hospitals operate on NEGATIVE OR LOW MARGINS
Safety-net hospitals tend to perform _____ (better/worse) on the quality metrics given higher weight
Safety-net hospitals tend to perform WORSE on the quality metrics given higher weight
What are the three main funds for France's payers?
Salaried workers Farm workers Professionals and self-employed
What are the sale taxes in the UK?
Sales taxes are 17%.
READING: The 'Alternative Quality Contract' Based on a Global Budget Lowered Medical Spending and Improved Quality by Zirui Song
Savings were accounted for by lower prices achieved through shifting procedures, imaging, and tests to facilities with lower fees, as well as reduced utilization among some groups. Quality of care also improve, compared to control organization, with chronic care management, adult preventive care, and pediatric care within the contracting groups improving more in year 2 than in year 1. These results suggest that global budgets with pay-for-performance can begin to slow underlying growth in medical spending while improving quality of care.
In WWII what helped win the war?
Science and technology helped win the war, e.g., radar, jet engines, atomic bomb, antibiotics
When is overuse seen more often?
Seen more often when there is a lack of consensus about what is appropriate
What does SMI stand for?
Serious Mental Illness
The Balanced Budget Act of 1997 set a what?
Set a ceiling on aggregate payments for Medical Doctors services (of all kinds) based on GDP growth and a few other factors
In France prices are set by whom?
Set by the French Health ministry.
What did the Doc Fix Bill Set up?
Set up a two-tier payment system -Fee for Service increases of 0.5% for next 4 years, freeze for next 6 years, 0.25% increase thereafter -5% Bonus in 2019-2024 if 25% of Medicare revenue from Value-based programs in 2019 and 75% in 2023 -0.75% increase after 2024 if >75% from Value-based programs
What does the NICE board set?
Sets their strategic priorities and policies, but the day to day decision-making is the responsibility of our Senior Management Team (SMT).
Define Thalidomide
Sleeping pill often prescribed to pregnant women
Describe procedural democracy: state over federal
Smaller units -> better information and responsiveness
How do you decide what processes to assess?
Strong evidence of process-outcome linkage
Oregon medicaid experiment
Study began in 2008 Oregon had enough funding to give Medicaid to 10K additional people 90K uninsured persons eligible 30K selected by lottery (randomly) 10K given Medicaid and could be compared with those who were in the lottery but were not selected RESULTS -Increased use of health care services -Raised rates of diabetes detection and management -Lowered rates of depression -Reduced financial strain -No significant improvements in measured physical health outcomes in the first 2 years
What are some of the difference between the different plans in the 10 provinces and 2 territories of Canada?
Some small differences in fee structures and rules
Sometimes you have to pay up ___ (1) in EDs
Sometimes you have to pay up FRONT in EDs
Specialists can be in more than _____ (a number) ACO
Specialists can be in more than ONE ACO.
What is the trend of Growth in Medicare Spending for Physician Services, 2000 - 2010
Spending per beneficiary: went up Medicare Economic Index: Less increase than spending per beneficiary, but still an increase Fee updates: A slight increase, lower than Medicare Economic Index
What is the cost of aortic valve replacement?
Standard Bioprosthetic Aortic Valve -$5,277 -Requires Operating Room Sapien or CoreValve -$30,000 -Requires a Cath Lab but with an OR team close at hand
Status of New Hampshire who is not expanding Medicaid
State Senate leaders lawmakers on Feb. 6, 2014, said they had reached a bipartisan deal to expand Medicaid to 50,000 low-income New Hampshire residents. The plan would use federal funds to help eligible residents purchase private insurance. Gov. Maggie Hassan (D) praised the deal during her State of the Union address later that day. However, the full Legislature must still sign off on the proposal before seeking approval from the federal government
What is the political philosophy for state regulation? (4)
State government is closer to the people -Better able to ascertain needs of its citizens More accessibility and accountability Greater responsiveness Greater willingness to take risks and innovate -Oregon Experiment -Massachusetts reform
Describe state health departments: mix of state and federal funding
State health departments: mix of state and federal funding 2005: "Typical" state public health agency budget -50% funding from federal grants, contracts, cooperative agreements -Can we even say typical: range is 6% (Utah) - 83% (North Dakota)
Regulation of physicians and other providers is shared by what? (3)
State, federal, and private entities
States that will have greatest enrollment in Medicaid will also experience larger _____ (1) in spending
States that will have greatest enrollment in Medicaid will also experience larger INCREASING in spending
Describe the Drug Price Competition and Patient Term Restoration Act of 1984: Hatch-Waxman Act (1)
Streamlined rules for testing of generics, required only proof of equal bioavailability
RAND Health Insurance Experiment
Study of the impact of cost sharing on utilization and health outcomes 1980s Patients and families randomized to different levels of cost sharing Cost sharing reduced utilization but did not result in worse health outcomes
Define Serious mental illness (SMI):
Substantial disorder of thought, mood, perception, orientation or memory, any which grossly impairs judgement, behavior, capacity to recognize reality, or ability to meet the ordinary demands of life. This includes, but is not necessarily limited to, diagnosis of schizophrenia, schizoaffective disorder, psychotic conditions not otherwise specified, bipolar disorder, and severe depressive disorders
define medicare part B
Supplementary Medical insurance (SMI) program covers physician, outpatient, home health and preventive services
How is Part B financed?
Supplementary Medical insurance, SMI Financed by beneficiary premiums and general revenue
What are some supply-sensitive services?
Supply-sensitive services include physician visits, diagnostic tests, hospitalizations and admissions to intensive care among patients who chronic illnesses
Systems are evolving to handle misuse ____ (1), but there remains lots of room for improvement.
Systems are evolving to handle misuse RISKS, but there remains a lot of room for improvement
Under Donabedian's Model what falls under process?
TECHNICAL CARE Screening Prevention Diagnosis Treatment Follow up care INTERPERSONAL CARE Respect Communication Knowledge and Information
1994 to 2006: 53M to 170M in MBHC (T/F)
TRUE
ACOs aim to meet patient centeredness criteria. (T/F)
TRUE
Alternative Quality Contract have strong quality incentives where outcomes weighed more strongly than processes. (T/F)
TRUE
Approximately 2% reduction in DSH payments over the next 5 years (T/F)
TRUE
Areas in which spending is higher do not show higher quality care, better patient outcomes, or more satisfied patients. (T/F)
TRUE
At first devices for sever arotic stenosis had limited distribution when first introduced; steep learning curve for provider. (T/F)
TRUE
Because virtually all care utilization, even a routine outpatient visit, is very expensive (especially in the US), health insurance generally covers most or all kinds of utilization (T/F)
TRUE
Care in the United States is, in general not sufficiently oriented toward primary care (T/F)
TRUE
Careful evaluations of ACO experiments are needed. (T/F)
TRUE
Costs of mental disorders have not risen as fast as medical costs more generally, probably in part because of MBHC. (T/F)
TRUE
Discussions about care options often do not occur or are limited or "not heard" during time of death (T/F)
TRUE
Every year Congress has intervene to prevent SGR mandated reductions. (T/F)
TRUE
Examining variations, and learning how to reduce inappropriate or unnecessary variation, can simultaneously improve outcomes and reduce cost (T/F)
TRUE
Expansion will result in an increase of 15.9 million new Medicaid beneficiaries and reduce the uninsured by 11.2 million (T/F)
TRUE
Federal and State join run program accounting for largest budget item for states (Medicaid) (T/F)
TRUE
For an insurance market to work, you need lots of health (low cost) people paying premiums to cover the costs of the relatively small group of sick (high cost) participants (T/F)
TRUE
For states expanding Medicaid, approximately half of the population would meet income requirements for Medicaid enrollment (T/F)
TRUE
Hospitals are big, important players in the healthcare game. (T/F)
TRUE
Improving any 2 of Access, Cost, and Quality is not that hard... but improving all 3 is very difficult (T/F)
TRUE
In the UK there are very active P4P programs. (T/F)
TRUE
In the UK there have been improvements to wait times in the last 15 years. (T/F)
TRUE
In the United States, units of services (how much service is being done) is NOT higher in the US, but often lower. (T/F)
TRUE
Individual insurance market has high costs and many exclusions (T/F)
TRUE
Insured and non-poor persons often use EDs as a source of usual or routine acute care (T/F)
TRUE
It is important to track quality of care by race/ethnicity. (T/F)
TRUE
Lots of things contribute to health other than health care (T/F)
TRUE
Managed behavioral health care has had some successes (T/F)
TRUE
Measure of equity capture an element of quality not assessed in current reporting systems. (T/F)
TRUE
Medicaid expansion will provide coverage to those previously not eligible (T/F)
TRUE
Medicaid was grown from an entitlement program for the poor to a program accountable for 15% of the all national health expenditures (T/F)
TRUE
Modern theories of quality improve have come to medicine. (T/F)
TRUE
No known studies have evaluated how the receipt of (nonhospice) PC in NHs may be associated with quality and/or utilization (T/F)
TRUE
Nurses are aging. (T/F)
TRUE
Often times, the prognoses of death is not communication and/or patient/family "doesn't hear" (T/F)
TRUE
PCMHs and ACOs all have arrangements that may favor primary care (T/F)
TRUE
Patient native preferences cant vary that much by geography (T/F)
TRUE
Practice improvement module in American Board of Internal Medicine (ABIM) recertification (T/F)
TRUE
Primary care is important in improving health outcomes and reducing costs (T/F)
TRUE
Describe the Kefauver-Harris Efficacy Amendment (1962) (7)
Thalidomide: sleeping pill often prescribed to pregnant women -widely used in Europe -FDA inspector Francis Kelsey refused to approve the New Drug Application (NDA) -During the delay it was shown to cause birth defects -This scandal pushed the Amendments through Amendment required evidence of efficacy, not just safety Increased/strengthened FDAs control over drug approval process
The ACO concept is _____ (1) not revolutionary.
The ACO concept is EVOLUTIONARY not revolutionary.
What is the Carte Vitale (what it looks like and what it contains)?
The Carte Vitale is a green plastic card with a small memory chip that contains digital records of every visit, referrals, injections, operations, x-rays, diagnostic tests, prescriptions, and billing information.
WEBSITE: Mark R. Chassin (President of Joint Commission)
The Center is developing solutions through the application of the same Robust Process Improvement (RPI) methods and tools that other industries rely on to improve quality, safety and efficiency. In keeping with its objective to transform health care into a high reliability industry. The Joint Commission will share these proven effective solutions with the more than 20,000 health care organizations and programs it accredits and certifies.
Who buys the medicines in the UK?
The Government buys the medicines
The MA AQC experience is a private sector _____ (1)
The MA AQC experience is a private sector INNOVATION
The US federal system is a very ____ (1) form of federalism
The US federal system is a very SPECIFIC form of federalism
The US has _____ (above/below) average supply and utilization of physicians and hospital beds.
The US has BELOW average supply and utilization of physicians and hospital beds
The US has _____ (less/more) use of expensive medical technology.
The US has MORE use of expensive medical technology.
The US has the _____ (highest/lowest) price for drugs, office visits and procedures.
The US has the HIGHEST price for drugs, office visits and procedures
The US spends a lot _____ (more/less) than other countries, both in absolute terms and as a percent of GDP
The US spends a lot MORE than other countries, both in absolute terms and as a percent of GDP
READING: US Health in International Perspective by Institute of Medicine
The United States spends much more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries. While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century. What accounts for the pardoxical combination in the United States of relatively great wealth and high spending on health care with relatively poor health status and lower life expectancy?
Define deductible
The amount that an individual or family has to pay out of pocket each year before insurance takes effect -Very high deductibles can be like "catastrophic coverage" -no deductible = "first dollar coverage"
The average Primary Care Provider need to interact with whom in order to care for their panel of patients?
The average Primary Care Provider needs to interact with 229 PHYSICIANS WORKING IN 117 DIFFERENT PRACTICES to care for their panel of patients.
Every year since 2002 the growth of medical doctor services has exceed the target of what?
The balanced budget act of 1997
READING: The relative contribution of multiple determinants to health outcomes by Health Affairs
The best estimates are about 10% of health is attributable to medical care
The biological basis of mental disorders still poorly _____ (1)
The biological basis of mental disorders still poorly UNDERSTOOD
What is the cause of supply sensitive care?
The cause is an overdependence on the acute care sector and a lack of the infrastructure necessary to support the management of chronically ill patients in other settings
Define coordinated care
The combination of services that meet patients needs and the connection between and rational ordering of those services
Define quality in the health care field.
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
The field of Healthcare is going through a _____ (1) change
The field of Healthcare is going through a TRANSFORMATIVE change
Define Health care services
The full array of services performed to promote, maintain and restore health Refers to call care settings... -Office -skilled nursing facilities -Nursing home -Hospital -Home and Schools
Who pays the providers in the UK?
The government pays the providers
Define cross-subsidization
The idea that hospitals lose money on Medicare and Medicaid patients and have to make it up on private patients
READING: Reduced Mortality with Hospital Pay for Performance in England by Matt Sutton... CONCLUSION
The introduction of pay for performance in all NHS hospitals in one region of England was associated with a clinically significant reduction in mortality. As compared with similar U.S. programs, the UK program had larger bonuses and a greater investment by hospitals in quality-improvement activities. Further research is needed on how implementation of pay-for-performance programs influences their effects.
Define risk pooling
The larger the number of insured people (the risk pool), the more predictable their health experiences and health costs will be
Describe Physician Directed Medical Practice in PCMH
The personal physician leads a team of individuals who collectively take responsibility for the ongoing care of each patient
The potential to impact healthcare with technology innovation is virtually ____ (1)
The potential to impact health with technology innovation is virtually LIMITLESS
Define medical underwriting
The process of assessing risk
The concepts of supply sensitive and preference sensitive care are potentially helpful ways to better understand what?
The sources of variation
There are ____ (number) administrative workers per office based physician.
There are 2.2 administrative workers per office based physician
How is Canadian Health Care like Medicare?
There are private providers and public financing
There has been _____ (improvement/worsening) in composite process measures
There has been IMPROVEMENT in composite process measures
There is a theory that there is _____ (1) of regulators and regulated
There is a theory that there is INDEPENDENCE of regulators and regulated
There is an average of _____ (number) credentialing applications per doctor per year (e.g., insurers, hospitals, other care facilities)
There is an average of 18 credentialing applications per doctor per year (e.g., insurers, hospitals, other care facilities)
Experiment: Scylla and Charybdis
There is broad agreement that FFS naturally and inevitably produces increasing and often inappropriate service use (and increasing cost) Capitation without appropriate regulation probably provides incentives for underutilization
There is a physician ____ (1) in Canada, which produces waiting periods for some services
There is physician SHORTAGE in Canada, which produces waiting periods for some services
There may not be a shortage of physicians, but there is a _____ (1) of primary care physicians
There may not be a shortage of physicians, but there is a SHORTAGE of primary care physicians
How is the cost savings of Canada comparable with the US?
They have an efficient payment system and bargaining clout with providers over prices
What happens when a UK patient wants a treatment that the NHS does not pay for?
They have to queue up for services (a.k.a wait lists)
From 1970 to 1980 what happened to hospital costs?
They more than tripled -Medicare hospital spending up from $5B/year to about $25 B/year
What is UK's method of rationing?
They ration on the supply side (NICE)
What do health IT alters use?
They use consumer-reported data from consumer devices
What can explain the US's dramatically high health care costs?
This is mostly explained by higher prices, not by the delivery of more services, though in the US high tech services are used more often
WEBSITE: www. nih.gov INTRODUCTION
To employ science in pursuit of fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to extend healthy life and reduce the burdens of illness and disability. NIH, through its 27 institutes and centers, supports and conducts research, domestically and abroad, into the causes, diagnosis, treatment, control, and prevention of diseases and promotes the acquisition and dissemination of medical knowledge to health professionals and the public
What is the goal of health care?
To improve health outcomes
What is the key feature of the ACA?
To incentivize high-value healthcare provided in hospitals
WEBSITE: www.fda.gov INTRODUCTION
To rigorously assure the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices, and assure the safety and security of the Nation's food supply, cosmetics, and products that emit radiation. FDA advances the public health by helping to speed innovations to market that make medicines and food more effective, safer, and more affordable, and assisting the public in getting the accurate, science-based information they need to use medicines and food to improve their health.
As a NDPB, NICE is accountable to who?
To their sponsor department, the Department of Health but operationally we were independent of government.
Too few _____ (1) physicians are being trained
Too few MINORITY physicians are being trained
What is the cost of Medicaid expansion?
Total Federal and State medicaid spending, 2014: $415 billion -57% of total spending attributed to Federal government
Explain ideology vs. Math of Expansion
Tough Decision for States with Republic Government, but population voting Democratic in Presidential Election -Ex: Arizona, New Mexico, Nevada Math vs. Ideology -If AZ participates, they gain $1.6 billion in Federal funds and associated health care jobs -Also gain support of Latino constituents, which could help in future elections -However, risk of being criticized by party and losing support
READING: Obama budget will seek record funding for new doctors by Kelly Kennedy
Train 13,000 primary care residents in high-need communities ($5.23 billion over 10 years) Extends higher payments to Medicaid providers, including physician assistants and nurse practitioners, by one year ($5.44 billion) Enlarge National Health Services Corps from 8,900 primary care providers in 2013 to at least 15,000 annually ($.395 billion over next six years)
Where do people under age 65 in the US get health insurance?
Two thirds of nonelderly population has private coverage -62% have employer-sponsored coverage -5% purchase individual policies 15% have Medicaid or other public coverage 18% are uninsured
UK patients cannot get treatments that the ___ (3) doesn't pay for.
UK patients cannot get treatments that the National Health Service does not pay for.
Give examples on how P4P solutins may be context dependent
US different than UK MA different from TX Inpatient different from outpatient Global different from partial
What is US's method of rationing?
US has demand side (ability to pay) They ration by access and cost Rationing by private insurance companies and CMS
US tends to favor market based solutions, but all countries rely on a combination of market and _____(1) solutions in health care
US tends to favor market based solutions, but all countries rely on a combination of market and GOVERNMENT solutions in health care
Under Hospital Compare what is unclear about quality?
Unclear whether quality of care improved for all racial/ethnic groups and/or whether racial/ethnic disparities in quality decreased
Define individual mandate
Under the ACA most individuals are required to purchase health insurance or face a penalty All citizens and legal residents must have qualifying health insurance or pay a fine The mandate is phased in over 3 years, 2014-2016 In 2016 the fine is the greater of... -2.5% of income over a particular threshold -$695 per person in family to max of $2085 There are exemptions... -Financial hardship, religious objection, in jail, undocumented immigrants
Describe a more nuanced look at unwanted variation. (3)
Underuse of effective care Overuse of supply sensitive care Misuse of preference sensitive care
Who is eligible for SCHIP?
Uninsured children < 200 % FPL who do not qualify for Medicaid
Describe Provider Reimbursement Methods
Units of payment: continuum of aggregation -Visit or procedure (FFS) -Episode of illness Global surgical fees DRGs (diagnosis Related Groups) for hospitals Bundling -Capitation payment: a single payment per month or year for all care for a single person
What is total health care system spending dependent on? (formula)
Units times price
Define mal-distribution of physicians
Urban and suburban issues have a physician oversupply; rural areas have an undersupply
What is Thalidomide now used to treat?
Use in the treatment of multiple myeloma
What is the critical trend with quality measures?
Using market forces to drive quality improvement by using public reporting and pay for performance
What degree does an Advanced Practice Nurse usually have?
Usually MA degree
VA studies consistently show palliative care consults associated with ____ (higher/lower) quality of care ratings.
VA studies consistently show palliative care consults associated with HIGHER quality of care ratings
Intuitively what does value have to do with?
Value has to do with paying a fair or reasonable amount for something
Variation in appropriate care are markers of _____ (1) quality
Variation in appropriate care are markers of SUB-OPTIMAL quality
What were the implications associated with the US vs. Southern Easter Underwriters Associate (1944), McCarren-Ferguson Act (1945)
Variation. Regulatory requirements could vary across states -What about large self-insured employers
What is a Medicaid waiver?
Vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children's Health Insurance Program (CHIP) Way of increasing flexibility in Medicaid services and eligibility Must be budget neutral Different types of waives: research and development, demonstration, managed care, and HCBC -Example: RI Global 1115 Waiver
Name some administrative tasks in the health care field (3)
Verifying patient insurance information Figuring out co-pays at the point of service Billing and payment collection
FFS reimbursements creates incentives for what? (2)
Volume More services
Describe Medicare Part D
Voluntary prescription drug benefit through private plans contracting with Medicare -Stand-alone prescription drug plans (PDPs) -Medicare Advantage prescription drug plans Financed through general revenue (75%), payments from states (12%), and premiums (13%) Federal cost $58 billion (estimated) in 2014
Describe Employer-Based Private Insurance history
WWII price and wage controls (National War Labor Board), 1942 Competition for workers on the basis of fringe benefits (health insurance) Post-war, unions continued this strategy, negotiating for health benefits as part of compensation strategies Enrollment in group hospital insurance plans grew from 12 M (1940) to 142 M (1988)
Where is Take Care located in?
Walmart
Do Medicare ACOs work?
We dont know yet.
READING: The Long-Term Effect of Premier Pay for Performance on Patient Outcomes by Ashish K. Jha CONCLUSION
We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Exceptions of improved outcomes for programs models after Premier HQID should there remain modest.
What should we do about EMR adoption and Interoperability to create transformative change?
We should have meaningful use of EMRs
What was the science of risk adjust well developed for?
Well developed for some outcomes, but imperfect
Measurement science is well developed for what?
Well developed for structure, process, and outcome
READING: Primary Care: Current Problems and Proposed Solutions by Thomas Bodenheimer and Hoangmai H. Pham
Well written, clear, really helps you see the big picture regarding the challenges and opportunities in primary care, and how the delivery system is changing
Why is the role and importance of wealth is more important than it used to be?
Women who are in the richest 10% will live 35 years past 55 while the poorest 10% will only live 28. Therefore, rich people have longer lives.
What does the National Institute for Clinical Excellence (NICE) decide? (3)
What tests, medications, and treatments will be covered.
When measuring interpersonal care you have to ask the ____ (1)
When measuring interpersonal care you have to ask the PATIENT
What happens when someone loses their job in France? (Regarding coverage)
When they lose their job, the government steps in and pays.
READING: A Primary Care Home for Americans by Kevin Grumbach
Why is primary care endangered? -Traditional medical culture in the US exalts and financially rewards specialization -Administrative hassles, challenges to clinical autonomy, and income reduction, caused by managed care are souring some physicians in the practice of medicine -Heightened expectations for accountability and performance Review of the difficulties achieving comprehensiveness, first contact care, continuity, and coordination Challenges of accountability and oversight The paradox of time: a little more time, and a lot more to do Putting the primary care house in order: the patient centered medical home
How do safety-net hospitals lose out on DSH payments (3)
Will it be made up from increased revenue from health insurance expansion?
READING: Increasing Demands for Quality Measurement by Robert J. Panzer
Yet there remain a number of challenges, including diverse purposes for quality measurement, limited availability of true clinical measures leading to frequent reliance on claims data with its flaws in determining quality, fragmentation of measurement systems with redundancy and conflicting conclusions, few high-quality comprehensive measurement systems and registries, and rapid expansion is required measures with hundreds of measures straining resources
Define co-insurance
a fraction of the cost of a service that the insured person has to pay
Define community rating
all individuals or groups in a single risk pool One premium rate for everyone Sick people pay the same rate as healthy people By law people in the same company, the same group, have to pay the same premium
Define Social justice
another word for this might be fairness
Describe Blue Shield (physicians) history
great Depression reduced patients' ability to pay MD fees out of pocket in 1939 the California Medical Association set up first Blue Shield plan to cover MD expenses Idea spread nationwide Controlled by state medical societies Starting in 1974 Blue Cross and Blue Shield plans began to merge
Explain The Little Clinic
in 2010, the company was purchased by The Kroger Co. The Little Clinic operates 77 clinics in select Kroger, Fry's, and King Soopers store in Ohio, Kentucky, Tennessee, Arizona, and Colorado. The company also provides management for 40 branded clinics in Florida and Georgia