Value-Based Healthcare
For the osteoporosis quality metric the population was (women/men) ___ and older who suffered a ___ The metric was the proportion who had a ___ measured or a ___ initiated within ___ months
women; 67; fracture BMD; bisphosphonate; 6
What is an example of fee for service + pay for performance?
Medicare incentive payment program (MIPS)
What is capitation?
Monthly premium per member (per member per month)
What is the greatest difference between CPOMS (pharmacists) and nurse service?
Drug therapy started
What is the triple aim? (3)
Experience of Care Health of a population Per Capita Cost
Did the phone telephone and follow-up letter improve the number of patients filling their prescriptions?
Yes
What is the number one factor associated with primary non-adherence?
concern about SE
What are some other reasons for primary non-adherence? (3)
didn't know about Rx Don't believe in drug benefit unable to afford
The alternative payment model is a hybrid between what three things? What is one example?
fee for service shared savings capitation Comprehensive Primary Care
In capitation insurance company is also the what? What is an example of this?
healthcare provider Kaiser
The US spends the (most/least) on health care and has (lower/higher) quality of healthcare
most; lower
new medication ordered but not picked up by the patient This affects ___ to ___ patients per month
primary non-adherence 30-50
Which of the following services will get reimbursed in fee for service model? 1) Physician assessing a patient with arthritis 2) Physician calling a patient to discuss lipid lab results and initiate statin therapy 3) Nurse calling a patient to discuss lipid lab results and initiate statin therapy 4) Physician discussing lipid lab results and initiating statin therapy at a clinic visit 5) Pharmacist reviewing a patient's diabetes regimen at a clinic visit (pharmacists can't bill as providers)
1 and 4
What does a health system need to succeed in value-based reimbursement programs 1) Leadership culture that prioritizes the triple aim 2) Sophisticated data analytics capability (if it isn't measured you can't change it) 3) Multidisciplinary care management teams 4) All of the above
4
What is the best star rating for capitation? How many HEDIS measures are there? If you get 4 stars what do you get? What additional thing do you get if you have 5 stars?
5 80 5% bonus on monthly member payments can enroll members at any time
What was the CPOMS compared to?
A nurse service over telephone vs. pharmacist at each clinic
What legislations are involved in value-based health? (2) What government body is working towards a value-based program?
ACA MACRA CMS
What are the 5 quality target domains
Effectiveness of care Access to care Experience of Care Utilization Plan descriptive information
What of the following payment models is not an example of value-based care? 1) Performance-based payment 2) Risk-based payment 3) Fee for service payment 4) Capitation Payment
Fee for service
What is a bundled payment? What does this discourage? It incentivizes efforts to reduce what?
Fixed amount for an episode of care unnecessary care; readmissions
What does HEDIS stand for?
Healthcare Effectiveness Data and Information Set
What is the accrediting body for capitation quality incentives? Accreditation is required by what? Is quality data publicly reported? Medicare has high money incentive for high ___ scores
National Committee for Quality Assurance Payers (government and many private) Some HEDIS
Are telephone calls usually reimbursable? Can pharmacists bill as providers?
No No
Value = ___/___ With value we provide care that improves ___ This is done by making decisions based on ___ and engaging ___ in their care
Outcomes; cost Health evidence patients
Was the pharmacist group or nurse group more cost effective? Which was more expensive based on annual cost for provider? Which was loser per patient achieving HEDIS? Why was the nurse group more costly?
Pharmacist group Pharmacists Pharmacists More hip fractures
In fee for service payment the there is incentive to do what?
Provide more services (more money)
What are the four components you are reporting on to get a pay for performance with MIPS? What percent is each component worth?
Quality (50%) Advancing Care Info - EMR (25%) Clinical practice improvement (15%) Resource use (10%)
For shared savings you have to report what two things? You have to show cost savings of at least ___% to get shared savings
Quality and cost savings 2
Key factors for success with population management strategies involving pharmacists (4)
Relationships Data availability Technology Documenting outcomes
What is the osteoporosis management service called? Pharmacists intervened using what?
clinical pharmacy osteoporosis management service (CPOMS) collaborative drug therapy management protocol
With alternative payment model the healthcare provider gets what up front? Is quality reporting and cost savings reported? Is there a value-based bonus?
per member per month fees Yes Yes
What is included in value-based reimbursement? If providers perform well on ___ they get more money Providers are motivated to do what?
quality measures quality measures provide good care
How did pharmacists address adherence?
telephone survey
With value we want to decrease ___ This is done by not doing unnecessary ___, being ___, using ___ providers and using ___ therapies
waste tests; efficient; non-physician; cost effective
