HLSA 300 Final
community hospitals
private hospitals that serve patients who are insured. funding comes from private donors and/or agreements with private insurance companies
4 main types of innovation
product process marketing method organizational method
Active Error
human and some aspect of general system (well-practiced) = FAILURE
Origins of errors
Human System
MACRA
Medicare Access and CHIP Reauthorization Act of 2015 made MIPS and APM
PCMH
Patient Centered Medical Home
Patient Safety
Shame and Blame culture
Roemer's Law
- a built bed is a filled bed -Fisher and Wennberg found that residents in areas with higher per capita hospital bed supply were 30% more likely to be hospitalized than areas with fewer beds
Exclusive Provider Organizations (EPO) payment
- discounted FFS for EPO contracted providers -no coverage or price protection out-of-network
the charge (usually fixed)
- the retail price set by the provider ("chargemaster")
Private health insurance history Khanacademy
-1920s: group of docs - offer membership model - attempt for risk pooling -1930s: group of teachers, schools negotiated on behalf of workers, pay for health insurance - employer sponsored insurance -1940s: WWII, gov had wage control, employers could not raise wages, instead offered fringe benefits: health insurance -1954: fed gov considered fringe benefits as tax free benefits -1960s: almost 3/4 of workers were getting ESI
Medicare KhanAcademy
-1965 created by Lyndon Johnson to help people >65 yrs -elderly have low income and high medical expenses -coverage for disabled who also have low income high expense -later covered people with kidney failure and ALS -social insurance program, not many qualifications
uninsured KhanAcademy
-47 to 60 million Americans -people go between insured and uninsured due to employment status, changes in coverage by medicaid, lose eligibility for insurance -most are employed but do not have insurance -about 1/3 make less than FPL,another 1/3 make 2-3 x FPL, other third makes >60K -cost of insurance for 1 person - 6 K -fam of 4- 18 K -cost high since no negotiation w/ hospitals
specialist physicians
-6 main groups -internal medicine: endocrinology, geriatrics -obstetrics/ gynecology -surgery (5 year residency), orthopedic, neurosurgery -hospital-based: anesthesiology, pathology, radiology, "hospitalists" - often trained in internal medicine, but do not go into primary care practice -psychiatry -broad medical specialties: dermatology, neurology
Bundled Payments ACA
-Bundled Payments for Care Improvement Initiative via CMMI -would integrate part A and B services -4 different models to choose from: -retrospective hospital stay -retrospective hospital stay and post-acute (ending 30 to 90 days after discharge) -retrospective post-acute and long-term care -prospective for entire hospital stay -episodic payment
ACOs ACA
-CMS program -allow for shared savings and shared risk -pioneer ACO and regular ACO porgrams: shared savings can range from 50%-70% -virtual organizations designed to integrate care: loose affiliations between local hospitals
reimbursement for outpatient care
-FFS fee schedules (like Medicare) -encounter/visit based fees -capitation for a set of services
global capitation ACA
-Medicaid Global Payment System Demonstration Project -administered by Center for Medicare and Medicaid Innovation (CMMI) -five states chosen for 3 year demonstration -move from FFS to a fixed price per member based on age, health status, and gender -large safety net health systems or networks eligible -represent comprehensive payment scheme
Medicare structure PART B KhanAcademy
-Medicare Part B: pays for providers, separate payment, have to enroll in part B, not completely free even after 65 - have to pay $100 per month as premium, still have to pay deductible and co-pay -no taxes to pay for it
Medicare structure PART A KhanAcademy
-Medicare part A: expenses in hospital, acute, ppl have to pay $1000 deductible for first 60 days of hospitalization, also pay co-insurance -funded by 2.9% tax on all Americans - 1/2 paid by individual wages, 1/2 paid by employer: payment of taxes for 10yrs qualifies coverage of part A after 65
flaws in fee-for-service
-Uncontrolled utilization: moral hazard, overutilization of specialty care, producer-induced demand -uncontrolled prices and payments: charges set at artificially high costs, insurers were passive payers of claims, inefficiencies absorbed by raising premiums -focus on illness rather than wellness: lucrative for physicians to hospitalize patients -professional fess separate from facility fees
How are people covered? KhanAcademy
-about 50% : employer-based insurance -about 1/3 : the govt ( 1/2 medicare and 1/2 medicaid) -very low amount: people who pay for their own insurance or insurance companies -rest: people who do not have any insurance, have to pay OOP - uninsured: 47-60 million people
steps in regulation
-advanced
relative value units (RVUs)
-assigns 3 RVU to more than 6000 services according to CPT under Medicare Fee Schedule -RVU for physician works, based on the Resource-Based Relative Value Scale (RBRVS) -RVU for office expense -RVU for malpractice expense
policy process
-awareness raising -problem definition -id options -policy selection -implementation -evaluation
tax credits for 100-400% FPL
-based upon sliding scale of income -pay off difference between actual cost of premium and the max income federal law allows for them to pay -based on benchmark second highest silver plan -2% for very low income, 6.3% for middle-income and 9.5% for higher income (400% FPL) -in some cases silver plan upgraded for 100-250% FPL. -100-250% has enhanced 97% AV plan -150-200% gets 87% AV enhanced plan -both are better than platinum plans due to added coverage without additional premium -200-250% get 73% enhanced AV plan, better deal than 70% silver plan
Federal Poverty Level ( FPL)
-calculated by the gov for use by welfare and social programs -actual FPL changes every year and is a fixed amt (adjusted by family size) that predicts whether a household has enough money to afford basic services, food, etc -percentage of FPL is used as an index to determine eligibility for Medicaid and individual market advance premium tax credits (APTC)
Health Maintenance organization (HMO) payment
-capitation for certain specialties or provider groups -salary (Kaiser or county facilities -discounted FFS
choice restriction
-closed panel (in-network access): no access outside the panel -open access (out-of-network access): outside option is allowed, but at higher out-of-pocket cost
Medicare expenses KhanAcademy
-cost very high at first in 60s, expenses dropped in 80s, increased in 90s, stabilized in 00s. -generally above the rate of inflation -1980s: prospective payment system, changed hospital payments, cost of part A -1990s: balanced budget amendment 14% goes towards medicare
Inpatient Prospective Payment System
-created in 1983 -based on concept of Diagnosis Related Groups -shift away from "cost plus" reimbursement
Prospective UR
-decision to refer or not -preauthorization (pre-certification) -second opinions -inform concurrent review about case
dentists and dental staff
-dentists - specialists - orthodontics, oral and maxillofacial surgery, pediatric, periodontics, prosthodontics, endodontics, public health, and oral pathology -dental hygensist: cleaning and education -dental assistants - aiding in procedure and cleaning done by dentist
Medicaid states KhanAcademy
-different states have diff rules -NY: up to 400% FPL can get medicaid -NC: up to 200% FPL can get medicaid -most children covered by medicaid - CHIP
Preferred Provider Organizations (PPO) payment
-discounted FFS for participating providers -out of network services have higher cost sharing, and prices are not negotiated by payer (based on customary and reasonable costs) -not protected by negotiation when out of network: balance billing
how does medicare attempt to control costs?
-do no engage in utilization review in the FFS environment -benefit limits and caps -pilot programs -prospective payment -pass on costs to beneficiaries
Several different approaches ACA
-evaluation by CMMI of payment models: quality reporting and monitoring required -success of ACOs driven partially by market participation -resistance to jumping in quickly -already more than 60 ACO partnerships have started to implement -still based on FFS payment with profit sharing component
why did premiums increase in 2017?
-expiration of risk corridors and reinsurance -pop represents more risk due to lack of programs
safety net provider - public hospitals
-federally qualified health centers: community and migrant health centers, homeless and housing health centers, rural health centers -standalone clinic -private practices that take Medicaid and discounted fees from patients (cash business) -non-profit hospitals
Private health insurance payment Khanacademy
-fee-for-service: payment for each service -problems: high healthcare costs, fragmented care - no incentive for providers to talk to each other, cost-sharing increases over time -managed care - insurers find groups of docs and hospitals, creates contracts, payment schedule -disease management programs, deductible according to cost of doctor -networks
home care
-generally custodial or unskilled care, personal care, attendant care
allied health and non-physician practitioners
-generate billings but not always independently -allied health professionals: physical therapists and assistants, occupational therapists and assistants, radiology technicians, and respiratory therapy technicians -non-physician practitioners: nurse practitioners, physician assistants, certified nurse midwifes
physician equivalents
-generate billings independently -optometrist (OD) -clinical psychologists podiatrists -chiropractors -acupuncturists
limitations of billing process
-generate lost of administrative data: sometimes useful in monitoring quality, but typically lacks outcome information -FFS billing and itemization resulst in massive amount of coding and paperwork/formats for each payer, incentivizes volume over efficiency -fee schedules often reimburse more for procedures when compared to evaluation and management
Geriatric Care Managers (GCMs)
-help families create and implement long term care plans for their loved ones -public sector workers called benefits counselors or case managers -private sector workers called care managers
stabilizing market if adverse selection is driving premiums
-higher indiv mandate penalties -higher employer mandate penalties -increase incentives to adopt medicaid exapnsion -extending the reinsurance program -extending the risk corridor program -invisible high risk pool
ACA control costs
-independent payment advisory board
physician provider offices
-independent practice associations (IPAs) -accountable care organizations are often led by large medical groups
State regulatory authority
-insurance regulation -licensure of providers and facilities -certification of facilities
limitations of the policy process
-issue regulations under administrative Procedures Act
Concurrent UR
-length of stay and when to discharge -discharge planning: expected inpatient stay, anticipated outcomes, subsequent appropriate setting, special requirements
decreasing high costs in healthcare
-limiting access to care -eliminating unnecessary care -improving health -lower fees increased use of primary care -prospective payment systems -denial of claims -competition -decreased drug costs -negative effects on medical research -decreasing overhead for insurance companies and providers
Affordable Care Act
-medicaid expansion: eligibility for households with incomes up to 138% FPL -insurance market: federal health insurance markets and exchanges in all states -market reform: no pre-existing conditions, essential health benefits and mandates -premium tax credits that lower costs for households with incomes between 100 -400% FPL
readmissions ACA
-medicare has already stopped paying for readmissions within 30 days of discharge -ACA expands that to include Medicaid -Medicare also institutes penalties for hospitals with high rates of readmission -Still focused on DRG reimbursement, not a new payment model
ACA rewards bundling and integration
-moving away from fee-for-service - ACA is not prescriptive about private insurance reimbursement -however, medicare and medicaid changed could shift expectations about payment and integration: global capitation, bundled, ACOs, no payment for readmissions in medicaid, penalties for high readmission hospitals
risk in ESI
-need large, healthy "risk pool" -offers multiple plans -require employees to pay share of cost
the price (variable by payer source)
-negotiated or set by the payer -often captured as the "allowed" or "paid amount"
health insurance market reforms
-no pre-existing conditions -10 essential health benefits -no annual caps on lifetime limits -caps on OOP spending -individual mandate -3:1 age-based premium rating
Freestanding Emergency Centers (FEC)
-not urgent care centers -full-service emergency departments open 24 hrs
inpatient care
-overnight stay in hospitals -measure utilization: discharges, inpatient days, average length of stay, capacity, average daily census, occupancy rates -large decrease in the number of hospital beds - PPS became norm in all except TEFRA hospitals
claims adjudication
-paid - amount claim based on negotiated rate or some agreed upon Usual Customary & Reasonable Cost (UCR) -denied - services delivered may not be in the benefit package, claim may lack appropriate information to process -adjusted - reduction to charge amount, often to reflect actual fee schedule or negotiated amount
The Military Health System (MHS)
-part of US department of defense -provides comprehensive medical services for military operations and responds to natural disasters and humanitarian crises around the globe -for active duty members -uses Tricare health insurance network
diversification
-partnering outside of your niche or expertise -vertical integration
expansion
-partnering within your are of expertise to gain better bargaining position or market power -horizontal integration
Medicaid KhanAcademy
-partnership between federal and state govt -fed gov pays at least 1/2 -state gov pays at most 1/2 -costs 400-500 billion in costs -means tested insurance: have to show you don't make much money -covers disabled - extra benefits - long term care
private clinics
-patients have health insurance -affiliated with privately owned hospital -affiliated with physician group partnership -established by an individual physician family practice
risk corridors in the indiv market (2014-2016)
-plans that guessed wrong on their premiums (both +/-) would share in the losses and gains -plans that priced their premiums within +/- 3% of actual spending would keep the profits/ losses -plans that priced their premiums between +/- #% and +/- 8% would have to pay back some of their gains, or receive subsidies for their losses (funded by counterparts)
risk adjustment in the indiv market
-pool of funds paid out to plans with lower premiums and higher risk scores in a specific market
consolidation
-popular theme in healthcare -mergers between insurers -mergers between members of the delivery system
consequences of prospective payment
-potential for cost shifting -used as the benchmark throughout the healthcare systems -rewards volume for physicians -hospitals take on more risk: resulted in decreases in avg length of stay, early discharges, sever cases still pay better creating incentives for upcoding
risk bearing contracts
-potential for gains, shared savings, or payback: full capitation, ACOs, bundled payments, global budget, episode payments
risk pooling
-premiums are based upon a large group of individuals -people living in a geographic area, workers in the same firm - employers use an open enrollment period when people can choose coverage for next year, special enrollment period for new employees -insurers estimate the costs of the people they predict to enroll (in advance of open enrollment) -employee characteristics could be used to estimate premiums -indivs and small firms can no longer have their medical history used to underwrite and price a policy.
how is the indiv health insurance market financed under the ACA?
-premiums paid by: indiv OOP, tax credits, cost sharing reductions -individual mandate -employer mandate -other general income tax dollars
Primary Care
-prevention, diagnostic, therapeutic, health education, counseling, minor preventive surgery -is ambulatory care -three major factors: point of entry, coordination of care, essential care
general physicians
-primary care -provide preventive services -treat regularly occurring, less severe problems -the basis for the patient-centered medical home
hospitals
-provide inpatient and outpatient services -must be licensed -organized physician staff -med records
Types of Hospitals
-public hospitals: government owned (often county or district) -voluntary hospitals: non-profit, but privately owned -proprietary hospitals - investor-owned, for-profit -some are general acute care hospitals, some are specialty hospitals -other types: community hospital, size and location, teaching hospitals, osteopathic hospitals
palliative care
-relieves patients of their pain instead of medical care
retrospective UR
-review of medical records -review appropriateness and patterns -feedback to physicians -claims review
utilization review (UR)
-review patterns in use prospectively and retrospectively -typically done by entity at risk -to ensure cost-efficiency -plan subsequent care -appropriateness of services determined by published Clinical Guidelines -3 types
Critical Access Hospitals (CAH)
-rural hospitals -CMS reimburses CAHs for medicare patients at 101% of cost
6 dimensions of healthcare quality
-safety -effectiveness: gap between design and implentation, new guideline -equity -efficiency: waste - tensions between safety and effectiveness -timeliness: system responsiveness, access -patient-centeredness: options, aligns with patient values and goals
pure community rating
-same premium for a specific plan and coverage category
concerns of ACA costs
-solvency of medicare -increases in health insurance premiums -prices of pharmaceutical drugs -price transparency
sub-acute care
-special sub-acute units (hospital, long-term care facilities) -home health -outpatient surgical centers
reinsurance in the indiv market (2014-2016)
-stop loss insurance provided by fed gov to insulate plans from losses for excessive claims -if an enrollee used $45,000 worth of services in a given year, reinsurance funds would pay for additional claims
ACA individual mandate
-tax penalties for not having coverage. higher of the two options: -2014: 1% of income above the filing threshold OR $95 per person (1/2 penalty for kinds) up to $285 -2015: 2% of income above the filing threshold OR $325 per person (1/2 penalty for kids) up to $975 -2016: 2.5% of income above the filing threshold OR $695 (1/2 penalty for kids) up to $2085 per family
nursing homes and long-term care
-type of inpatient care -institution based: intermediate care -community based -nursing homes : skilled nursing facilities - rehab and custodial, hospice agencies -end of life care -home health -residential settings: assisted living, board-and-care facilities -ability to manged co-morbid chronic conditions
Medicaid changes ACA 2010 KhanAcademy
-uniform standard for who gets medicaid -all Americans up 133% FPL gets medicaid -single childless adults covered -expanded eligibility -US gov pays 90-100, federalized, states pay 10% after several years -supreme court decision, fed gov could not force medicaid expansion
high cost in healthcare
-use of expensive, new diagnostic tests and treatments -increased cost of health care goods and services: drugs -marketing of new drugs, services, and procedures -overuse of specialists -high administrative costs -doctor fees -defensive medicine -aging of the population
fee schedule
-used by Medicaid could be based on procedure code -could be partially driven by severity -may differ by type of provider depending on state and insurer -sometimes, rather than a dollar amount, it is based upon some percentage of Medicare
experience rating
-used by large group employers to price premiums based on the risk of the pool based on their actual health care use, spending and experience on average in the past - in indiv market, people with illnesses, older people and women charged more because of past experience
three legged stool
1. access to care 2. cost of care 3. quality of care
Donabedian 7 pillars of quality
1. efficacy 2. effectiveness 3. efficiency 4. optimality 5. acceptability 6. legitimacy 7. equity
3 steps of access
1. gaining entry into the healthcare system (usually through insurance coverage 2. accessing a location where health care services are provided (geographic availability) 3. finding a healthcare provider whom the patient trusts and can communicate with (personal relationship)
assisted living
24-hr personal care assistance as well as meals, social activities and other amenities
memory care
24-hr personal care assistance as well as meals, social activities and other amenities, for those with dementia, staff-to-resident ratio is lower, increased security, external access restricted
Medicare structure PART C KhanAcademy
Medicare Part C: began in 1997, buy private health insurance that would then pay providers and hospitals, medicare paid premiums, sometimes prescription included, sometimes did not have to pay for co-pays, deductibles, and premiums -today, 1/4 medicare expenses used to purchase private health insurance
Medicare structure PART D KhanAcademy
Medicare Part D: comprehensive drug benefit through Medicare Modernization Act in 2003 -addition to part A and B, no taxes to pay for it, added to debt
MIPS
Merit Based Incentive Payment System based on performance
MACRA reporting fields
Quality; Resource Use/cost Clinical Practice Improvement Meaningful Use of Certified EHR Technology
Coinsurance example
You pay $200 in premiums per month for a Bronze (60% AV) Preferred Provider Organization (PPO) plan. Your deductible is $5000 annually and your out-of-pocket maximum is $6,750. Your in-network coinsurance is 20% and and your out-of-network coinsurance is 40%. You decide to go to an out-of-network hospital for care and your total bill for your 3-day hospital stay is $20,000. If you had used an in-network provider, your average cost for the same 3-day stay would have been $15,000. How much do you owe out-of-pocket for your health services, excluding your monthly premium. Answer: you would pay the first $5,000 for deductible. Then, 40% of average cost for in-network (15,000-5000deductible =10000) which is 4,000. then 5000 for balance billing. since there is an out of pocket cap of 6,750 which does not include balance billing, you would pay the 5,000 deductible, 1,750 of coinsurance and the 5000 balance billing, making the total 11,750. If in network, pay 5000 deductible, 20 % of coinsurance (15000-5000 = 10,000, .2x10,000) =2000. The total being 7000. but there is a spending cap which leads to a total of $6,750.
healthy 2020 SDOH
a "place-based" organizing framework, reflecting 5 key areas of SDOH which include economic stability, education, social and community context, health and health care, neighborhood and built environment
Usual, Customary, and Reasonable (UCR) cost
a calculated average of claims for a specific service
cromnibus
a combination of long-term omnibus spending bill and a shorter-term continuing resolution
Anderson's Model of Health Services Use
a conceptual model aimed at demonstrating the factors that lead to the use of health services. According to the model, usage of health services is determined by three dynamics: predisposing factors, enabling factors, and need
Pioneer ACO Model
a program designed for early adopters of coordinated care.
Medicare Shared Savings Program (MSSP)
a program that helps a Medicare fee-for-service program providers become an ACO.
per diem
a provider is paid a fee by the insurer for providing a specific service
adverse selection
a situation where sellers have information that buyers do not or vice versa, about some aspect of product quality. in the case of health insurance, adverse selection is the tendency of those in dangerous jobs or high-risk lifestyles to get life insurance -certain health plans attract riskier enrollees than competing health plans, resulting in higher premiums in the future -specific benefits, lower deductibles, lower co-payments, specialized networks, etc might all attract riskier patients -ACA attempts to limit adverse selection by requiring standardization of health benefits and setting the "metal tiers" and use risk mitigation to limit losses/gains by health plans
omnibus
a spending bill that packages together all 12 of the appropriations bills
Advance Payment ACO Model
a supplementary incentive program for selected participants in the Shared Savings Program.
price protections
actuarial values: 90% - platinum 80% - gold 70% - silver 60% - bronze
modified community rating -ACA
age (3:1) and smoking status (1.5:1) to be used in setting premiums
process
all that is done to patients in terms of diagnosis, treatment, monitoring, and counseling
Next Generation ACO Model
an initiative for ACOs that are experienced in coordinating care for populations of patients. It will allows provider groups to assume higher levels of financial risk and reward than are available under the Pioneer Model and Medicare Shared Savings Program (MSSP).
urgent care center
an outpatient clinic where physicians and other healthcare professionals provide a convenient and cost-effective way fro patients to get immediate treatment for minor illnesses and injuries
third party payers
any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients -ex: medicare, medicaid, CHIP, TriCare
ACOs
are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.
health savings account
can be used for OOP. accounts earn interest and any unused money is not lost. To be eligible, people must have insurance plan with lower premiums and higher deductibles than a traditional health plan. plans are called high-deductible health plans
APM criteria
certified EHR tech quality measures medical home model expanded or participants to bear more than a nominal amount of financial risk
billable providers - independent authority
clinical psychologists, acupuncturists, chiropractors
Who is eligible for MIPS
clinicians billing more than $30,000 a year in Medicare part Band providing care fro more than 100 medicare patients
Who is exempt from MIPS
clinicians newly enrolled in medicare below low volume threshold participating in APMs
cost-sharing structure in insurance types
co-payments more prevalent in HMO, while coinsurance is used more in PPO
social determinants
conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks
tricare
covers about 9 million active duty and retired military personnel and their families
personal cost sharing
deductibles, coinsurance, co-payments, OOP maximum -OOP max of about $6550 per individual or $13,100 for the family unit
State Children's Health Insurance Program (CHIP)
designed to help provide coverage for uninsured children when their family's income was below average but too high to qualify for Medicaid. The fed gov provides matching funds to states for health insurance for these families
osteopathic medicine
emphasizes musculoskeletal system of the body, preventive medicine, holistic approach
hospice care
encompassing approach to treating terminally ill patients in the last weeks or months of their lives, may include palliative care
employer-sponsored insurance
expenses for health insurance and other benefits are tax deductible for the employer (payroll tax) and for the employee (income tax). The cost of the insurance coverage is shared between the two (each pays share of premium) -minimum value: pays at least 60% of the cost of coverage -caps on coverage: cannot place lifetime or annual caps on coverage -OOP: must limit OOP expenses
global budget
fixed total dollar amount for all care delivered. However, participating providers can determine how dollars are spent. global budgets limit the level and the rate of increase of healthcare cost. Global budgets typically include a quality component as well
allopathic medicine
focus on neutralizing effects of disease
pay-for-coordniation
goes before FFS by coordinating care between the primary care provider and specialists. Coordinating care between multiple providers can help patients and their families manage to a unified care plan and can help reduce redundancy in expensive tests and procedures
Veterans health administration (VHA)
gov operated health care system provides comprehensive health services to eligible military veterans
What conditions demonstrate readmission rates best?
heart attacks, heart failures, pneumonia, COPD, hip/knee replacement, bypass surgery
home health care
higher level of care which requires medical training, includes checking vitals, assisting with braces, medical equipment, may also provide custodial care
independent living
homes within a complex that offers transportation, security and recreational activities, but not health care services
employer mandate
in 2016, employers with 50 or more full-time equivalent workers must provide affordable coverage (9.5% of wages) for an individual, but not the whole family, to all full time (30 hour per week) workers. If not, the employer will face penalties -premium can't exceed 9.5% of wages -should cover 95% of workforce -penalty is $2000 per 30 hr/week worker (minus the first 30) if the company doesn't offer coverage to any of their 30+ hr/week workers -penalty is $3000 per 30+ hour per week workers who goes onto to the exchange and obtains a subsidy if the employer did not offer them affordable coverage
Hospital Value Based Purchasing Program
incentive payments to acute care hospitals for providing high quality care, following clinical practice guidelines, and enhancing patient experience.
value
interaction between cost and care
continuing or joint resolution
legislation that keeps money flowing to federal programs whose regular spending bills are unfinished
swiss cheese model
major accidents and catastrophic systems failures tend to reveal multiple smaller failures leading up to the actual hazard (latent to active) no single barrier is foolproof
senate health, education labor, & pensions committee
measures relating to education, labor, health, and public welfare
low volume threshold
more $30,000 a year in Medicare part B and providing care fro more than 100 medicare patients
disruptive innovation
new technology that displaces an established tech cheaper and more convenient made by outsiders embraced by poorest customers in market
stopgap bills
now the norm to keep federal agencies running, reqd in each of the previous 20 years
specialized outpatient clinis
offer care in specialty areas such as cardiology, urology, and wound care
flexible spending accounts
offered by some employers. employers can shoose to have a limited amount of money deducted from their paychecks for OOP expenses, not subject to income tax. account does not earn interest and if any money is unused, employee does not get it back
executive order
official documents, numbered consecutively, through which the President of the US manages the operations of the federal govt
house ways & means committee
oldest committee in Congress with chief tax writing committee, revenue, appropriations, and banking
cost
price x volume
partial or full capitation
patients are assigned a per member per month payment based on their age, sex, lifestyle, medical history, and benefit design. payment rates ate tied to expected usage regardless of whether the patient visits more or less. Like bundled payment models, healthcare providers have an incentive to help patients avoid high-cost procedures and tests in order to maximize their compensation. Under partial or blended capitation models, only certain types or categories of services are paid on a basis of capitation -sometimes not accepted by specialists
Cost sharing reductions
payments made by the federal government to health plans selling insurance in the healthcare.gov or state exchanges designed to subsidize lower income individuals deductibles and other cost sharing requirements. These Cost Sharing reductions are available to people earning between 100% and 250% of the federal poverty level and effectively upgrade the typical Silver Plan (70% actuarial value) to a higher actuarial value plan (with lower deductibles, coinsurance/copayments, and out of pocket maximums). The enhanced plans have 73%, 87%, and 94% actuarial values based on the income group of the enrollee
need
perceived - disability, symptoms, diagnoses, general state evaluated (actual?) - symptoms, diagnoses
access
provides a lens for understanding our health care system. if you don't have access you aren't using health care -often measured by looking at patterns of use, availability of providers, and whether people have a provider for care -measures of "realizes access": usual source of care, number of MD visits, # of preventive services used, # of ER visits -measures of unrealized access: lack of usual source of care, not able to get appt with a certain # of days, lack of providers, delays or inability to get care -the timely use of personal health service to achieve the best health outcomes
adult day health care
provides everything with adult day social care but also has medical services found in nursing homes
State Innovation Model
provides federal grants to states under cooperative agreements to design and test innovative state based multi payer health care delivery and payment systems
predisposing factors
race, age, beliefs, marital status, past illness, education, occupation, family size, ethnicity, religion, residential mobility, values concerning health and illness, attitudes towards health services, knowledge about disease
government
receive taxes from individuals, in return govt provides services, assisting with risk sharing. govt pays through Medicare and Medicare mainly which directly pays money to providers. can purchase insurance from insurance companies for certain citizens (smaller amt than payment to providers).
employer
receives goods and services from workers, in return pay wage and salary as well as the payment of premium
Hospital Readmission Reduction Program
reduce medicare payments fro hospitals with excess 30 day readmissions
bundles or episode-of-care payment
reimburse healthcare providers for specific episodes of care such as an impatient hospital stay. This healthcare payment model encourages efficiency and quality of care because there is only a set amount of money to pay for the entire episode of care
community health clinic
related in nature to public safety-net hospitals because the patients they serve are poor and underserved. Funding for community health clinics comes from govt sources, as does funding for public hospitals
assisted living
residences provide help with activities of daily living including basic health services, recreational and social activities but not skilled nursing care
continuing care retirement communities
residences that provide a continuum of care from independent living to assisted living to skilled nursing. These are designed to enable seniors with progressively declining health to remain in a single residential location or give healthy seniors the peace of mind that all their future needs are covered
skilled nursing homes
residences with 24/7 care by licensed health professionals including all housekeeping, medical and social needs
Latent Error
resources without training= accidents waiting to happen
house energy & commerce committee
responsibility for the telecommunications, consumer protection, food and drug safety, public health research, environmental quality, energy policy, interstate and foreign commerce
regular order
rules, precedents, and customs of Congress that constitute and orderly and deliberative policymaking process
structure
setting in which care occurs and the capacity of that setting to produce quality
risk sharing
several individuals pay premiums, pooling of money = pooling of risks
downside shared savings program
shared savings includes both the gain share potential of an upside model, but also the downside risk of sharing excess costs of healthcare delivery between provider and payer. Because providers are taking on greater risk with this model, the upside opportunity potential is larger in most cases than in an all-upside program
upside shared savings program
shared savings programs provide incentives for providers with respect to specific patient populations, a percentage of any savings realized is given to the provider. upside-only shared savings is most common with Medicare Shared Savings Program (MSSP) ACOs, but all MSSP must move to downside model after 3 years.
Quality measures
structure, process, outcome
adult day social care
supervision and care in a structured setting during daytime hours usually only on weekdays. Meals and therapies sometimes offered
enabling factors
support, insurance, community, income, type of regular source, access to regular source, ratio of health personnel and facilities to population, price of health services, urban-rural character
virtual companion care
tablet computer to monitor safety and mood can be monitored, medication reminders provided
private, individual insurance
tax credits available if low-to middle income. offered health insurance companies, brokers, and health insurance marketplaces
senate committee on finance
taxation and other revenue measures; Medicare, Medicaid, CHIP, TANF
Aviation Analogy
teamwork, leadership, decision-making
actuaries
use claims data to predict spending and set premium based on their experience
deductible
the amount of money you must pay out-of-pocket toward your health care before an insurance company will pay any part of your claim. For example, if you signed up for a plan with $2,000 deductible, you would need to pay $2000 out of your own pocket before the insurer would start paying for any portion of your care
the cost (fixed on provider side)
the amount spent on providing care (including overhead, capitals costs, etc)
copayment
the fixed amount per service or visit you pay for health care use. For example, if your insurance policy requires $20 copayments for primary care, $40 copayments for specialty care, and $5 copayments for prescription drugs, you would have to pay those amount each time you received a service once you met your deductible
Cost sharing
the money that insured users of the health care system must pay, in addition to their monthly insurance premiums, to actually use services. Cost sharing includes deductibles, coinsurance and co-payments
Premium
the monthly amount that health insurers charge for coverage. If a portion of the premium comes from an employer and the remainder comes from the employee, the entire amount is the premium while the separate amounts are called the Employee Contribution respectively -in individual markets, people have to pay full premium but may receive tax credits to help subsidize the cost -most medicare beneficiaries do not have to pay medicare premiums
fee-for-service
the most traditional of healthcare payment models, fee-for-service requires patients or payers to reimburse the healthcare provider for each service performed. there is no incentive to implement preventative care strategies, prevent hospitalization or to take any other cost-saving measures
Coinsurance
the percentage of the cost of services you are responsible for, after meeting your deductible. This is charged INSTEAD of a co-payment and is a percentage-based calculation. For example, if you have a $2,000 deductible and are required to pay 20% coinsurance, you would have to pay out-of-pocket until the deductible was met, then 20% of any costs remaining
Indian Health Service
this system of gov hospitals and clinics provides health services to about 2 million American Indians or Alaskan natives living on or near a reservation -withing US department of Health and Human Services
facilitation
to lower the threshold or increase the ease
partnership for patients
to reduce preventable hospital-acquired conditions (HACs) by 40 percent and 30-day hospital readmissions by 20 percent.
population health
trying to improve access to high value care, while also incentivizing wellness and health status rather than simply the absence of illness examples - MD global payment model, ACOs
pay-for-performance
value-based reimbursement, healthcare providers are only compensated if they meet certain metrics for quality and efficiency. Creating quality benchmark metrics ties physician reimbursement directly to the quality of care they provide
moral hazard
when an individual does not have an incentive to avoid risks because they are protected from the consequences or when someone has insurance coverage, they will use it
kingdom's model of agenda setting
window of opportunity -problem stream -policy stream -politics stream
co-payment example
you pay $200 for bronze (60% AV) health maintenance organization (HMO) plan. deductible is $5000 and OOM is 6750. copayments are $60(PCP), $70 (specialty), and $300(hospital). hospital stay costs 15000. You pay 5000 deductible and 300 con-payment for a total of 5300. because deductible is satisfied, you pay co-payments of $60(PCP), $70 (specialty), and $300(hospital) for the rest of the year until OOM is met
