MP 508

There are five components that aim to fulfill the Triple Aim:

1.-Focus on individuals and families: care should be customized at an individual level utilizing families and caregivers as partners. Redesign primary care 2.-services/structures: a team of professionals must be established that can deliver the majority of necessary care. 3.Population health management: partnerships within the community are necessary to promote prevention and wellness. 4.-Cost control platform: cooperative relationships with provider groups must be in place to control costs. 5.-System integration and execution: services across the continuum of care must be coordinated.

How are Accountable Care Organizations (ACO) different from managed care of the past?

Accountable Care Organizations (ACOs) are provider groups that have agreed to be accountable for the overall costs AND quality of care for their patients. In this model, risk is shared AND savings earned from improved care are shared. ACOs include the primary care physician, specialists, hospital, and the payer. The Affordable Care Act (ACA) has encouraged more ACOs to form that support Medicare beneficiaries through the Medicare Shared Savings Program (financial incentives for providers to meet quality targets AND share in the savings). In contrast, Managed Care Organizations (MCOs) have a different approach to improving cost-efficiency that has been criticized. They grew in popularity in the 1990s, but largely excluded physicians. In addition, MCOs lead to the emergence of HMOs which are restrictive (require prior authorization, review utilization). MCOs share risk, but are fee-for-service payment

Why is it particularly important to have an integrated delivery system when caring for individuals with chronic conditions?

Chronic conditions (multiple, complex conditions) account for ⅕ of all health care spending, which is about 1% of patients. These patients need strategies in place that get them higher value of care. This includes integrated and coordinated mental health, physical health, social needs, and family caregiver involvement. These patients need the most resources and have the potential for the most serious negative consequences. ACOs target this population through comprehensive care management programs. Risk stratification is used to identify people at high risk for adverse clinical events. Segmentation is used to separate high-risk patients into subgroups with common needs. This includes improving transition of care.

Phase 3wellness and population health (1980-present).

Chronic diseases are better managed and focus is on lifestyle and health environment, the latter including the social determinants of health, health disparities, functional status, and living longer. New infectious diseases include HIV/AIDs ad antibiotic-resistant agents. New challenges include terrorism, natural disasters, and pandemic. Health reform and technology occurring.

What is the prospective payment system in Medicare?

DRG (Diagnosis Related Group) - inpatient payment is based on your diagnosis. This is regardless of length of stay in the hospital. Implementation led to a decline in length of stay (inpatient services were transferred to outpatient). There was no reduction in quality of care or health outcomes; rather unnecessary stays (thus Medicare costs) were reduced.

What is the difference between fee-for-service and capitation payments?

Fee for service: A system under which doctors and hospitals receive a payment for each service they provide. Capitation: They are fixed, pre-arranged monthly payments received by a physician, clinic, or hospital per patient enrolled in a health plan, or per capita.

1) Public Health: Four pillars: global, national, state, local. These pillars are aimed to address disease prevention, health promotion, and the health of populations.

Global: HIV, Clean Water, vaccinations, chronic diseases. National: surveillance and research using compiled public health statistics, issue standards related to food safety, conduct training and help with the public health workforce to the epidemiological intelligence service State: statistics, licensing of health facilities, disease surveillance, and they use its broad police power to enforce public health standards in compliance with treatment. In large states many of these functions are decentralized to local governments Local: level where most services occur. Based on statistics and epidemiology.

What has been the health care spending trend for the past few decades?

Health care costs have increased for employers and employees. This burden is also costing the government more in GDP. It is a major issue for reform facing this era of healthcare. 18% of GDP (⅙ of US economy)

What implication does rising health care spending have on the government, employers, and individuals?

Health care markets in their current from may not be truly competitive and therefore may not allocate resources efficiently. Cost have put substantial pressures on government budgets, which may crowd out expenditures on other goods and services adversely affecting U.S companies competitiveness.

What is "hotspotting" in healthcare?

Healthcare hotspotting is the strategic use of data to reallocate resources to a small subset of high-needs, high-cost patients. A small number of individuals drives much of the cost in the American healthcare system. An example is in Camden, New Jersey where many data-based and health peer coaches have been utilized to serve the populations' needs.

Why is it important to consider politics and interest groups in the policy making process?

Healthcare is constantly a top issue for voters during election season. Both sides recognise the need to decrease healthcare spending while improving quality and access but the presidential candidates usually hold diverse views on many key health issues. Healthcare industries spend the most on lobbying efforts with trillions of dollars are at stake with how much money is spent and how it is spent on healthcare programs. ACA is always an important issue that is influenced by politics. With rising concerns about rising out of pocket costs and the threat to health coverage amid COVID-19, there will be pressure on the administration and congress to strengthen the ACA if it is upheld, reinstate protections if it is overturned, and develop policies to ensure adequate health coverage.

Inpatient care

Hospital care in general acute care facilities or community hospitals, or tertiary/quaternary care facilities for more specialized care such as cancer treatment or orthopedic rehabilitation

the emergence of chronic disease (1920-1980)

Infectious diseases still prevalent (1917 Flu Pandemic) and chronic diseases emerged. However, government public health initiatives, antibiotics, and immunizations led to decline in morbidity and mortality of infectious diseases during this time. The ongoing construction of the Panama Canal revealed the role of vectors in transmission. In addition, the Pure Food and Drug Act (1906) passed and demand for national health plans grew. Health insurance grew. The Framingham Study on behavioral and environmental determinants for cardiovascular disease, Surgeon General's report on tobacco use, and Salk vaccine against polio emerge. In 1946, the Hill-Burton Act passed to build hospitals. In 1950, the NIH was funded. In 1965, Medicare and Medicaid were established

Understand geographic variations in health care. Recall Atul Gawande's "Cost Conundrum" and work by the Dartmouth Atlas.

Large difference across the country in spending for care of similar patients This indicates that the health care system may not be as efficient as it could be. Geographic variation only partly explained by prices of health care services severity of illness. Income and preferences of individuals. Some of the variations in medical practice is probably due to regional differences in the supply of medical resources. Some regional appear more prone to low-cost, highly effective patterns of care vs others that are more prone to adopt high-cost patterns of care and to deliver treatments that provide little benefit or care even harmful. Spending in high-spending regions could be reduced without producing worse outcomes or reductions in the quality of care. Policies that reduce spending in high-spending areas would not necessarily lead to increased efficiency and could result in worse health outcomes unless the reductions targeted ineffective or harmful treatment.

Describe the different types of government health insurance programs. How are they similar and different in terms of who they cover, how they're financed, and which parts of government are responsible for their administration and delivery.

Medicare: federal by CMS Eligible >= 65, certain diagnoses (SSDI,ESRD,ALS) Medicaid: State-federal partnership "50 state,50programs Mandatory benefits standards set at federal match VA, Military health system, Federals IHS: Federal

Describe moral hazard and adverse selection as they relate to health insurance.

Moral Hazard: the tendency to use a service when available regardless of need. Adverse Selection: the separation of risk so that you accumulate disproportionately higher risk individuals or lower risk individuals within a pool leading to higher costs for the high risk pool. As opposed to a mixed pool where lower and higher risks are combined; thus spreading the risk to a broader group of individuals.'

Long-term care

Often needed after an acute medical episode; this intervention varies depending on care needs, including skilled nursing facilities (SNFs), homecare, or appropriate rehabilitation care.

Palliative care and hospice care

Pain management, End of Life, physical, emotional, spiritual, and social needs addressed from a multidisciplinary approach. This care focuses on relieving suffering.

What do the different parts of Medicare cover and how are they financed? What is part A, B, C, D of Medicare?

Part: A Hospital Coverage Coverage for hospitalization and inpatient care: -Inpatient Hospital stays. -Skilled Nursing care -Hospice -Home care. Part: B Medical coverage Outpatient care -Doctor visits -surgery -Lab Test -Medical Equipment -Preventive exams Part: C Medical Advantage Combines Part A & part B, Part D . can be added as needed. Often fully covers: -Wellness Exams -Vision Exams -Hearing Exams Often partially covers: -Glasses -Hearing aids Part: D Prescription Drug coverage Help with the cost of prescription drugs not covered by original Medicare. Must have Part A or B to enroll. The Centers for Medicare & Medicaid Services (CMS) is the federal agency that runs the Medicare Program. CMS is a branch of the Department of Health and Human Services (HHS).Medicare is paid for through 2 trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare. Hospital Insurance (HI) Trust Fund Payroll taxes Other sources: Income taxes paid on Social Security benefits Interest earned on the trust fund investments Medicare Part A premiums from people who aren't eligible for premium-free Part A Supplementary Medical Insurance (SMI) Trust Fund Funds authorized by Congress Premiums from people enrolled in Medicare Part B (Medical Insurance) and Medicare drug coverage (Part D) Other sources, like interest earned on the trust fund investments

What are the important components of the PCMH (patient centered medical home) model?

Personal clinician Physician-directed team oriented medical practice Whole person orientation (patient centered) Care is coordinated AND integrated Emphasis on quality AND safety Enhanced access Payment reform -> value and quality

Ancillary care

Physical therapy (PT) and occupational therapy (OT), outpatient dialysis, hospice care, independent labs and imaging, pharmacy, medical device facilities (ex: hospital bed, wheelchair, etc.), chiropractor, and naturopathic medicine are the many services that support the basic medical care delivery.

Major components of the U.S. healthcare system: describe the function of each.

Public Health Ambulatory Inpatient care Long-term care Ancillary care Auxiliary care Palliative care and hospice care

How can we hold down costs and what are some ideas for controlling costs?

Regulate health care industry changing payment to prepaid. value-base purchasing (pay for quality). Controlling price (wage and price control) .Control supply, shifting risk to individual's competition. More transparency in pricing, integration of service and bundling of payment, increasing primary care rate, focus on quality.

Why are health care costs increasing?

Rise of chronic illness, overuse, overtreatment, consumers and providers do not have perfect information, patients and providers lack incentive to minimize their cost of purchasing and providing medical treatment.

What are the roles of the state and local governments in shaping health policy?

State governor sets the agenda, approves, or vetoes bills, and oversees the implementation of the laws. He or she also creates the budget and submits it for approval. The federal agencies must interact with similar state health care agencies for implementation of federal as well as well sate policy. Appellate process goes through appellate courts and, in rare instances, all the way to the US Supreme Court. State cases can also be appealed to the US Supreme Court if it they involve a constitutional question. The local government are seen as instruments of states policy because they implement state laws. For example, mayor of chief executives sets the agenda and oversees the importation of the laws. He or she also creates the budget and submit it for approval. Local chief executives must also operate within a legislative environment by passing polices that govern the health care infrastructure, by passing budgets and hiring staff.

What is Medicaid expansion? As part of the ACA, it was expected to expand coverage to which population? What is the controversy?

The ACA expansion of Medicaid was restructured to cover the vulnerable, highest need population. All low income individuals were added to Medicare in 2012 by Congress, which was seen as an overstepping of its constitutional power. It is a voluntary choice for each state government to adopt this expansion, rather than a federal mandate leaving over 2 million people uninsured. To date, 39 states (including DC) have adopted the Medicaid expansion and 12 states have not adopted the expansion.

What is the current state of the Affordable Care Act? (i.e. enrollment, implementation of the provisions, politics)

The ACA is presently active. The individual mandate is constitutional and still in place, however the Tax Cut and Jobs Act (December 2017) repealed the associated fines (now $0). The Health Insurance Marketplace exists in each state and is managed by either the state or federal government. 39 states have expanded Medicaid, with success, while 12 remain to expand leaving millions uninsured. Overall since implementation, many have enrolled and have better access to care.

What are the key features of the Affordable Care Act (ACA)?

The Affordable Care Act (ACA) is the most significant healthcare legislation since the 1960s including these 16 features: Individual Mandate - requires US citizens and legal residents to have qualifying health coverage. Employer Requirements - offer coverage OR vouchers for the Exchange. Expansion of Public Programs - expand Medicaid coverage and funding for the Children's Health Insurance Program (CHIP). Premium and Cost-Sharing Subsidies to Individuals/Families - credits to purchase insurance through the Exchanges. Premium Subsidies to Employers - small business tax credits. Tax Changes Related to Health Insurance or Financing Health Reform Health Insurance Exchanges - state based exchanges with benefit tiers; not open to incarcerated individuals. Benefit Design - comprehensive benefits package that covers 60% of actuarial value; abortion is not covered. Changes to Private Insurance - coverage for individuals with pre-existing conditions, administrative simplification, dependent coverage for children up to age 26, prohibit lifetime limits on dollar value of coverage, prohibit rescinding coverage, lower deductibles, and limit waiting periods. Internet website to ensure consumer protections. Funding within HHS to implement healthcare reform policies. State Role - create the Exchange for individuals and small businesses, enroll newly eligible beneficiaries into the Medicaid program. (American Health Benefit Exchanges & Small Business Health Options Program (SHOP) Exchange) Cost Containment - administrative simplification, Medicare, prescription drugs. Improving Quality/Health System Performance - comparative effectiveness research, alternatives to malpractice litigation, disparities, Medicare and Medicaid. Prevention/Wellness - funding, community-based programs, coverage of preventative services, nutritional transparency. Long-Term Care - skilled nursing facilities disclose information, CLASS program. Other Investments - Medicare, workforce, community and school health centers, trauma care, disaster preparedness, and non-profit hospital community needs assessment every three years. Financing - oversight from Congressional Budget Office (CBO).

Phase 1infectious and communicable diseases (1850-mid 1900s),

The American population was rural and many large-scale epidemics (cholera, yellow fever, smallpox, malaria) were common. The role of sanitation was recognized and the first quarantine laws were passed. After the Civil War, immigration and western migration led to urbanization and overcrowding. This caused acute health problems (pneumonia, tuberculosis). Health departments expanded, improved water and sewage systems, but most medical care was still at the home due to risk of hospital infection.

Why is there an effort to move away from the fee-for-service (FFS) payment model?

The FFS payment model reimburses quantity and is flawed because of uncontrolled utilization (moral hazard, speciality care, provider-induced demand), illness-focused rather than wellness-focused, and has uncontrolled prices, payments, and as a result increased premiums.

What is the relationship between the issue of equity and government policies? How is the healthcare market different from other industries?

The Health Care Market is different from other industries because of uncertainty (when care will be needed AND efficacy of treatment), essentiality of care, ambiguous role of competition, information asymmetry (providers>consumers>insurers), and less price sensitivity since patients don't typically pay the full amount.

What are some examples of health policy initiatives or regulations that have focused on access to care, quality of care, and cost of care?

The Institute of Healthcare Improvement (IHI) launched the Triple AIM Initiative to help health care organisations improve the health of a population's patients' experience of care(including quality, access, and reliability) while lowering the per capita cost of care. Helps identify and fix problems such as poor coordination and overuse of medical services and aims to redirect attention to activities that have the greatest impact on health. Health care costs: Hospital price transparency went into effect on January 1, 2021 allowing Americans to know the cost of a hospital item or service before receiving it. Each hospital in the US will be required to provide clear, accessible pricing information online about the items and services they provide. The Heroes Act safeguards COVID-19 patients from balance billing. This is the potential for patients to get a surprise bill after inadvertently receiving out-of-network care. American Rescue Plan: the income cap on ACA subsidies (400% FPL) was lifted and no one would have to pay more than 8.5 percent of their income on premiums for ACA marketplace plans. COBRA subsidies give workers and their families their former employer's coverage for up to 18 months. In some cases up to 3 years. Scope of Practice (SOP): Expansion of SOP improves high quality, affordable care particularly where there are physician shortages. To extend the capacity of the healthcare workforce to manage COVID-19, many states temporarily waived SOP restrictions for a wide range of healthcare professionals. Expanding pharmacist's role in the delivery of healthcare facilitates the implementation of community clinic-pharmacies, which increases patient access to care. Health Technology: Federal government has crafted policies to support implementation of Electronic Health Records (EHRs), mobile health devices, application programming interfaces (APIs), machine learning, and other digital health technologies. Insurers and regulators rapidly crafted interim solutions for payment for HCP telehealth services and governance to protect patient confidentiality in order to meet the urgent needs for remote care amid the pandemic. Establishment of FDA's Digital Health Centre of Excellence- to support and regulate digital health products. Government will continue to play a major role in shaping the future of health tech. Medicare: Large divide between how political parties propose supporting Medicare beneficiaries. Proposals from both sides include: Broadening Medicare eligibility Expanding supplemental benefits for Medicare Advantage Authorising negotiations of drug prices Maintaining provision offered by the ACA that benefits seniors Repealing legislation that accelerates insolvency Introducing caps on certain drug co-pays Implementing a Medicare-for-All or a government administered public option Medicaid: Congress passed legislation that requires Medicaid to cover COVID-19 testing and eliminate cost-sharing related testing services. Lawmakers set up a fund to cover testing for individuals under state Medicaid plans. Medicaid Waivers Medicaid Disaster Relief State Plan Amendments (SPAs), other Medicaid and CHIP SPAs, and Other State-Reported Administrative Actions to Address COVID-19 Section 1115 Waivers to address COVID-19 Blanket Section 1132 Waivers Section 1915(c) Waiver Appendix K Strategies to Address Covid-19 Healthcare Supply Chains: New trade policies implemented in 2018 imposing tariffs on goods from China disrupting supply chains for health organizations for medical equipment and supplies. PPE, treatments, and life support coupled with trade tariffs created shortages. FEMA initiated the Supply Chain Stabilization Task Force to address limited supply of critical protective and life-saving equipment FDA set up a medical device supply chain notifications system to monitor supply levels Mental Health Political debates around gun control, suicide rates, domestic violence, and substance abuse.

What is the "triple aim", as discussed in Berwick's article?

The US must pursue a broader system of linked goals to achieve higher value care. Berwick's article states that the three aims (triple aim) must be pursued to better the US healthcare system: improving the individual experience of care, improving the health of populations, and reducing per capita costs of health care. These are all interdependent goals.

What are the main arguments made by the states that have refused to expand Medicaid?

The argument in states that are against Medicaid expansion is that the 10% cost falls on them (taxing the populations the program aims to help) and takes away from other programs.

What segment of the US population accounts for majority of our health care dollars?

The elderly

Why is there a demand for health insurance?

The greatest driver of demand for healthcare services and workers is the aging of the US population. The number of people over 65 will grow from 43 million in 2012 to 84 million in 2050 and the nation's overall population grows older. Older people need both a great quantity and complexity of healthcare services. The growing older population is Medicare eligible, so the riding need for services will be covered, increasing health utilisation. Economic expansion and job growth are projected for the next decade. Increasing number of overall jobs and employment is directly correlated to

What is the challenge of applying the population health model to an illness?

The population health model functions at the group level and aims to provide services to the entire "definable patient population". This includes providers in the network, cost and quality of care, transitions, and discharge planning. This can also involve community partnerships that target prevention and wellness. In contrast, an illness is specific to an individual patient in a specific clinical encounter. Applying the population health model in this scenario would limit patient autonomy in their care and decisions and family involvement. Complex chronic conditions require careful management.

Describe the difference between the population health and the medical model

The population model looks at the health of an entire population and the needed policy and public health changes that must be implemented in order for the overall health to be addressed. This is believed to be a preventive measure for disease before it even occurs along with health promotion. Environment, human behavior, lifestyle, and medical care are all aims of this model. The medical model aims to treat the individual and emphasizes disease diagnosis, tx, and care in the most effective and efficient manner. Disease that bypasses the efforts of a population model of intervention must be addressed and treated by the correct implementation of the medical model.

How would you define social determinants of health? How do these determinants affect the social gradient in morbidity and mortality?

The social determinants of health include economic status (low-income, middle-income, high income) and geography. There is inconsistency between states in access to affordable care. Lower income individuals are less likely to get preventive care services and more likely to utilize the emergency department, however this gap is addressed when these individuals are insured. Lower-income individuals are also more likely to experience unsafe prescription drugs. Determinants of Health include: Genetics, Behavioral, Environmental and Physical Influences, Medical Care and Social Factors.

What are the 3 phases of health care history in the U.S? (consider the social dynamics, health status, and structure of the health care system in defining these phases)

The three phases of health care history in the US are 1) infectious and communicable diseases (1850-mid 1900s), 2) the emergence of chronic disease (1920-1980), and 3) wellness and population health (1980-present).

What are some problems with traditional (non-integrated) health care delivery models?

The traditional (non-integrated) health care delivery model has several issues: 1) acute illness is the focus 2) lack of emphasis on prevention 3) volume-based (not quality) 4) lack of coordination/integration 5) inadequate access to primary care (unnecessary utilization of emergency department) 6) specialization is unnecessarily emphasized 7) care delivery is fragmented.

Describe the uninsured population in terms of income, employment status, age, and health status.

The uninsured population consists of undocumented immigrants, who are not covered by the ACA, and those who are eligible, but do not enroll and pay individual mandate fines. In California, much of the uninsured is the Latino population. The latter population may benefit from outreach. In addition, many businesses have deferred participation and instead pay the fines (not offering coverage) or transition employees to part-time worker status. There is concern for adverse selection in terms of the health status of individuals who do enroll (the elderly and sick) who are more likely to enroll early, while healthier and younger individuals who may benefit from preventative and wellness services opt out. In states without Medicaid expansion, many individuals who are not insured through their employer and ineligible to participate in the insurance market (low income) fall into the Medicaid gap and remain uninsured. Example is Texas.

Define and explain uncertainty, information asymmetry, and externalities in the context of the healthcare market.

Uncertainty: Consumers do not know when illness will strike so they do not know when there will be demand for care. Information asymmetry: Information is unavailable to all parties. Externalities: Happens when it was not the intention. The effect that results of something that happens. Positive vaccination; bc of this people who were not the target of the intervention actually benefitted (side consequence)

How has Medicaid changed since passage of the ACA?

With passage of the ACA, categories for Medicaid eligibility were largely eliminated - becoming based on income only. However, this depends on where you live, specifically whether you live in a Medicaid expansion state or not.

Co-insurance:

financial risk transferred to the consumer; a percentage of the total costs, deductibles, and co-payments that the consumer is expected to pay -A response to moral hazard The percentage of costs of a covered health care service you pay 20% for example after you are paid your deductible.

Insurance premium:

monthly payment to insurance company to shift financial risk (for a health problem) to the insurance company who assumes that risks. the amount of money and individual or business must pay for an insurance policy.

2) Ambulatory:

services to people in physicians' offices, clinics, outpatient centers, urgent care centers, and hospital emergency departments. Simple ambulatory care involves a visit for a relatively low acuity health problem and is provided typically as a single visit with perhaps a follow-up, all involving the resolution of an acute problem or the managing of a chronic condition. Complex ambulatory care requires more technological infrastructure such as imaging and surgeries as well as skilled clinicians. This includes nonwestern medicine.

Deductible

the amount a person has to pay out of pocket before the insurance benefits are paid.

Co-payment

the amount that a person is to pay for each service or prescription.

Auxiliary care:

working in parallel to the general health system are mental health services and oral health.