Value Based Payment Reform
Most important = SDOH = behavior + environment Least important = medical care
Which part of healthcare (medical care, environment, behavior, and genetics) is most/least important for a person's health
1. Patient experience 2. Care coordination 3. Patient safety 4. Preventive health 5. At risk population
5 quality measures to report
High dollar charges for medical services inadvertently received from out of network providers -happens most often in ERs -caused by growing costs + insurance companies -capitalistic evolution by the gov -poses financial burdens = can be double of out of pocket expense Doctors No bearing
Surprise medical bills + 4 characteristics Patients often assume if they choose a hospital covered by their health insurance, the ____ at the hospital also will be covered but state law restricts hospitals from directly employing physicians, so a hospital being in the health plan's network has ____ ____ on a doctor being in the network
PCMH + tightly managed specialists Operational excellence + pop health + people and culture + digital patient experience Pop health + experience of care + control costs Too much care, too little care, wrong care Entry point redesign + clinical integration + pop health infrastructure + financing Most
What did Baylor propose to try to control costs? What are the 4 organizational priorities? What was the triple aim? What were the 3 quality problems? 4 accountable pop health essentials Although physicians received only about 20% of all the money spent on personal health care in this country, their decisions determine ___ of the remaining expense
Population health
What is the end goal of MACRA?
UnitedHealth > CVS (due to COVID tests and boosters) Novartis > Pfizer > J&J > roche > Merk > Moderna > BioNTech > abbvie > regeneron > novo nordisk
Who was the first and second most profitable payer in 2021 10 most profitable pharma companies in 2021
Social = everyone can receive care Market = do not need universal coverage because everyone has a place to go
Why do both social and market justice individuals like PCMHs?
1. Technology 2. Training 3. Research 4. Sophisticated institutions/products/processes
4 things the US health care system leads the world in
-improve quality/patient health -advance electronic medical records -control spending -provide reimbursement incentives for changing clinical practices
4 characteristics of MIPS and APMs
-Paying a lump sum/single fee to hospitals for encounter and all services for up to 90 days after discharge -trying to move away from FFS Ex: ortho and cariology
2 characteristics of Bundled payment + 2 example fields in which this is used in
-Provided a new way to provide care for vulnerable populations in Austin in conjunction with Dell Med and Seton -Took an integrated delivery person (whole person care) to better patient care coordination by having a social worker follow up and guide patients Long time to schedule a specialist appointment bc low priority/pay Solution: medical school residency opened up slots
2 characteristics of Community Care Collaborative as a PCMH 1 limitation + solution
One sided = CMS will share savings with no risk (bonus or no bonus) Two sided = ACO can achieve SHARED SAVINGS if they reduce costs below the limit and save money but must also share risk for loss (bonus or penalty) -makes organizations/providers responsible for costs 3 years
2 types of shared savings + 1 characteristic for two sided How long are shared saving tracks?
-government/PBH insurance -covers a lot of people -realized costs were going out of control so aimed to reduce costs + provide quality care
3 characteristics of Centers for Medicare/Medicaid (CMS)
-transfers risk to provider -not based on volume but rather quality, patient satisfaction, use of technology, cost related to peer charges -needed due to CMS realizing healthcare expenses going out of control (silver tsunami)
3 characteristics of value based approaches
1. Baylor Scott and White 2. Kaiser Permanente 3. Seton
3 examples of ACOs
Failure in care/delivery, overtreatment, fraud/abuse Junk, profit Low value care (not needed but can make more money if carried out) High infant/maternal mortality rates (no prenatal care) Hospital acquired conditions + low quality care at higher cost Expand primary care + decrease specialty care
3 indicators of Too much care One man's __ is another man's ___. This is in reference to? Indicator of Too little care 2 indicators of Wrong care What can be done that was successful in georgia?
-acknowledge drivers of health behavior/status -move away from patient education and towards patient self education -work at institutional and policy levels to focus on patient
3 ways to improve individual health to improve pop health
1. Changes the way care is given/paid for by CMS 2. Changes health delivery model to primary care/community based care 3. Transforms primary care to achieve pop health 4. Moves to risk based alternative payment models
4 actions/changes of MACRA
-control costs while making sure to pay physicians -alternative to FFS Part B -medicare advantage + comprehensive primary care plus -3 ways: accountable care organizations (ACOs) + patient centered medical home (PCMB) + bundled payment
4 characteristics of Alternative Payment System (APM)
-provider selects a CPT code with an itemized charge associated that is recognized by insurance companies -encourage excess volume -medicare/medicaid set the amount of payment to physician -risk is on insurance companies
4 characteristics of Fee For Service
-value based -used for primary care in HMO -discourages over utilization -transfers risk to providers -doctor groups get one lump sum to provide care for entire month
5 characteristics of Capitation
-for those who do not qualify for ACOs -strategy by policy makers to use small incentives (bonus) to lower costs while improving quality + enhancing patient satisfaction -Replaces FFS part B payments to physicians -quality analyzed via resource utilization, improving interoperability, improving clinical practice/patient engagement, and peer to peer analysis -applies to physicians, chiropractors, midlevel practitioners, speech/physical therapist, audiologist
5 characteristics of merit based incentive payment system (MIPS)
-determines an outpatient physician's reimbursement (specifically those on Part B) based on the quality of care they provide that is supported by technology -shifts the risk of losing money from insurance companies to the provider to force them to be accountable for quality, costs, and patient satisfaction (value based care) -difficult to repeal because would require refund of a lot of money -uses CMS/medicare/medicaid as vehicle for policy bc they pay the hospitals/doctors so hospitals/doctors must follow -created due to high medical expenses and congress didn't want to cut doctors' salaries -passed with bipartisan support -2 categories: automatic payment system (APM) + merit based incentive payment system (MIPS)
7 characteristics of Medicare Access and CHIP Reauthorization Act (MACRA)
-primary/PBH/safety net care -helps patients in managing decisions + care plans -community clinics -team based with providers linked by IT -comprehensive, coordinated/integrated/facilitated, committed, and accessible -funded by taxpayer money + limited quantity -value measurement (report quality) + value based purchasing (reimbursement tied to value performance) Vulnerable medicaid people go here because they get paid more for seeing Medicaid patients while other doctors do not want to see Medicaid patients because they get paid so poorly Community care collaborative
7 characteristics of Patient Centered Medical Homes (PCMH) What type of covered patients typically go here? 1 example in Austin
-high costs + low quality -equity issues -decreasing life expectancy -duplication, overlap, inadequacy, inconsistency, inefficiency, waste -complexity -financial manipulation -fragmentation
7 ways in which the system is broken
Primary care
ACOs led by ___ ___ are the most successful
Group of doctors who work together to provide all the care a person needs for a calendar year -mirrored HMOs -hospital or IPA/physician organization is lead organization (does not have to be same person) -distributes savings through hospital/IPAI contracts -hospital reports costs/savings to CMS, assumes responsibility, and binds MD in contract -one sided vs two sided risk -preferred by the government but not many
Accountable care organizations (ACOs) + 6 characteristics
Rated the care doctors provided + charged patients more if they saw a doctor with not as good outcomes Working with insurance companies to get them to receive a single lump annual payment for each individual in exchange for providing as much care as a patient needs + expanding access to primary care + giving patients access to care team Will make money by receiving the same fee for each patient each year + saving the patient unnecessary hospital visits and other medical expenses through preventive care
CLAY JOHNSTON ARTICLE How did Bind Insurance (the 1 insurance who supported) reform the payment system to be more value based? How is Harbor Health "disrupting the system"? How does Dr. Johnson believe his approach to "disrupting the system" will lead to profit for his company, while reducing cost to the patient and overall system?
He tried to launch a different model of primary care by reforming the payment system w/insurance companies (Harbor Health) = FFS --> value (improve care + decrease cost) Population health To save money/cut out low value care/waste Insurance companies feared they would not make as much money + existing system works Because would not make as much money
CLAY JOHNSTON ARTICLE What did Dr. Johnston try to do to "disrupt primary care"? What did Dr. Johnston imply when he commented "how can we create a whole system of keeping people healthy?" Why did Dr. Johnston and Dell Med, and now Dr. Johnston's company, ask insurance companies to pay a single price (amount) for care (for an individual) over a whole year? Did it work? Why? Why did the vast majority of insurance companies not consider the proposition? Why did the Dell Med consultant believe Dr. Johnson's idea of expanding into primary care over specialty was not a good approach?
Medicare method to pay for hospitals admissions based on diagnosis (fixed amount for each diagnosis)
DRGs
Increasing Shared, information blocking
Health care spending as % of GDP has been ____ Although the HITECH Act moved hospitals/physicians into the digital age by providing cash incentives to obtain and use EHRs and even threatened a deduction of Medicare payments if not adopted, health records are still not being ____ among competitive providers. This has resulted in ____ ___
Profit = revenue - expenses Increasing revenue or decreasing expenses Because they are the middleman so can simply raise costs for consumers if hospitals demand more money
Profit formula 2 ways to make a profit Why are insurance companies okay with always raising prices?
More
Providers always charge ___ and insurance companies pay ___ than Medicare rates
Somewhere you can go to receive care even if you do not have money -not geographically distributed enough to help everyone + chronically underfunded County hospitals
Safety net clinics + 2 downsides Safety net clinics are usually ___ hospitals
Stops patients from being blindsided by high medical bills for emergency services, services provided at in-network hospitals, and for lab work -Only applies to those who have insurance regulated by the Texas Department of Insurance -Prohibits the failure to pay a surprise medical bill from hurting one's credit report -Does not protect against surprise ambulance bills Established federal regulations against surprise bills + the payment amount 1. Require private plans to cover out of network claims and apply in network costs 2. Prohibit covered providers from billing patients more than in-network cost sharing amount for surprise bill -Emergency services -Post emergency stabilization services -Non-emergency services provided by out network providers at in network facilities Non-emergency No
Senate Bill 1264 + 3 characteristics No Surprises act + 2 provisions Which 3 settings do surprise bill protections apply to? Treatment, equipment/devices, telemedicine, imaging/lab, and pre/post operative services are defined as ___ ___ services Do consumers have federal protection against surprise bills for nonemergency services?
Value based, reward
Shifting the risk from insurance companies to the provider may help motivate providers to provide ___ ___ care and may be associated with greater ___ than risks
More old people need money but not enough young people to balance/offset
Silver tsunami
