2014 National Healthcare Quality and Disparities Report Chartbook on Care Aff...
Healthcare reform beacon-may 2013
1. HEALTHCARE REFORM 2.0
WHAT IT MEANS FOR CME AND MEDICAL
COMMUNICATION PROFESSIONALS
Debra Gordon, MS
President, GordonSquared, Inc
debra@debragordon.com
2. ABOUT ME
• 20+ years writing about medicine and
health care
• 8 years as a newspaper reporter
• 13 years as independent medical writer
• Managed care experience (provider
relations manager for mid-sized HMO)
• Kaiser Family Foundation media fellowship
• ~50% of business now related in some way
to healthcare system/policy
• Certified health policy wonk
4. LEARNING OBJECTIVES
• Describe key components of the Affordable
Care Act and other healthcare reform
initiatives
• Discuss the potential impact of the ACA and
healthcare reform on CME and other medical
communication businesses
• Identify potential new clients/funding for CME
and medical professionals
7. COST
Kaiser Family Foundation. April 2011. Available at: http://www.kff.org/insurance/snapshot/OECD042111.cfm
Growth in Total Health Expenditure Per Capita, US, and Selected Countries, 1970-
2008
OECD=composite of 34 industrialized countries
9. ANSWER
The greatest contributors for the rise in health care spending in the past 20
years:
• The rising prevalence of treated disease accounted for 50.8 percent of
growth in overall spending among adults and 77 percent in the case of
Medicare spending. Higher spending per treated case accounted for a 39
percent increase and joint effects of the two accounted for the remaining
10.2 percent.
• The doubling of obesity since 1987 contributed to 10.4 percent of the
overall rise in spending.
• Increasing treatment intensity accounted for 11.9 percent of the growth
spending between 1987-2009.
“Understanding the relative contribution of changes in treatment guidelines,
obesity, rates of screening, and disease detection would provide critical
information on where best to invest in slowing the rise in treated prevalence.”
Thorpe KE. Health Affairs. 2013;32:851-858.
11. LACK OF ACCESS
• Regardless of demographic characteristics, health insurance
coverage affects medical service utilization and cost.1
• Uninsured people more often forgo or delay medical services
compared with people who have health insurance coverage.1
• Uninsured people cost the health care system more than insured
the insured.1
High numbers of uninsured = uncompensated care = higher costs for
the insured
This “hidden health tax” costs US families and their employers paid
an extra $1,017 in health care premiums in 2008-92
1. US Census. Health Status, Health Insurance, andMedical Services Utilization: 2010. 2. Families USA. Hidden Health Tax: Americans
Pay a Premium. May 2009
12. LACK OF COORDINATION, WASTE
If banking were like health care, transactions would take not
seconds but days or longer as a result of unavailable or misplaced
records.
If home building were like health care, carpenters, electricians, and
plumbers each would work with different blueprints, with very little
coordination.
--- National Institute of Medicine. Best Care at Lower Cost: The Path
to Continuously Learning Health Care in America. 2012.
13. LACK OF COORDINATION
"Nobody is responsible for
coordinating care. That’s the dirty little
secret about health care."
--- Lucian Leape, MD, Harvard health policy analyst
and a nationally recognized patient safety leader.
• Confusion about who is managing a patient's care -- and lack of coordination
among those caregivers – contributes to the estimated 44,000 to 98,000 deaths
from medical errors each year.
• 15,000 Medicare patients every month suffered such serious harm in the hospital
that it contributed to their deaths.
• “For families, the sense that no one is on top of their loved one's care can be one
of the most harrowing experiences related to a hospital admission.”
Source: Rabin RC. Available at: http://www.kaiserhealthnews.org/Stories/2013/April/30/Coordination-of-care.aspx.
14. WASTE
More than 130 unnecessary tests and
procedures
~20% of medications prescribed to elderly are inappropriate
15. Test Recommended?
Pelvic exam/Pap OK
Mammogram/Ultrasound OK
Pelvic ultrasound OK
Baseline EKG Nope
LDL-particle Nope
Carotid artery ultrasound Nope
Abdominal ultrasound Nope
Bone density scan Nope
Case Study: 57 yo woman in good health
• Borderline high LDL cholesterol
• Not sure if she’s in menopause
• Mother died of breast cancer before age
65
• Exercises 4-5 times a week
• Healthy weight
• Doesn’t smoke
• Healthy diet
• No family history of osteoporosis or heart
disease
• Normal blood pressure
• Normal blood sugar
• Some carpal tunnel in wrist
Total cost: $2200
WASTE
16. WASTE
• Current waste [in the healthcare system] diverts resources from
productive use, resulting in an estimated $750 billion loss in 2009.1
• 30 percent of all Medicare clinical care spending could be avoided without
worsening health outcomes. Extrapolated to total US healthcare spending
this equals about $700 billion in savings.1
Total Medicare expenditures in 2011 were $549.1 billion.2
1. Reducing Waste in Health Care. Health Affairs Policy Brief. 2012. 2. 2012 Annual Report Of The Boards Of Trustees Of The Federal
Hospital Insurance And Federal Supplementary Medical Insurance Trust Funds
18. LACK OF TRANSPARENCY
If shopping were like health care, product prices would
not be posted, and the price charged would vary widely
within the same store, depending on the source of
payment.
------ National Institute of Medicine. Best Care at Lower
Cost: The Path to Continuously Learning Health Care in
America. 2012.
20. TRANSPARENCY
“Consumers who received strong and clear information on
quality alongside cost data were more likely to choose high-value
providers that offer high-quality care at lower costs.”
--- Hibbard J, et al. An experiment shows that a well-designed report on costs and
quality can help consumers choose high-value health care. Health Affairs. 2012;31(3):
560-568.
Hibbard J, et al. Health Affairs. 2012;31(3): 560-568.
21. QUALITY
If . . .
• Automobile manufacturing were like health care, warranties for
cars that require manufacturers to pay for defects would not exist
so few factories would monitor and improve production line
performance and product quality.
• Airline travel were like health care, each pilot would be free to
design his or he own preflight safety check, or not to perform one
at all.
--- National Institute of Medicine. Best Care at Lower Cost: The Path to
Continuously Learning Health Care in America. 2012.
22. QUALITY
Compared to Australia, Canada, Germany, Netherlands
Indicator AUS CAN GER NETH NZ UK US
Overall 3 6 4 1 5 2 7
Quality of care 4 7 5 2 1 3 6
Effective care
Safe care
Coordinated care
Patient-centered
2
6
4
2
7
5
5
5
6
3
7
3
3
1
2
6
5
4
1
1
1
2
3
7
4
7
6
4
Access 6.5 5 3 1 4 2 6.5
Cost-related access problems
Timeliness of care
6
6
3.5
7
3.5
2
2
1
5
3
1
4
7
5
Efficiency of care 2 6 5 3 4 1 7
Equity of care 4 5 3 1 6 2 7
Long, healthy, productive lives 1 2 3 4 5 6 7
Davis K, et al. Mirror, Mirror on the Wall. 2010 Update. The Commonwealth Fund
23. 2,000 DEATHS A WEEK FROM MEDICAL
MISTAKES
Makary M. How to Stop Hospitals From Killing Us. WSJ. September 12, 2012
24. QUALITY
If the care in every state were of the quality delivered by
the highest-performing state, an estimated 75,000 fewer
deaths would have occurred across the country in 2005.
--- Best Care at Lower Cost: The Path to Continuously
Learning Health Care in America. The Institute of
Medicine. 2012
26. “You’re worried…you’re going to piss the
doctor off, …[that] it’s going to change
the relationship. …I don’t want to rock
the boat.”
--- 49-year-old man
Frosch DL, et al. Health Affairs. 2012;31(5):1030-1038
29. MAJOR GOALS OF HEALTHCARE REFORM/ACA
Increase access
Improve quality and
outcomes
Contain spending
• Increase Medicaid
eligibility
• Health insurance
exchanges
• No preexisting
conditions
• Children up to age 26
covered on parent
policy
• Accountable care
organizations
• Value-based
purchasing
• Health information
technology
• Patient-
centered/empower
patients
• “Free” preventive care
• New reimbursement
models (bundling,
capitation, shared risk)
• Reduce
errors/waste/fraud
• Insurance stop/loss
31. INCREASE ACCESS: INDIVIDUAL MANDATE
Household income >133% of federal poverty level (FPL) must
enroll in plan with “minimum essential coverage” or pay
penalty
• 2014: 1% of household income over threshold or $95,
whichever is greater
• 2015: 2% of household income over threshold or $325,
whichever is greater
• 2016 and beyond: 2.5% of household income over
threshold or $695, whichever is greater
• Total household penalty cannot exceed 3 times the
individual penalty
33. EXCHANGES: CLIFF NOTES VERSION
• Individual to each state
• Launch Jan 1, 2014
• Online marketplaces
• By mid 2012, federal government had spent more than $1B in grants to states to
establish exchanges
• States fund operations after 2014
• Open to small business employees (for firms with fewer than 50 employees) and
individuals
• As many as 80% of those enrolling as individuals could have subsidies
• Up to 400% of federal poverty level ($94,200 for family of four)
33
Sources: HHS, Commonwealth Fund
35. PICK YOUR PLAN
Bronze: covers 60% of costs
Silver: covers 70% of costs
Gold: covers 80% of
costs
Platinum: covers 90%
of costs
36. INCREASE ACCESS: MEDICAID
• Expand Medicaid to all, including childless adults, at 133% or less of
federal poverty level
• State-by-state decision
• 100% funding by feds through 2016; then 90%
37. INCREASE ACCESS: EMPLOYERS
• If you do not offer health insurance to 95% of full-time employees and their
children and. . .
• Have at least one full-time employee who receives a tax credit or subsidy
on the Exchange
Then you. . .
• Face penalties of up to $2,000 per year per full-time employee, minus the
first 30 full-time employees.
• If you offer health insurance.
• The coverage must have a minimum value and be “affordable” based on a
percentage of the employee’s salary
• If employee still chooses to purchase insurance on the Exchange, the
employee generally will not be eligible for any tax credit or subsidy
• If the plan does not meet the definition of “minimum value” or
“affordable,” and an employee seeks coverage on the Exchange and is
eligible for a tax credit or subsidy, then employer faces a $3,000 annual
penalty for each such employee.
38. ESSENTIAL BENEFITS FOR COMMERCIAL HEALTH
INSURANCE
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral
health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care
38Source: HHS
39. INCREASE ACCESS
• No more pre-existing condition denials/ratings
• No more annual/lifetime caps
• No out-of-pocket cost for preventive services/screenings
• Coverage of children up to age 26
• “Free” preventive care
40. IMPROVE QUALITY: NATIONAL STRATEGY FOR QUALITY
IMPROVEMENT IN HEALTH CARE
Three Aims
1. Better Care: Improve the overall
quality of care, by making health care
more patient-centered, reliable,
accessible, and safe.
2. Healthy People/Healthy
Communities: Improve the health of
the U.S. population by supporting
proven interventions to address
behavioral, social, and environmental
determinants of health in addition to
delivering higher-quality care.
3. Affordable Care: Reduce the cost of
quality health care for individuals,
families, employers, and government.
Six Priorities
1. Deliver safer care
2. Engage patients and family as partners
in their care
3. Promote effective communication and
coordination of care.
4. Promote the most effective prevention
and treatment practices for the leading
causes of mortality
5. Promote wide use of best practices to
enable healthy living.
6. Make quality care more affordable for
through new health care delivery
models.
41. IMPROVE QUALITY
• Hospital Readmissions Reduction Program
• Readmissions dropped from ~19% in 2011 to 17.8% (70,000 fewer
preventable readmissions)
• Accountable care organizations
• Medicare Stars
• New reimbursement models
• Center for Medicare & Medicaid Innovation to test to delivery models
• National strategy for quality improvement
42. IMPROVE QUALITY: MEDICARE STARS
• Covers all Medicare Advantage (MA) plans, point-of-service plans, local
preferred provider organizations (PPOs), regional PPOs, and private fee-for-
service plans
• Designed to link the beneficiary experience and quality of care to
payments
• Provides bonuses based on performance
• First bonuses distributed in 2012 to plans with ≥4 stars
• Bonuses will offset payment reductions to MA plans mandated by the
Affordable Care Act (ACA)
• Payments expected to be reduced by 12% by 2017
43. DIABETES QUALITY INDICATORS
Outpatient
• A1c control
• LDL control, including statin
adherence
• Blood pressure control, including
prescription for and adherence to
ACEIs/ARBs
• Dilated eye exam
• Urine screening for microalbumin
or medical attention for
nephropathy
• Foot exam
Inpatient
• Glycemic control: diabetic
ketoacidosis, nonketotic
hyperosmolar coma, hypoglycemic
coma
• Inpatient diabetes care measures:
associated infection-surgical site;
health care-related infections
• Blood pressure and LDL control
Meeting initiatives =
increased reimbursement
2013 Physician Quality Reporting System (Physician Quality Reporting)); Measures Groups Specifications; CMS.
Roadmap for Quality; Centers for Medicare and Medicaid Services. 2012 Measure Data: Medicare Part D Report Card
Master Table 2012.
44. CONTAIN SPENDING/IMPROVE QUALITY
• Health insurance stop/loss ratio
• Require insurance companies to
justify premium increases
• Independent Payment Advisory
Board: focus on targeting waste,
reducing costs, improving
outcomes, expanding access.
• Reduce payments to Medicare
Advantage plans
• Bundling services
• Shared savings
• Pay-for-performance
• Pay-for-reporting
• Pay-for-use (EMR)
• Prospective payment
• Risk sharing
• Value-based purchasing program in
FFS Medicare—financial incentives
to hospitals
• Accountable Care Organizations
(ACOs)
• Patient-Centered Medical Homes
(PCMH)
45. CONTAIN SPENDING
“Employers are no longer willing to pay whatever premium a
health plan charges. Instead, they are questioning whether their
employees covered by the plan are healthier and more
productive and use less sick time. They are asking providers to
prove that their care is making a difference in patients’ lives. In
other words, they are demanding value for their healthcare
dollars.”
--- O’Malley C. Quality Measurement for Health Systems: Accreditation and
Report Cards. Am J Health-Syst Pharm. 1997;54:1528-1535
46. NEW DELIVERY MODELS = NEW
INCENTIVES=IMPROVED QUALITY?
Patient-Centered Care
49. “…providing care that is respectful of and responsive
to individual patient preferences, needs, and values
and ensuring that patient values guide all clinical
decisions…”
“ „Patient-centeredness‟ is a dimension of health care quality in its own
right…its proper incorporation into new health care designs will involve some
radical, unfamiliar, and disruptive shifts in control and power, out of the hands
of those who give care and into the hands of those who receive it.” – Donald
Berwick
“Providers partner with patients to anticipate and satisfy the full
range of patient needs and preferences. Providers support staff in
achieving their professional aspirations and personal goals.”
DEFINING PATIENT-CENTERED CARE
50. BENEFITS OF EMPOWERED PATIENTS
• Improves quality of delivered health care and reduces
costs1
• Creates more motivated patients who:2,3
• Make better day-to-day health decisions
• Are more likely to keep appointments
• Tend to be more satisfied with their care
• Tend to experience fewer complications
• Are more adherent
• Have an improved quality of life
Empowered patients = improved quality
501. Bodenheimer T, et al. JAMA. 2002; 288(19):2469-2475; 2. Lorig K, et al. Diabetes Care. 2010;33:1275–1281; 3. Lorig K, Alvarez S. Diabetes
Educator. 2011;37:128.
51. PATIENT-CENTERED MEDICAL HOME (PCMH)
PRINCIPLES
• Personal physician for each patient trained to provide first contact,
continuous and comprehensive care
• Physician-directed medical practice headed by personal physician
who leads team of individuals that provides ongoing care for
patient
• Whole-person orientation. Physician provides care for all stages of
life, including acute and chronic care
• Coordinated/integrated care across all elements of the health care
system
• Quality and safety
• Enhanced access to care through open scheduling, expanded hours,
email, etc.
• Payment that recognizes the added value of a PCMH
Patient-Centered Primary Care Collaborative. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home.
Accessed March 9, 2012.
52. ACCOUNTABLE CARE ORGANIZATIONS (ACOS)
• Include hospitals, physicians, and other providers
that manage care across the entire spectrum of care
• Can be a real (incorporated) or virtual
(contractually networked) organization
• Create incentives for providers to work together to
treat patients across settings
• Improve care coordination to reduce fragmented
care, control costs, and improve outcomes
Key Point: Put patients first
CMS. Improving Quality of Care for Medicare Patients. http://www.cms.gov/sharedsavingsprogram; Longworth DL. Clev Clinic
J Med. 2011;78(9):571- 582.
53. CURRENT MODEL VS ACO MODEL
Current Model ACO Model
Siloed/fragmented care Teamwork, including administrative
staff
Primary care physician = gatekeeper Coordinated care across
organizations; primary care physician
as “advocate” or “coach”
Paternalistic care Patient-centered care
Little focus on data Information technology critical
Acute-care focused Preventive and chronic-care focused
Little attention to cost Protocols to streamline care, improve
quality, reduce redundancies in order
to reduce costs
ACO = accountable care organization.
AHRQ. The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care. 2010;
Shortell SM et al. Health Affairs. 2010;29(7):1293-98; Health Affairs. Health Policy Brief. 2010;
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=23
54. CCM requires
integrated
systems of
care, informed,
empowered
patient
ACOs provide
financial
models for
PCMH and
integrated care
for PCMH
patients
Chronic
Care
Model
(CCM)
Accountable
Care
Organization
Patient-
Centered
Medical
Home
(CMH)
CHRONIC CARE MODEL + ACCOUNTABLE CARE
ORGANIZATION = PCMH
“The patient-centered medical home is the foundation for
everything that calls itself an ACO.”
-- Karen Davis, PhD. President. The Commonwealth Fund
The Commonwealth Fund. Better to Best. March 2011. http://www.pcpcc.net/files/better_best_guide_full_2011.pdf
55. Chronic
conditions requi
re
Patient
engagement
PCMH/ACO Quality initiatives
Improved
quality/reduced
costs
Healthcare systems need to engage patients and provide
patient-centered care. Without it, they will not meet
chronic care quality initiatives
PUTTING IT ALL TOGETHER
57. “. . . scholars and policy makers see a role
for CME in improving health care
outcomes, specifically physician
performance and patient health status.”
--- Moore DE, et al. J Cont Educ Health Prof. 2009; 29(1):1–15.
WHERE DOES CME COME IN?
58. KEY ADULT LEARNING PRINCIPLE
“Adults learn best when convinced of the need for
knowing the information”
Implication for CME: The changing healthcare system requires that
healthcare providers learn new ways to deliver care, interact with
patients, and improve quality and outcomes
• Greater emphasis on evidence-based medicine
• Greater emphasis on comparative effectiveness
• Greater emphasis on performance improvement/Six Sigma
• Greater emphasis on care coordination across settings
• Need to empower patients to take a more active role in their
health
• Need to integrate technology into medical practice to improve
outcomes (electronic health records, mobile health)
59. IMPLICATIONS OF QUALITY EMPHASIS FOR
CME
• Greater incentives for clinicians to partake of CME
• New options for marketing CME
• New funders:
• Healthcare systems, whose reimbursement is based on
quality outcomes
• Payers, who are under pressure to control costs given
medical/loss ratios. competitiveness of health exchange
products, and mandated (unfunded) benefits
• Large, self-funded employers who are also trying to reign
in costs
• Federal government which promised to provide affordable
health care for all
60. FOR HEALTHCARE COMMUNICATORS
1. Transparency around quality will put intense
pressure on providers to improve quality in order to
retain patients.
Opportunity: What services can you provide to help
your clients (or their clients) improve quality and
communicate outcomes to consumers?
61. 2. Patient empowerment/patient-centered care is at
the heart of successful healthcare reform, meeting
quality indicators, and increasing reimbursement.
Opportunity: How can you help your clients (and their
clients) empower patients and provide patient-
centered care? Think training and education, direct
marketing, social media.
62. 3. The shift from fee-based to value-based purchasing
means a shift in the way care is delivered and
assessed.
Opportunity: How does this shift affect your clients’
business and their clients’ business? How can you help
them maximize revenues/reimbursement/sales in the
new world?
63. 4. Millions of uninsured and thousands of small
businesses will be shopping for insurance on the
state health insurance exchanges.
Opportunities: Member education/coaching, website
management/design, marketing for insurance
companies
64. 5. 220.5 million insured Americans just got access to
free preventive care services; 30 million previously
uninsured Americans will have access in 2014. This
will result in a significant uptick in chronic and acute
disease diagnosis and treatments.
Opportunity: Patient education, provider education,
companies that sell drugs/products to manage/treat
these conditions, health
education/prevention/promotion for large employers
65. LEARNING OBJECTIVES
• Describe key components of the Affordable
Care Act and other healthcare reform
initiatives
• Discuss the potential impact of the ACA and
healthcare reform on CME and other medical
communication businesses
• Identify potential new clients/funding for CME
and medical professionals
66. RESOURCES
• Kaiser Family Foundation: www.kff.org
• The Commonwealth Fund: www.commonwealthfund.org
• US government: www.healthcare.gov
• The Robert Wood Johnson Foundation: www.rwjf.org
• The Center for Studying Health System Change: www. hschange.com
• Health Affairs: www.healthaffairs.org
• Office US government site: www.healthreform.gov
We spend more than any other industrialized/western country on health care and our costs have increased faster than any other country.By 2020, health care will consume 19.8 percent GDP. At the same time, many Americans are not receiving recommended care and nearly half of all Americans suffer from chronic disease such as diabetes or hypertension.
-- my mother nuclear stress test-- Why did she order a pelvic and a transvaginal ultrasound? The transvaginal gets the ovaries, uterus, and fallopian tubes and would pick up on any changes in the endometrial lining that might be of concern. What did the abdominal ultrasound add?Why did she order the LDL-P test? A study published in 2007 in the Journal of the American College of Cardiology found that it does not predict coronary artery disease in health individuals and should not become part of routine practice. Another article I found recommended it just for patients who are resistant to cholesterol-lowering drugs to diagnose a secondary cause for the high LDL, such as insulin resistance. For the record: although my friend’s LDL had been high in previous years, this time it was the lowest it had been in 20 years.Why did she order a carotid artery ultrasound? The American Academy of Physicians, as part of the Choosing Wisely Initiative designed to reduce unnecessary testing, says it should not be performed in asymptomatic people. Plus, my friend doesn’t have any risk factors for stroke.Why did she order a bone scan? It is not cost effective or needed in women younger than 65 with no risk factors. My friend never smoked, is not underweight, had not had any unusual fractures, does not have a family history of osteoporosis, and exercises regularly. The scan showed some osteopenia in her wrists (pre-osteoporosis) so the doctor recommended my friend take calcium + vitamin D daily and do weight bearing exercises–which is what she should be doing anyway. Why did she order an EKG? The Choosing Wisely initiative says there is no reason to order an EKG for someone with no cardiovascular symptoms, ie, chest pain or shortness of breath.Redundant and unnecessary tests are a major contributor to the bloated cost of health care in this country. The American Board of Internal Medicine, which began the Choose Wisely initiative, estimates that a third of healthcare costs in this country are related to unnecessary tests and procedures.Indeed, a study published in the journal Health Affairs in 2009 found that eliminating redundant tests in hospitals would have saved more than $8 billion in 2004 alone, nearly 3 percent of all inpatient costs.Take a look at the Choosing Wisely web site. To date, the nation’s leading medical specialty societies have identified 90 tests and treatments we and our doctors should question. Print out the list or download it to your phone and the next time your doctor orders a test or treatment, whip it out and ask the most important one-word question you can ask: “Why?”
Every 1 percent increased penetration of MA plans = 1 percent reduction in FFS spending per enrollee
The average charges for joint replacement range from about $5,300 at an Ada, Okla., hospital to $223,000 in Monterey Park, Calif., the Department of Health and Human Services said. That doesn’t include doctors’ fees.Hospitals within the same city also vary greatly. At Beth Israel Medical Center in New York, the average charge to treat a blood clot in a lung is $51,580. Down the street at NYU Hospitals Center, the charge for the same care would be $29,869.
We are NOT getting our money’s worth.
The number of people who die every week from medical mistakes in this country would fill four jumbo jets. Imagine the outrage if four 747s crashed every week. Now think about the outrage from all these needless deaths. See the disconnect?
Need for empowerment with medical homes, ACAMedical home criteria:Personal physician for each patient trained to provide first contact, continuous and comprehensive carePhysician-directed medical practice headed by personal physician who leads team of individuals that provides ongoing care for patientWhole-person orientation. Physician provides care for all stages of life, including acute and chronic careCoordinated/integrated care across all elements of the health care systemQuality and safetyEnhanced access to care through open scheduling, expanded hours, email, etc.Payment that recognizes the added value of a PCMH
A study published in the journal Health Affairs in June 2012 said it best: We are afraid to challenge our doctors. We are afraid to take control of our own health. We are afraid to insist that our healthcare providers listen to us first, before insisting we listen to them.Researchers from several large universities conducted focus groups with educated, middle- and upper-class individuals. The participants told researchers that they felt compelled to “conform to socially sanctioned roles in the clinical consultation.” In other words, they won’t ask questions unless their doctor invites them to and they view physicians as authoritarian. They said they had to work too hard to figure out things the doctor should explain, and that they often felt that they needed a friend or family member during doctor appointments just so they could understand what’s being said.They also said they felt the need to be “good” patients, and worried that if they questioned their doctor’s authority or decision they would be seen as “challenging” the doctor, which could lead to repercussions. A similar survey in Great Britain found that half of all adults there are “too scared” to challenge the medical advice and diagnoses they get from their doctors, even when they think their doctor is wrong.It’s almost unbelievable to think about, but patients fear retaliation and retribution if they question their doctors! Can you imagine feeling this way about your waiter in a restaurant? The plumber who fixes your bathroom toilet? The beautician who cuts your hair? Yet these people work for us just as our doctor works for us. So what is it about the patient/physician relationship that puts the doctor in charge instead of the one who hired him/her—us?
More than half of the uninsured have incomes at or below 138% of poverty.
Most legal residents must purchase health benefits or pay a penaltyPenalty is the greater of a flat dollar amount per person or a percentage of the household’s incomeBy 2016, flat penalty is $695 per personBy 2016, 2.5%Of 30 million uninsured residents projected for 2016About 19 million will be exempt from penalty taxAbout 6 million are expected to pay the penalty in 2016Total collections estimated to be $7 billionIndividual mandate upheld by Supreme Court in June 2012
These are all diabetes quality indicators being used by CMS, NCQA and other major accreditation agencies.
We didn’t have the data; we didn’t have the ability to access data. Today we do through the electronic health record.Your funders are demanding value for their CME dollars
Patients engaged in self management are not only more motivated to reach goals they set for themselves, but also make better day-to-day health decisions. [Lorig 2010, 2011] They are more likely to keep their appointments, and tend to be more satisfied with their care. Plus, they tend to experience fewer complications and have an improved quality of life.[sources TK] ReferencesBodenheimer T, Lorig K, Holman H, Grumbach K. Patient Self-management of Chronic Disease in Primary Care. JAMA. 2002;288(19):2469-2475.Lorig K, Ritter PL, Laurent DD, et al. Online Diabetes Self-Management Program. Diabetes Care. 2010;33:1275–1281; Lorig K, Alvarez S. Letter to the Editor. Diabetes Educator. 2011;37:128.
One way we are trying to better focus on the patient is through patient-centered medical homes. This, of course, requires new reimbursement models.Patient-Centered Primary Care Collaborative. Joint Principles of the Patient-Centered Medical Home. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed March 9, 2012
Spend more time here
Moore wrote this in 2009; today the quote is even more relevant since reimbursement and accreditation are now, more than ever, dependent on quality outcomes.
Self funded AT&T . . .
Medicare hospital compareACOs
Examples: Pharma providing motivational interviewing trainingIncorporating this into sales rep training, pull throughMessaging in marketing material directed at healthcare entities
Curaspan as example
Consumersupport assistors; education and outreach; Navigator management; call center operations; website management; andwritten correspondence with consumers to support eligibility and enrollment.
4. Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas.In English. This and other components of the bill, including grants to small businesses that implement wellness programs and a requirement that all chain and fast food restaurants post nutritional information about their menu items, begins to get at another major problem in our country and healthcare system: Lifestyle-related illnesses like diabetes and heart disease, and the lack of incentive for physicians to push prevention.diabetes, hypertension, hyperlipidemia, depression, asthma, COPD, etc) and significant uptick in identification of breast and cervical cancers.
