Health Care Euphoria Revolution in Care: See New MN web site for links to informationhttp://www.ci.minneapolis.mn.us/dhfs/toolkit.asp#P66_4020Researched the following - National Alliance for Health Reform • ICSI- Framework for Guidance in procedures and practice • RHIC- Alignment of Health Care Coalitions - Standardize quality of service • QASC- Quality Control benchmarking associationChange in Focus-Quality of Service, Benchmarking and Education1. Service and Delivery Clinician Model Change • Follow up and transformation of support services • Quantitative research on best clinical practice based on results • Creation of consultation service added to the clinician care model • Delivery of education on health care - Full circle of care • Moving preventive care upstream as a social factor from a downstream medical model • Moving wellness program from backburner to center stage2. Research completed in following Areas – Investigated health reform • Corporate America- Wellness Programs • Wellness/Fitness benefits specifically targeted for Health Reform • Medicare Health System - Preventive care services – know 100% coverage • Long Term Care - Coverage and services - Utilized for active life • New evidence based testing techniques - Applicability benchmarking
Health Reform vs. Policy, PracticeTrends in America Today• Medical Industry – Researched and created agencies for standardization of practice, delivery and quality, Nationwide• Insurance Industry – Embraced wellness programs, education, participation in telephonic services – through policy plan and specialty providers• Research Industry -National effort, involvement in Patient Education – Improvement in ways to provide quality control measurements, drive services for elimination of barriers to consulting using best practice tested formats• Movement towards a healthier nation, based on wellness sponsored programs directed by Corporate America and Communities• Medicare-Health platform expansion for preventive care and standardized plan designs (% close of drug donut hole) for the disabled and retired (A+B+C+D) formula• Long Term Care – Looking at aging as a unique adult segment with Increased health care needs, services and support for assisted living• Patient Responsibility for selection of care - Make choices based on quality, outcomes and price. provide tools to rank providers of medical servicesImprove the Health and Quality of life through National, Regional and Community involvementvia improved clinical procedures, electronic medical records and informed users by moving thenation from a focus on sickness and disease to one based on wellness and prevention.
Changes in Health CareA. Education of Policy Owners on Benefits – Revision to four page Summary Plan Description with preventive care being most important. Priority ranking given to Heart, Cancer, Diabetes, Obesity screeningsB. Complete Change in Medical Focus – Education on health care –Consultation and counseling for improved result outcomes –Quality and payment based on outcomes, not proceduresC. Service and Delivery Clinician Model Change 1. Follow up and transformation of medical services - National Non-Profit Collaborative 2. Consultation after the preventive care & testing results - Connecting the entire Medical Network to patient 3. Moving Preventive Care upstream and combine social factors from a downstream medical model 4. Deliver wellness program not only to Corporate America but to all Americans 5. Focus on driving up participation rates in exercise, activities and eating more nutritious foods 6. Paying for Wellness – Monitor the 85% of Medical Loss Ratio with claims statistics. Use evidence base benchmarked results
HHS-National Prevention StrategyProvide a vision, goals, recommendations, and action items thatpublic, private and non-profit organizations and individuals can meetto reduce preventable death, disease and disability in the U.S.Draft Goals• Healthy Communities• Preventive Clinical and Community SupportDraft Strategy Directions (SD) and Recommendations (R)• SDI1 Healthy Physical, Social and Economic Environment• SDI2 Eliminate Health Disparity• SDI3 Prevention and Public Health Capacity• SDI4 Quality Clinic Preventive Services• SDI5 Tobacco Free Living• SDI6 Reduce Alcohol and Drug Abuse• SDI7 Healthy Eating• SDI8 Active Living• SDI9 Injury Free• SDI10 Mental and Emotional Well Being
Goals of the New Health Preventive Care Strategy• Saving the “Obese Child Generation” – Add nutritional eating habits, structured activity, “monitoring- breakfast through dinner”, Understand the Nation of Food Allergies (body overload), develop new school cafeteria menu programs• Age 20 to 40 - Promote and train on nutritional eating habits, cooking, foster life, work, & health balance, spend quality time with children, teach better shopping & eating habits, increase time for exercise activities, games• Ages 41 to 64 – Focus on keeping active middle generation free of chronic disease, preventive testing and active exercise built into an active social life. No longer full time care givers to parents.• Age 65 -90 - Medicare, LTC have improved preventive care payment guidelines focusing on understanding needs and utilization of benefits – trend to keep active while adding support, nutrition, weight maintenance and strength building exercise, home and in institutions.
Institute for Clinical Systems Improvement (ICSI) Framework of Health Care Guidelines Area of Effective AudienceMission of our collaboration is to champion the cause of health carequality and to accelerate improvement in the value of the health carewe deliver to and for:• Public Policy• Family and Social Network• Physical and Social Environment• Community Support for Healthier Lifestyles• Educators and Schools• Employers and Workers• Health Plan and Payers• Faith Based OrganizationICSI Guidelines – Designed to assist clinicians by providing ananalytical framework for Evaluation and Treatment of PatientsNot intended to replace judgment or protocol -seehttp://www.icsi.org/guidelines_and_more for Guidelines
Regional Health Improvement Collaborative (RHIC)www.nrhi.org for more details on their goals and objectives
RHIC Footprint-40 Regional HealthImprovement Collaborative in the U.S
(RHIC )Regional Health Improvement Collaborative Goals & Outcomes• Performance Measurement: provide actionable information about the cost and quality of healthcare services, the health of the population, and/or the extent to which state-of-the-art methods of delivery, payment, and health promotion are being used in their community.• Payment and Delivery System Reform: serve as neutral planning and problem- solving forums where win-win multi-payer, multi-provider payment and delivery reforms can be designed.• Training and Assistance in Performance Improvement: operate programs which enable physicians, nurses, hospital administrators, and other healthcare professionals to obtain affordable training, coaching, and technical assistance on ways to analyze problems in care delivery and ways to design and successfully implement solutions.• Patient Education and Engagement: help citizens in their communities (a) understand and actively engage in activities that will maintain and improve their health, (b) choose providers and services based on their cost and quality, and (c) support the delivery of higher quality, more coordinated care.• Strategic Planning and Coordination: can play critical planning, coordinating, and support roles that will ensure that healthcare reform efforts are designed and implemented successfully in their community
Why RHIC is Collaborative Body Neutral, Trusted Mechanism for Transformation of Health care SystemKey Health care stakeholders effected in each Community by RHIC – Health care providers, i.e., hospitals, physician groups, physicians, home health agencies, nursing homes, clinics, etc.; – Healthcare payers, i.e., health insurance plans, public programs such as Medicaid, and employer groups that directly contract with providers; – Healthcare purchasers, i.e., employers who purchase health insurance for their employees; and – Healthcare consumers or consumer organizationsObjective is to plan, facilitate, and coordinate the many differentactivities required to change Social Mindsets
Quality Alliance Steering Committee(QASC) National Quality Control Arm MN Community Measurement• Aimed at implementing measures to improve the quality and efficiency of health care across the United States.• Measurement of the follow includes medical groups, clinics, physicians, hospitals, health plans, employers, consumer representatives and quality improvement organizations.• Mission to accelerate the improvement of health by publicly reporting health care information• Ensure that quality measures are constructed and reported in a clear, consistent, and person-focused way• MN Community Measurements QC project – Mine data submitted directly by more than 300 medical clinics statewide• MN Community Measurements (QASC Project) Over the next three and a half years we will add 11 new measurements, including six new measures of specialty care-See D5 Diabetes project- http://www.thed5.org/QASC Involved in existing and emerging sector-specific quality allianceshttp://www.healthqualityalliance.org/about-qasc or http://www.mncm.org/site/
QASC National CollaborationThe High-Value Health Care (HVHC) projectQuality of Care Initiative Guidelines• Help health care providers improve the quality of patient care.• Help consumers make informed choices about health care providers.• Help provide payments that support provider efforts to improve quality and efficiency, rather than simply paying for more intensive treatments.• Help reduce large racial and ethnic disparities in care.The QASC and HVHC Project are supported by staff at the Engelberg Center for Health CareReform at the Brookings Institution.
Corporate Wellness Programs and Services Provided by Insurance Carrier or Third Party• Health Risk Assessments• Employee Health Screening and Biometric Testing• Wellness Coach / Health Coach Programs• Employee Wellness Newsletters• Custom Wellness Programs• Corporate Wellness Incentive Plans, Points-based Tracking Systems,• Gym Discounts• Interactive Online Wellness Tools, i.e., health calorie counters• Follow-up and counseling employees• Follow-up with physicians• Health improvement and disease prevention programs• Organized worksite-wide wellness program activities.Wellness Council of America (WELCOA) is most respected resource forworkplace wellness in America, with a membership in excess of 3,200organizations: http://www.welcoa.org
Top 10 Benefits of Corporate Wellness Programs1. 3 to 1 return on investment. This means that for every $1 spent on Corporate Wellness Programs, corporationssave an average of $3.2.Are an absolute necessity for self-insured companies as every dollar saved goes directly toward the bottomline. A million dollars saved is literally a million dollars left over in self-funded health care accounts.3. Add to the longevity of each and every employee. An investment in Corporate Wellness Programs is aninvestment in the health of your co-workers and employees.4. Can now be monitored using ROI Tracking systems in order to show direct savings off of ICD-9, CPT-4, andPharmaceutical codes in order to accurately show where cost savings are occurring and identify other healthareas that savings can be achieved.5. Viewed by employees and potential new hires as an employee benefit. Some employees will not work for acompany that does not offer Corporate Wellness Programs.6. Are fun and motivating. Although there can be a “shock factor” associated with beginning Corporate WellnessPrograms, most employees come to look forward to Biometric Testing, Health Challenges, Health Fairs,Promotional Materials, and other key elements of Corporate Wellness Programs.7. Improve the health status of employees, thus reducing absenteeism in the workplace.8. Have a lasting effect upon reduced sick leave.9. Can help identify the problem areas such as cardiovascular diseases, muscular skeletal problems, diabetes,cancers, and other health areas. Using this information, specific interventions can be created within CorporateWellness Programs in order to improve health and reduce short-term and long-term health costs.10. Can utilize high-tech devices and services such as Health Stations, KAM Devices, and ROI Tracking in order tohelp each employee on their road to better health and track the financial efficacy of each and every interventionbeing used within the Corporate Wellness Programs.
National Health Care WellnessSample of 3,200 Wellness-Fitness Companies in U.S.WELCOAs Premier Provider Network-members• Advantage Health• Optum Health• Health Fitness• Health Designs• BioIQ• Staywell Fitness• HealthSource Solutions• Global Fitness• WellSource Inc.• Hallmark Business ConnectionsPaul Zane Pilzer: “A growing industry racking up $200 billion dollars a year in Sales,growing by 12% annually, all mostly involved with employers having more than 1,000employees” (Creating a have and have not society)
Medicare- Standard Coverage• Medicare Part A covers inpatient hospital care, skilled nursing facilities and some home health care. The benefits start once youve paid your Part A deductible, which for 2010 is $1,100 for the first 60 days of hospitalization, plus an additional $275 per day for days 61 through 90 and $550 per day for days 91 through 150. You are responsible for all costs beyond 150 days.• Medicare Part B is an optional premium-based plan that covers physician services and outpatient hospital care. You must be enrolled in Part B to be eligible to purchase a Medicare supplement plan. For new enrollees in 2010, the Plan B monthly premium is $110.50 for individuals earning $85,000 or less and couples earning $170,000 or less. Those with higher incomes pay Part B premiums ranging from $154.70 to $353.60 per month. Medicare imposes a $155 annual deductible on Part B enrollees, after which it pays 80 percent of the Medicare-approved amount for health care services• Medicare Part D - prescription drug coverage is insurance run by an insurance company or other private company approved by Medicare. There are two ways to get Medicare prescription drug coverage: (Donut Hole closed 50% 2011) a. Medicare Prescription Drug Plans b. Medicare Advantage Plans
Medicare –Additional Coverages Medigap Vs. Part C -Medicare Advantage Plan• Medigap plans all pay 100 percent of your Medicare Part A co- insurance and 100 percent of your Medicare Part B co-insurance for preventive care, at least 50 percent of your Part B co-insurance or co-payment for services other than preventive care, and at least 50 percent of the first three pints of blood for a transfusion. The plans vary according to whether and how much they pay of other costs such as the Part B deductible, Part B excess charges and foreign travel emergencies.• Medicare Advantage Plans must cover all of the services that Original Medicare (A & B) )covers except hospice care. Original Medicare covers hospice care even if you’re in a Medicare Advantage Plan. Medicare Advantage Plans aren’t supplemental coverage (Medigap Plans). Medicare Advantage Plans may offer extra coverage, such as vision, hearing, dental, and/or health and wellness programs. Most include Medicare prescription drug coverage (Part D).U-Care –Carrier Plan Design analyzed for Advantage Plan 2011 Services
Medicare Preventive Health Care Health Reform Check List• Abdominal Aortic Aneurysm Screening• **Bone Mass Measurement• Cardiovascular Screenings• Colon Cancer Screening (Colorectal)• Diabetes Screenings-risk factors must be present• Diabetes Self-Management Training• Flu Shots• Glaucoma Tests• **Hepatitis B Shots• HIV Screening.• **Breast Cancer Screening (Mammograms)• **Medical Nutrition Therapy Services must have exclusion• Pap Tests and Pelvic Exams (includes clinical breast exam)• Physical Exam• **One-time “Welcome to Medicare” physical exam• **Yearly “Wellness” exam• Pneumococcal Shot• Prostate Cancer Screenings• ** Smoking Cessation (counseling to stop smoking)- Preventive** effective 2011, 20% Co-Insurance/B Deductible removed for Preventive Services many have age restrictions https://www.cms.gov/MLNProducts/35_PreventiveServices.asp for information
U-Care-Preventive Health Care Advantage Benefits• Health Club Savings-$15 off club membership-no more 8 times per month required - removed 2010 by PPACA• Enhance Fitness Class –Interactive Fitness Classes at community locations. (List www.ucare.org)• Do It Yourself Kit – portable exercise gear, pedometer, resistant band, activity health program, DVD aimed at older adults, activity log book• Tobacco –Smoking cessation –Mayo Clinic Quit line• Health Connection Nurse Line -24 hours a dayServices added to compete with Medigap plans, in 2010eliminated Medigap Plans E, H, I, J and high-deductible Planoffferings
Long Term Care Major Carriers• Berkshire Life Insurance Company of America• Genworth Life Insurance Company• Great American Life Insurance Company• John Hancock Life Insurance Company• Metropolitan Life Insurance Company• Penn Treaty Network America Insurance Company• Prudential Insurance Company of AmericaSource: Newman Long Term Care largest Long Term Care agencies in the UnitedStates-http://www.newmanlongtermcare.com
Long Term Care Policy Care SettingsHelp with Activity of Daily Lives, Help with AdditionalServices, Help with Care Needs in:• Home Health Care• In-Law Apartments• Housing and Aging Disabled Individuals• Board and Care Homes• Assisted Living• Continuing Care Retirement communities• Nursing HomesThird Party Full Service Administrator-Univita Health,Long termcare insurance companies rely on Univita for complete outsourcing ofkey support services listed above. http://www.univitahealth.com/our-business
What types of services are covered by Long Term Care Insurance – Nurses – Certified Nursing Assistants – Physical, Occupational or Respiratory Therapists – Home Health Aides – Homemaker Services – Transportation Services – Home Modifications – Medical Alert Systems – Some LTCI policies even allow for Family and Friends to provide your care
A Long-Term Care Ombudsman: Watch Dog for LTC Care Patients• Resolves complaints made by or for residents of long-term care facilities• Educates consumers and long-term care providers about residents rights and good care practices• Promotes community involvement through volunteer opportunities• Provides information to the public on nursing homes and other long-term care facilities and services, residents rights and legislative and policy issues• Advocates for residents rights and quality care in nursing homes, personal care, residential care and other long-term care facilities• Promotes the development of citizen organizations, family councils and resident councils• Long-Term Care Ombudsman efforts are summarized in the National Ombudsman Reporting System (NORS 2008 data) to include the number of facilities visited, the types of complaints handled and the kinds of complaints filed with ombudsmen. Data has been collected since 1996 and gives a good picture of the extent of ombudsman activities nationally and in every state. A 2001 report compares national data from FY 1996-2001.
The National Long-Term Care Ombudsman Resource Center• Provides consultation and information and referral for ombudsmen and for the residents, families and others who use ombudsman services;• Provides training opportunities and training resources for state and local programs;• Promotes public awareness of the role of ombudsmen in long-term care;• Works to improve ombudsmen effectiveness in meeting the needs of residents, including those served by managed care organizations and those in alternative settings, such as Medicaid waiver programs;• Identifies research needs and promotes research on issues which affect the ombudsman programs or their constituents;• Supports the ombudsman volunteer component through work with AARP and other national or state-wide efforts to recruit volunteers for the program;• Works cooperatively with all organizations and agencies which have as their mission the protection of the frail elderly who reside in long-term care settings and• Promotes understanding and cooperation between ombudsman programs and citizen advocacy groups.National Long Term Care Web Site http://www.ltcombudsman.org/about
Applicability Statistical Sampling New Benchmarking Technique• Step 1. Determine the most important factors that may affect Applicability Identify potential factors Table 1. Characteristics of individual studies that may affect applicability • Population • Intervention • Comparator • Outcomes • Setting• Step 2. Systematically abstract and report key characteristics that may affect Applicability in evidence tables; Highlight any effectiveness studies• Step 3. Make and report judgments about major limitations to Applicability of individual studies• Step 4. Consider and summarize the Applicability of a body of evidence Table 2. Elements to be included in a summary table characterizing the applicability of a body of studies Source: http://www.learn-medical-statistics.com/index.asp
Results of an Applicability Study for Postpartum Depression (PPD) • A more systematic approach to diagnosis and treatment in general. • Increased effectiveness of teamwork and communication. • Adapting and extending the structured tools used in the PPD study to the care of other patients with chronic disease. • Greater feelings of professional self-worth, combined with increased community recognition of the practice. • Added opportunity and support for practice staff to move into new roles or learn new skills. • Increased understanding of research and its benefits.3-year trial comparing usual care for PPD with standardized, two-stepscreening and a recommended therapy and follow-up program
Conclusion on Health Collaborative Initiatives• Patient Centered Care-Creates a model of an active participant, but few tools or resources exist to help patients make the change• Patients in General- Have not been told that they are supposed to change but no clear time line or one voice to listen to. Needs to be the Clinician• Patients-Have been asked to participate in process design, but first need to be taught and trained in how to talk to Clinicians• Patients are Strapped with High Deductible Health Plans (HDHP) and are afraid to see a Physician, for they lack clarity in cost of Services – They do not know if services are covered. System needs to clean payment reform and have price transparency prior to delivering clinical service.• Collaboratives-Need to take a lesson from drug companies: Generic drug prescription refills today are a commodity market. Wellness preventive services, testing and counseling should be priced based on evidence based results and become a commodity retail service, just like buying a set of tires.-rating of success by clinic and physician• Create a Medical Health Coalition who works with Patients, cradle to grave, linking their previous Health Care Plan to their Medicare coverage, to their Long Term Care Plan, for a lifetime of support. Electronic medical history-records are a start