in order to meet cost reduction targets, CMOs
* Share patient data across ecosystems
* Embed shared organizational intelligence
* Establish guidance for quality & cost within physician workflows
* Prepare physician leaders to create a culture of continual improvement
In 2007 the major primary care physician associations developed and endorsed the Patient-Centered Medical Home care delivery model that is focused on providing care that is comprehensive, patient-centered, coordinated, accessible, safe, and of the highest quality. By 2012, forty-seven states had developed medical home programs. This led to a significant need for “co-located” or “embedded” case managers in physicians’ offices and clinics. The word “co-locate” is defined as: “to locate 2 or more things together; to place close together to share common facilities”. Co-locating case managers in an office or clinic provides the ability for better communication and coordination, however it does not, in and of itself, assure an atmosphere of integration and collaboration that elicits the concept of working as a member of an integrated, collaborative team in order to share knowledge, principles, and care plans to help patients meet their goals. The term “embedded” is defined as: “to make something an integral part of; to attach (someone) to a group for the purpose of advising, training, or treating its members”. This definition goes further to describe the embedded CM concept and the CM’s close relationship or attachment to the group. “Embedded” more adequately describes the case manager’s role in becoming a truly integrated member of the group and a collaborative partner. Research studies over the years have shown that programs that have adopted truly integrated, collaborative care are significantly more successful than those who merely “co-locate” their case managers.
in order to meet cost reduction targets, CMOs
* Share patient data across ecosystems
* Embed shared organizational intelligence
* Establish guidance for quality & cost within physician workflows
* Prepare physician leaders to create a culture of continual improvement
In 2007 the major primary care physician associations developed and endorsed the Patient-Centered Medical Home care delivery model that is focused on providing care that is comprehensive, patient-centered, coordinated, accessible, safe, and of the highest quality. By 2012, forty-seven states had developed medical home programs. This led to a significant need for “co-located” or “embedded” case managers in physicians’ offices and clinics. The word “co-locate” is defined as: “to locate 2 or more things together; to place close together to share common facilities”. Co-locating case managers in an office or clinic provides the ability for better communication and coordination, however it does not, in and of itself, assure an atmosphere of integration and collaboration that elicits the concept of working as a member of an integrated, collaborative team in order to share knowledge, principles, and care plans to help patients meet their goals. The term “embedded” is defined as: “to make something an integral part of; to attach (someone) to a group for the purpose of advising, training, or treating its members”. This definition goes further to describe the embedded CM concept and the CM’s close relationship or attachment to the group. “Embedded” more adequately describes the case manager’s role in becoming a truly integrated member of the group and a collaborative partner. Research studies over the years have shown that programs that have adopted truly integrated, collaborative care are significantly more successful than those who merely “co-locate” their case managers.
When appropriately designed, the current shift to value-based reimbursement allows healthcare organizations to compete based on their ability to provide high quality and low-cost care that patients value. To address this challenge many healthcare organizations have successfully developed programs designed to deliver this type of high-value care. These programs typically focus on the needs of a specific segment of a patient population. The most successful programs are artfully crafted to address clinician preferences for providing outstanding care, patient desires for convenience and affordability, and detailed nuances of payment contracts to optimize reimbursement. The complexities of value-based healthcare reimbursement provide tremendous opportunities for organizations that develop thoughtful strategies to provide highly demanded care in a financially sustainable structure. In this workshop, we will interactively review case studies of innovative healthcare programs that have effectively created higher quality care and improved financial outcomes. This discussion will illustrate the concrete steps to develop programs and innovations that will enable your organization to thrive in a value-based environment.
AGENDA
Define value, common reimbursement arrangements and critical reimbursement levers
Discuss the types of risk associated with each reimbursement arrangement
Case studies that examine real-world examples of opportunity, revenue impact, and expense impact
SPEAKERS
Mason Roberts, ASA, MAAA, MBA, Associate Actuary
Stoddard Davenport, Healthcare Management Consultant
Nick Creten, FSA, MAAA, Consulting Actuary
We at Boehringer Ingelheim know that there are many issues affecting health care in the United States. In this presentation Dr. Lee Sacks of Advocate Health takes a look at accountable care organizations (ACOs) and their role in health care reform. Understanding the Implications of Accountable Care Organizations for Patients and Providers, was a web conference given on July 31, 2012 and which we hope will provide offer an understanding of best practices among ACOs and tips for helping constituents adopt and participate in ACOs.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
Soraya Ghebleh - Using Financial Incentives to Influence Clinical Decision Ma...Soraya Ghebleh
This slide deck discusses some of the relevant factors that should be considered when designing financial incentives for providers of healthcare services.
· Analyze how healthcare reimbursement influences your nursing praLesleyWhitesidefv
· Analyze how healthcare reimbursement influences your nursing practice.
Health care is significantly changing with time, and one of these changes is how health care facilities and providers are compensated for offering service. One of these ways is through reimbursement. Health care reimbursement is the payment given to a health care facility or a health care provider for offering medical service to a patient (Torrey, 2020). This cost is often covered by a patient’s health insurer or a government payer. In health care reimbursements are beneficial because they discourage DNP-prepared nurses from establishing their own independent practices. This is because at their own practices they would receive less reimbursement under their own number than under that of a physician. If the reimbursement rates were equal more DNP-prepared nurses would establish their own practices and this would increase competition.
Due to healthcare reimbursement, models that emphasize cost-effective decisions by DNP-prepared nurses are developed. These decisions are offer patients with quality medical care rather than sacrificing the patient service quality. Innovations such as price transparency tools as well as patient engagement apps help the nursing practice during the implementation of healthcare reimbursement. The patient outcome as well as the low-cost care provided by health care providers has an influence on the reimbursement received. Health care reimbursement tends to motivate health care providers because they earn more when the care they provide is of high quality as well as low cost.
DNP- prepared Nurses' role helps Nurse Practitioners to prepare for the advancement they will encounter in their nursing career in health care. This enables them to be more competent and have more knowledge when offering quality health care. The main goal of the health care reimbursement system is to pay health care providers based on their performance. This means that being more advanced and competent is beneficial for a DNP in order to provide high-quality care to patients. This simply means that if they offer high-quality care, the reimbursement will reflect this and they will be paid more. And if they are not competent, then the reimbursement will be vice versa.
2- Examine how the value-based insurance design (VBID) influences clinical outcomes and cost issues.
The aim of value-based insurance design is to increase the quality of health care while decreasing the cost by using financial incentives to promote cost-efficient health care services and consumer choices. In order to remove roadblocks as well as maintain and improve a person’s health, health benefit plans can be developed. These plans tend to save money by reducing future expensive medical procedures. They do this by covering treatments such as prescribed drugs at a low cost or no cost, preventive care as well as wellness visits (Lexchin, 2020).
The healthcare industry is making a shif ...
When appropriately designed, the current shift to value-based reimbursement allows healthcare organizations to compete based on their ability to provide high quality and low-cost care that patients value. To address this challenge many healthcare organizations have successfully developed programs designed to deliver this type of high-value care. These programs typically focus on the needs of a specific segment of a patient population. The most successful programs are artfully crafted to address clinician preferences for providing outstanding care, patient desires for convenience and affordability, and detailed nuances of payment contracts to optimize reimbursement. The complexities of value-based healthcare reimbursement provide tremendous opportunities for organizations that develop thoughtful strategies to provide highly demanded care in a financially sustainable structure. In this workshop, we will interactively review case studies of innovative healthcare programs that have effectively created higher quality care and improved financial outcomes. This discussion will illustrate the concrete steps to develop programs and innovations that will enable your organization to thrive in a value-based environment.
AGENDA
Define value, common reimbursement arrangements and critical reimbursement levers
Discuss the types of risk associated with each reimbursement arrangement
Case studies that examine real-world examples of opportunity, revenue impact, and expense impact
SPEAKERS
Mason Roberts, ASA, MAAA, MBA, Associate Actuary
Stoddard Davenport, Healthcare Management Consultant
Nick Creten, FSA, MAAA, Consulting Actuary
We at Boehringer Ingelheim know that there are many issues affecting health care in the United States. In this presentation Dr. Lee Sacks of Advocate Health takes a look at accountable care organizations (ACOs) and their role in health care reform. Understanding the Implications of Accountable Care Organizations for Patients and Providers, was a web conference given on July 31, 2012 and which we hope will provide offer an understanding of best practices among ACOs and tips for helping constituents adopt and participate in ACOs.
Making the shift to value-based care is not easy. However, a growing number of healthcare organizations are finding success leveraging Lean process improvement and health IT to reduce waste, lower costs, and improve quality.
In fact, leading health systems like Bon Secours, Prevea Health, and North Mississippi Medical Center are using these principles to improve care management processes and achieve better patient outcomes.
We have assembled these strategies into a new whitepaper. You will learn:
- How key concepts of Lean thinking can be applied to healthcare
- Why high-performing practices are using Lean to enable care team members to provide better care
- The financial advantages of a team-based, population health management approach in a value-based reimbursement system
Soraya Ghebleh - Using Financial Incentives to Influence Clinical Decision Ma...Soraya Ghebleh
This slide deck discusses some of the relevant factors that should be considered when designing financial incentives for providers of healthcare services.
· Analyze how healthcare reimbursement influences your nursing praLesleyWhitesidefv
· Analyze how healthcare reimbursement influences your nursing practice.
Health care is significantly changing with time, and one of these changes is how health care facilities and providers are compensated for offering service. One of these ways is through reimbursement. Health care reimbursement is the payment given to a health care facility or a health care provider for offering medical service to a patient (Torrey, 2020). This cost is often covered by a patient’s health insurer or a government payer. In health care reimbursements are beneficial because they discourage DNP-prepared nurses from establishing their own independent practices. This is because at their own practices they would receive less reimbursement under their own number than under that of a physician. If the reimbursement rates were equal more DNP-prepared nurses would establish their own practices and this would increase competition.
Due to healthcare reimbursement, models that emphasize cost-effective decisions by DNP-prepared nurses are developed. These decisions are offer patients with quality medical care rather than sacrificing the patient service quality. Innovations such as price transparency tools as well as patient engagement apps help the nursing practice during the implementation of healthcare reimbursement. The patient outcome as well as the low-cost care provided by health care providers has an influence on the reimbursement received. Health care reimbursement tends to motivate health care providers because they earn more when the care they provide is of high quality as well as low cost.
DNP- prepared Nurses' role helps Nurse Practitioners to prepare for the advancement they will encounter in their nursing career in health care. This enables them to be more competent and have more knowledge when offering quality health care. The main goal of the health care reimbursement system is to pay health care providers based on their performance. This means that being more advanced and competent is beneficial for a DNP in order to provide high-quality care to patients. This simply means that if they offer high-quality care, the reimbursement will reflect this and they will be paid more. And if they are not competent, then the reimbursement will be vice versa.
2- Examine how the value-based insurance design (VBID) influences clinical outcomes and cost issues.
The aim of value-based insurance design is to increase the quality of health care while decreasing the cost by using financial incentives to promote cost-efficient health care services and consumer choices. In order to remove roadblocks as well as maintain and improve a person’s health, health benefit plans can be developed. These plans tend to save money by reducing future expensive medical procedures. They do this by covering treatments such as prescribed drugs at a low cost or no cost, preventive care as well as wellness visits (Lexchin, 2020).
The healthcare industry is making a shif ...
VBP, Delivery System Reform, and Health and Social ServicesAndré Thompson, MPA
How are the services and supports you provide related to health, how valuable are your services and interventions for maintaining health, how would your services change if you were getting paid based on value rather than fee-for-service?
Healthcare by Any Other Name - Centricity Business WhitepaperGE Healthcare - IT
Whether referred to as integrated healthcare or accountable care, the
current focus on new healthcare models is a reaction to long-standing
concerns around quality, cost, and efficiency. Many of these issues stem
from care delivery systems that have been:
• Directed more at episodic treatment than prevention and early intervention
• Fragmented rather than integrated and coordinated
• Focused on patient eligibility and billing rather than patient engagement
within and outside of the care setting
• Customized to the idiosyncrasies of individual facilities rather than
standardized across care sites
• Rewarded more for volume than for quality and cost outcomes
The resulting inefficiencies have made healthcare less effective, less safe,
and more costly than can be tolerated, particularly against the backdrop of
a challenging worldwide economy. The old dictum ‘if you provide healthcare,
they will pay’ no longer applies. Public payers, private payers, and regulatory
agencies are wielding both carrots and sticks to drive healthcare organizations
toward greater coordination, demonstrable quality, and measurable
cost control.
The consensus on what ails our health systems, as well as the availability
of new technologies, has led to the creation of new models of delivery,
such accountable care organizations and integrated health organizations.
By whatever name, these healthcare models are designed to promote
accountability and improve outcomes for the health of a defined population.
Business Strategies in Healthcare (1).pdfTEWMAGAZINE
The healthcare industry is a vast and complex ecosystem that provides medical services, manufactures medical equipment and pharmaceuticals, and develops healthcare technology. Given its critical role in society, the strategies businesses employ within this sector are very important.
These strategies determine the success of individual companies and impact the overall quality, accessibility, and affordability of healthcare. This article explores key business strategies in healthcare, focusing on innovation, patient-centric care, strategic partnerships, and technology integration.
Running head HEALTH SERVICES IN RELATION TO ENVIRONMENTAL ANALY.docxcharisellington63520
Running head: HEALTH SERVICES IN RELATION TO ENVIRONMENTAL ANALYSIS 1
HEALTH SERVICES IN RELATION TO ENVRIRONMENTAL ANALYSIS 8
Health Services In Relation to Environmental Analysis
Dr. Mountasser Kadrie
July 27, 2014
As a manager in Ford Rehabilitation centre, I have encountered several challenges in both external environment and internal environment that have greatly challenged the increasing demands of my patients’ services as well as failure of the reimbursements of funds by the insurance providers. Environmental conditions normally affect human health in varied means. Interactions between the environment and human health usually lead to very complex ethical queries that are related to health policy decisions. There are various factors in the environment that can lead to risks and the same time benefits. They include genetically modified plants, nanotechnology, bio fuels and other technology. There is a body of evidence that have emerged saying that environment can affect the health of human being and at the same time human health can have impact to the environment.
The external factors are factors in the environment that cannot be controlled by an organization. There are several external factors that affect many health organizations; these factors include political conditions, government policies and regulations, technological environment and social environment. In my organization the two key external factors affecting my company are the social environment and technological environment. Social factors have developed challenge in the Ford rehabilitation centre. This is because many patient customers have varied and different types of beliefs which make the relations in the health centre challenged. It have become problematic to deal with some patients since it is difficult to know the type of services they need based on where they have come from. Various patients have diverse transformation in attitude towards health care. The patients are however very demanding in my organization because each one of them needs to be handled differently based on community variations. In order to curb this, as manager I have decided to implement several programs that will promote cooperation between my patients as well amendments that will bring in suitable services to each patient. Implementation of this programs will enable my organization to continue being indispensible and financially stable despite the social challenges affecting the availability of patients in the organization.
Another external factor in the environment that will have a great impact in my company is technological environment. Implementation of more advanced methods to serve my customers is likely to improve patients’ attendance and this will boost the compan.
Imagine a healthcare system where people live long, healthy lives, receiving quality, affordable care, with clinicians nationwide collaborating to improve outcomes. That's Accountable Care! Learn the benefits of becoming an ACO in this insightful eBook.
Bertus Van Niekerk: Unlocking the True Potential of Integrated Occupational H...SAMTRAC International
This presentation argues that the value of occupational health and safety, and corporate wellness programmes, can be increased exponentially through an integrated information system. This is accomplished by integrating data collected from a host of standalone safety technologies with an electronic health record, corporate wellness and ERP systems.
Main Value-Based Care Metrics for Healthcare PracticesPracticeBuilders2
In its essence, embracing value-based care requires a dedicated focus on carefully measuring and improving key performance metrics. By giving importance to healthcare performance measurement, physician performance metrics, and value-based care metrics, medical practices can pave the way for long-term excellence and innovation. https://www.practicebuilders.com/blog/value-based-metrics-for-healthcare-practices/
Healthcare transition in GCC: Current Painful Realities & Proposed Strategic ...STELIOS PIGADIOTIS
Goals of research effort
1. Hands on analysis of GCC and specifically UAE healthcare market.
2. Proposed 2016 strategies for CEOs in GCC healthcare ecosystem
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Navigating the Health Insurance Market_ Understanding Trends and Options.pdfEnterprise Wired
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Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
QA Paediatric dentistry department, Hospital Melaka 2020
How Do Organizations in Healthcare Measure the Value Proposition?
1. How Do Organizations in Healthcare Measure the Value Proposition?
By Carlos Arias MD, MPH, CPC
How Do Organizations Measure the Value Proposition? Both the numerator (Quality)
and denominator (Cost) must be measured to demonstrate value. We achieve Quality
through Effectiveness, Patient-Centered Care, Safety, Efficiency, Equitability and
Compliance.
Both quality and cost present major challenges for healthcare organizations.
Cost: Healthcare reimbursement programs have experienced continuous and
tremendous changes in the past years. When Medicare was created, all services were
paid as fees for service, which led to tremendous increases in the cost of care because
providers had little incentive to reduce or avoid unnecessary expenditures. Years after,
diagnosis-related group (DRG) was implemented as a method for decreasing
government expenses. Under the DRG payment system, hospitals are paid a fixed
amount for each diagnosis (DRG).
After this implementation, and obviously getting some reduction on the expenses, the
government initiated another model of payment: Capitation. Capitation payment can be
defined as paying a fixed amount per individual being treated for a well-defined group of
services. So, for example, a primary care provider might receive a capitation payment of
$ 50 to $100 per member per month to provide an individual’s entire primary care
physician services, including office visits, tests and other services. Once that model
came into play the payers wanted their risk reduced and implemented “risk contracts.”
These contracts created a situation whereby if a beneficiary patient needs more than
just the routine level of care, and no proper utilization best practices or guidelines exist
for the issues or they are not followed, the provider may lose money on that individual
due to overutilization. Luckily, the provider costs are spread across a population of
individuals so that providers or organizations such as Independent Physicians
Association (IPA) or Managed Care Organization (MSO) consider the entire population
that is capitated, rather than just an individual, and calculate if the total payments can
offset the total costs.
This is a very complicated topic that physicians face today. Overutilization of resources,
readmissions, inappropriate use of resources, duplication of tests, lack of care
coordination, and myriad other issues are causing an increase in the cost of these
programs, while Medicare decreases the payments to physicians year after year.
Our organization is facing these challenges and has decreased costs by increasing
infrastructure in Human Resources and technology across the entire organization. By
doing so, we can deliver a higher quality of care despite the “cost crisis” in healthcare.
Our model has been proven to work in this environment.
2. Quality: The degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional
knowledge is the definition that I would like to use to describe this value. The concept of
P4P has now become an industry standard and likely will persist into the future, as will
the 5 Stars Rating programs. These programs have not been around long--Stars rating
is a newborn—but while the outcomes are not defined yet, they have had an intense
start.
Infrastructure enhancement, education and training, improving technology, monitoring of
and detailed, current information on each and every patient are important factors to
increase the quality of care.
The following values integrate with and further define modern Quality care:
Effectiveness: I must emphasize the importance of using evidence-based and best
practice guidelines to provide high-quality care. Incorporating the most current valid
research evidence into decision making and combining this with patient experience is
essential to ensuring that care is properly delivered. Decreasing resource waste through
adequate staffing, assessment and utilization of modern technology, processes and
systems is also crucial. This type of assessment and implementation has been of
critical importance to my success as a healthcare administrator.
Patient-Centered Care: It is the expression of a higher state of compassion, empathy,
values, competencies, and relationship demanded by the most important and diverse
clients in customer history: our patients. Timeliness is key to decreasing any harm
(delay in healthcare can be catastrophic, including fatal losses). Intervention and
processes that avoid delay and denials are important operational opportunities that
operators, financial administrators and executives in healthcare must monitor very
closely. Barriers to accomplish a plan of care must be studied in detail and resolved.
Poorly chosen language may contribute to increased unnecessary admissions, side
effects of drugs, increased length of stay in the hospital and increased waiting times.
Inappropriate access to physicians or healthcare providers will increase unnecessary
admissions, re-admissions, increase of utilization of healthcare resources, unnecessary
ER visits and overall, will increase cost and decrease quality of care. Companies must
look systematically at their operations and create a cultural approach that satisfies the
needs of their patients. The patient-centered medical home approach is a positive
example of a cultural change in the healthcare industry that improves system
inefficiencies.
Safety: Safety is about preventing incorrect interventions, failure of a procedure or
process, and shortcomings in achieving a goal on a patient plan of care. Safe care
ensures correct diagnoses, avoidance of unnecessary risks, and that patients are
completely informed about and engaged with the nature and attendant risks of
diagnostic and therapeutic interventions. Understanding the patient culture and
effectively communicating with patients enhances the accuracy of the medical attention
process that includes, but is not limited to, the provider-patient relationship, diagnoses,
3. testing and pharmacological and non-pharmacological treatments. This ensures holistic
wellness.
Efficiency: Performance monitoring and optimization partnered with reduction of waste
it is the right way to be efficient, reduce cost and increase quality.
Equitability: Provide care despite gender, ethnicity, socioeconomic status,
geographical location, insurance company, or patient benefits (payer blind concept).
Identifying, constructing and stratifying indicators should be transferred to quality
improvement activities. The use of Population Management as a tool to drive a better
delivery system and propagation of Specific Case, Disease and Complex Case
Management programs will lead our organization to be effective in delivering care to all.
Compliance: The goal of the Program is to “promote the prevention of, detection, and
resolution of potential violations of the multitude of laws and regulations that affect the
work in all aspects of the business.” We utilized the Department of Health and Human
Services’ Office of Inspector General (“OIG”) Compliance Program Guidance for
Hospitals, the OIG’s Compliance Program for Individual and Small Group Physician
Practices and Federal Sentencing Guidelines (collectively referred to as “Guidance”) as
a foundation. A comprehensive compliance program incorporates the following seven
elements as recommended by the Guidance:
(1) High level oversight
(2) Integration of compliance into policies and procedures
(3) Open lines of communication
(4) Training and education
(5) Monitoring and auditing
(6) Response to detected errors
(7) Consistent enforcement of standards
Every compliance program should include written policies and procedures that address
specific risk areas to the practice. These policies and procedures should be reviewed
and updated annually to align with current practice operations. The culture of the
company should adopt compliance as its internal DNA.
The designation of a specific Compliance Officer (CO) with the appropriate experience,
authority and resources is critical to the success of a compliance program. A supporting
compliance committee should be responsible for assisting the CO in assessing a
practice’s regulatory, compliance and legal environment; developing standards of
conduct and policies and procedures to promote compliance; developing a system to
identify, report and respond to identified issues; and designing a system of controls to
carry out the practice’s compliance-related obligations.
Weighing cost and quality measures as further defined by the values described above, I
think an organization can address the value proposition in a more focused way and use
it to define who they are. “Selling” any company can be complex, but health insurance
4. companies and payers do examine the quality value proposition, and when the factors
of the value proposition are not balanced, it can lead to dissatisfaction and loss of
business. Healthcare customers want and need quality care, and therefore quality
should be the overall criteria for defining a Healthcare organization.