7A. Alternate

Question 1

What has fed govt agreed to change operating manuals to health care payers like insurance (wrt long term care)?

Answer 1

Originally, MCARE covers ACUTE CARE only, not LTC. It paid for home care, support services, med equipment as long as that the provision of the service = patient IMPROVEMENT (If there is no improvement, then it?s just maintenance and MCARE doesn?t pay for that). NOW, GOVT HAS CHANGED THAT. Will now pay for home care, rehab services that PREVENT deterioration, MAINTAIN shit.

Question 2

Opportunities recipes?

Answer 2

Problems, participants, and solutions lead to OPPORTUNITIES. Only issue is, today’s solutions may resemble yesterday’s falures, and solutions RECYCLE.

Question 3

How did ACO get recycled?

Answer 3

Prepaid group practice, HMO, IPA, ACO

Question 4

The problem with cost? (3)

Answer 4

1) Costs too much now, and rising too fast…not affordable for people withotu insurance, and increasingly even for people with insurance 2) Fee for service is increasing costs 3) Overuse drives up costs and drives down quality

Question 5

The problem with quality?(3)

Answer 5

1) 100k people die every year cuz of shitty quality care 2) Disease management may be poor, pts not satisfied 3) Low rank with other countries

Question 6

Solutions - 3 categories?

Answer 6

Organizational, Finacial,and Information/Systems

Question 7

Organizational Category? (4)

Answer 7

PCPs and multispecialty groups, HMO/PPO,ACO, medical home, consumer-directed care

Question 8

Financial Category? (4)

Answer 8

Shift price to consumer or risk to providers, rely on market, fix prices, global budget

Question 9

Information/Systems Categories? (4)

Answer 9

EMR, Evidence-based support, system-wide payment rules (all payers are operating by the same set of rules), concentrate purchasing power

Question 10

4 HIGH POTENTIAL FOR COST SAVINGS approaches?

Answer 10

Payment reform (like capitation, pay-for-performance….great idea, hard to do), effectiveness review for new drugs/technology BEFORE reimbursement (risk: limit innovation and arrival of new drugs to market), EMR (will require time, resources, cultural change), and improved care of patients with chronic conditions (10% of people account for 70% of costs)

Question 11

Why does drug effectiveness review have to happen? In other words, what’s the current situation like now?

Answer 11

Currently the drug has to be safe and effective for the purpose for it was tested. BUT, Doc can choose how a different way for it to be used, and the manufacturer gets paid.

Question 12

Evidence base for solutions?

Answer 12

Preettttyyy weak….we’re sort of taking a gamble here based on not much evidence that it works.

Question 13

What’s an ACO?

Answer 13

Organized group of doctors and/or hospital. It accepts rsponsibility for BOTH cost of people in its group and certain qulaity measures. Pts must agree to provide access to info AND are fre to get care outside ACO.

Question 14

Explain ACO quality measures. What are the implications?

Answer 14

You don?t get bonuses in ACO unless you 1) spend less than MCARE expected to spend on your population and 2) Meet quality measures that MCARE has established (pt satisfaction, readmission rates, efficient treatment protocols). If group meets quality standards and saves money, then you keep a share with govt. If not, you must pay up.

Question 15

What is a pt centered medical home?

Answer 15

A physician practice, delivering care that is accessible, comprensive, coordinated….big features include delegating certain tasks like pt education and support to other people to improve care and make doc more efficient. Same day appts, a bunch of people know your condition

Question 16

Is a pt centered medical home gonna cut costs?

Answer 16

This approach could be better, but NOT necessarily less expensive

Question 17

Mass 2012 Reform, implications?

Answer 17

FFS is dead in MAssachusetts. Impossible for solo practiioners to work alone…will be forced into a relationship.

Question 19

Who is considered dual eligible? (2)

Answer 19

1) Poor elderly people (usually dependent on nursing homes) 2) Younger people with AIDS, spinal injury, severe mental illness, multiple chronic illness

Question 20

What’s the issue with dual eligibles before CCA (Commonwealth Care Alliance)?

Answer 20

Care is uncoordinated (shitload of docs per year, pcp’s not notified of ED admits), inaccessible, impersonal, ineffective, shitloads of preventable hospitalizations

Question 21

Dual eligibles - FFS v. organized care?

Answer 21

FFS = majority acute care, the rest is distributed a little among DME (durable medical equipment), home health, PCP). With prepaid organized care, you have wayyyy less acute care, more for the other categories.

Question 22

Dual eligible organized care systems - successful?

Answer 22

They’re been tried in mini-doses around the country, and they’ve been proven to save money and improve quality…BUT hasn’t been proven to implement on a large scale.

Question 23

How does the CCA flow of payment work?

Answer 23

MCARE and MCAID funds are combine in a SCO (senior care option), which contracts with CCA, and CCA uses that one pot of funds to contract with their OWN CCA PCP’s, outside PCP’s, and hospitals/rehabs/nursing homes.

Question 24

Key factors that differentiate CCA from other systems?

Answer 24

Self-care techniques (including at-home lessons, even more than in office), narrow primary care service which work with CCA nurses, 24/7 service, tight contracts with hospitals, and PCP is authorized to do whatever he/she thinks is appropriate for patient. No care management outside of provider team (guess what, you can buy AC units!). Also, an EMR.

Question 25

Internal service concept?

Answer 25

ACA has risk sharing agreements with primary care sites and doesn’t micro manage…if they save more money than expected they can keep that money. This team approach shifts care OUT of the hospital.