7A. Alternate Flashcards
What has fed govt agreed to change operating manuals to health care payers like insurance (wrt long term care)?
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.
Opportunities recipes?
Problems, participants, and solutions lead to OPPORTUNITIES. Only issue is, today’s solutions may resemble yesterday’s falures, and solutions RECYCLE.
How did ACO get recycled?
Prepaid group practice, HMO, IPA, ACO
The problem with cost? (3)
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
The problem with quality?(3)
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
Solutions - 3 categories?
Organizational, Finacial,and Information/Systems
Organizational Category? (4)
PCPs and multispecialty groups, HMO/PPO,ACO, medical home, consumer-directed care
Financial Category? (4)
Shift price to consumer or risk to providers, rely on market, fix prices, global budget
Information/Systems Categories? (4)
EMR, Evidence-based support, system-wide payment rules (all payers are operating by the same set of rules), concentrate purchasing power
4 HIGH POTENTIAL FOR COST SAVINGS approaches?
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)
Why does drug effectiveness review have to happen? In other words, what’s the current situation like now?
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.
Evidence base for solutions?
Preettttyyy weak….we’re sort of taking a gamble here based on not much evidence that it works.
What’s an ACO?
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.
Explain ACO quality measures. What are the implications?
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.
What is a pt centered medical home?
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
Is a pt centered medical home gonna cut costs?
This approach could be better, but NOT necessarily less expensive
Mass 2012 Reform, implications?
FFS is dead in MAssachusetts. Impossible for solo practiioners to work alone…will be forced into a relationship.
Who is considered dual eligible? (2)
1) Poor elderly people (usually dependent on nursing homes) 2) Younger people with AIDS, spinal injury, severe mental illness, multiple chronic illness
What’s the issue with dual eligibles before CCA (Commonwealth Care Alliance)?
Care is uncoordinated (shitload of docs per year, pcp’s not notified of ED admits), inaccessible, impersonal, ineffective, shitloads of preventable hospitalizations
Dual eligibles - FFS v. organized care?
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.
Dual eligible organized care systems - successful?
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.
How does the CCA flow of payment work?
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.
Key factors that differentiate CCA from other systems?
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.
Internal service concept?
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.
