Exam 2 Flashcards
What are health consequences for the uninsured?
- poorer quality of health, lower rates of preventative care and greater probability of death
- more likely to receive an initial diagnosis of cancer in a late stage of the disease, poorer treatment outcomes, and to die within less time after diagnosis
- Less likely to receive timely diagnosis or treatment of STIs; less likely to be aware of HIV status
Uninsured adults are more than ____ percent more likely to die prematurely than adults with health insurance
25
Acute of sudden consequences of being uninsured
- Experience poorer medical outcomes following accidents
- Greater risk of dying while they are in the hospital and for two years after being discharged
- Those injured in accidents less likely to recover
- More likely to die from trauma, heart attacks, strokes
Chronic consequences of being uninsured.
- Less likely to schedule regular visits with physicians
- More likely to suffer from an undiagnosed medical condition that can be controlled with proper management
- Improvements in people with cardiovascular disease and diabetes in turning 65
Economic consequences of being inunsured
- Medical debt
- Miss more time from work when ill or injured; retire sooner
- Being absent means loss of earnings for both employee and employer
- Employee absence costs employers billions of dollars per year in wages paid to absent employees
Ultimately, people who have insurance also pay for the health care that people who are uninsured receive; this is called
hidden health tax
The World Health Organization (WHO) has identified universal health care coverage for adolescents as what?
a global health priority
Unmet health care need in adolescence is associated with what?
poor health outcomes as an adolescent – and as an adult
Rather than cost, forgo health care for other reasons such as?
concern for confidentiality, stigma, and judgmental attitudes among health care providers
Most global research related to adolescent health focuses on what type of approach
population-level
Hargreaves and colleagues used an individual-level approach to examine what?
whether individual-level factors lead to higher odds of adverse health outcomes
Objective of the National Longitudinal Study of Adolescent to Adult health
To estimate the association between unmet health care need in adolescence and 5 self-reported measures of adult health
National Longitudinal Study of Adolescent to Adult health: wave 1
Wave I – 1994/1995 (mean age 15.9 years)
National Longitudinal Study of Adolescent to Adult health: Wave IV
Wave IV – 2008 (mean age 29.6 years)
National Longitudinal Study of Adolescent to Adult health: dependent variables
- General health
- Functional impairment
- Missed any work/school in the last month for health reasons
- Depressive symptoms
- Suicidal ideation with the last year
National Longitudinal Study of Adolescent to Adult health: independent variables
Unmet health care need
- Cost
- Non-financial factors
- Perceived negative - consequences of accessing care
- Perceived low importance of the problem
National Longitudinal Study of Adolescent to Adult health: the highest unmet need
- depressive symptoms
2. missed school/work
Most common reason for unmet healthcare need:
- Perceived low importance
- Non-financial access problems
- Negative consequences of health care
- Cost
Adolescent health outcomes were the strongest predictors of what?
adult health outcomes
The odds of adverse adult health outcomes were 13% to 52% higher among subjects who had what?
who had reported unmet health care needs in adolescence
Unmet health care need may reflect what?
low health literacy/health engagement or other vulnerabilities
Adolescent health are influenced by a wide range of individual, family, peer, and societal factors that go beyond _____
health care
Unmet health care need in adolescence is common and is an independent predictor of what?
poor adult health
Interventions to improve health care access among adults have limited impact on what?
future health and health care costs
Reducing the unmet health care need among adolescents may be a highly effective investment to do what?
improve population health outcomes and reduce health care costs
Strategies to reduce unmet health needs
- Health engagement and care quality
- early intervention and investment
- reducing unmet health care need among pregnant women and young children
- Young people with mental health needs may perceive barriers to accessing care > health care providers should engage and communicate - Cost barriers to accessing services
- maintain you adults staying on parents’ insurance until the age of 26
Consumer perspective
The “price” of health care (physician’s bill, price of prescription, etc.)
National perspective
How much a nation spends on health care
national perspective equation
Formula: E = P x Q
Provider perspective
Cost of producing health care services (salaries, capital costs, rental of space, purchase of supplies)
Health care spending spiraled right after what?
the Medicare and Medicaid programs were created in 1965
When was medical inflation brought under control?
1990s
Trends in national health expenditures evaluated in 3 ways; what are the 3 ways?
- Medical inflation to general inflation (annual changes in consumer price index)
- Compares change in NHE to those in the gross domestic product (GDP)
- International comparisons
Consumer Price Index (CPI):
a measure of the average change over
time in the prices paid by urban
consumers for a market basket of consumer goods and services
What are the 3 main sources to assess whether the US spends too much?
- International comparisons
- Rise in health insurance premiums in the private sector
- Government health care spending for beneficiaries who receive health care through public insurance programs
Why healthcare costs can be a good thing?
- If E goes up, it means that people are using the healthcare system
- Means that people have jobs
- Creates jobs
- Alleviates suffering
- Improves lifes
What are reasons for cost escalation?
- increase in elderly population
- continued focus on medical model of healthcare delivery
- Defensive medicine
- administrative costs
- fraud and abuse (upcoding/anti-kickback statute)
What are providers using defensive medicine?
- They do not want to get sued
- Doing way more than they need to be because patient wants them to and to cover their own ass
What are the 6 Dimensions of quality?
- Safety
- Patient centeredness
- Effectiveness
- Timeliness
- Efficiency
- Equity
6 Dimensions of quality: Safety
Measures complications, falls, medication errors, mortality rates
6 Dimensions of quality: Effectiveness
Measures – receiving recommended care for condition
6 Dimensions of quality: patient centeredness
Measures – care and service, discharge instructions
6 Dimensions of quality: timeliness
dont kno
6 Dimensions of quality: efficiency
Measures – utilization of hospital services or procedures measured by discharge rate or average length of stay
6 Dimensions of quality: equirty
Measures – accreditation, EMR, nurse-to-patient staffing ratios
What are 7 ways that hospitals can make sure their environment is safe for their patients?
- Prevent central line-associated blood stream infections
- Re-engineer hospital discharges
- Prevent venous thromboembolism (VTE)
- Limit shift durations for medical residents and other hospital staff
- Use good hospital design principles
- Build better teams and rapid response systems
- Measure your hospital’s patient safety culture
Bipartisan Policy Center - Report: what is it and who funded it
Public policy advocacy organization founded by former U.S. Senate Majority Leaders Howard Baker, Tom Daschle, Bob Dole, and George Mitchell
- Advances the work of the Leaders’ Project on the State of American Health Care
- Intended to explore policy trade-offs and analyze the major decisions involved in improving health care delivery
Bipartisan Policy Center - Report: mission
develop and promote solutions that can attract public support and political momentum
Bipartisan Policy Center - Report: Executive summary
- Shortfalls in quality and efficiency of care lead to higher costs and poorer health outcomes.
- Health care providers do not have the payment support they need to communicate and work together effectively to improve patient care.
- Some patients do not receive medically necessary care while other receive care that may be necessary, or even harmful.
Bipartisan Policy Center - Report: framework needed
The ability to steadily implement effective reforms in payments, benefits, and regulation to accompany effective reforms in the delivery of care
- Implementing increasingly sophisticated person-centered measures of quality and cost
- Concurrently reforming public and private financing and delivery
- Investing in activities to support coordinated, high-value care in conjunction with payment and benefit reforms
A. Providing Better Performance Measures to Promote Reform and Build Evidence
Valid information on the quality and cost of health care, at the level of a patient or episode of care, is widely available and consistently applied
- Major focus should be on implementation of measures that describe and show ways to address racial, ethnic, and socioeconomic disparities in health care quality
- Collaborative, multi-payer regional approaches to delivery system reform
- Consistent use of performance measures
Types of quality measures
- Structural
- Process
- outcome
Types of quality measures: Structural
Capacity, systems, and processes to provide high-quality care
Types of quality measures: Process
What the provider does to maintain or improve health
Types of quality measures: outcome
Measures reflect the impact of the health care service or intervention
B. Accountability for Quality Improvement, Cost Reduction, and Value
- Congress should realign payments by increasing reimbursements for primary care and for other non-physician personnel (case coordination)
- Medicare should develop and implement a phased transition from provider reimbursement toward accountability for cost and quality at the population level
- Payment reform to include shared savings models, bundled payments, partial capitation linked to demonstrated results in improving value (Iowa SIM Model)
- Accountability payments risk-adjusted to ensure providers and organizations are not penalized for treating higher-risk patients
C. Make Investments to Support Coordinated, High-Value Care
Investments needed to provide the infrastructure to support more integrated, higher-value care
- The American Recovery and Reinvestment Act (2009) – modernize health information technology systems (EMR)
- Government grants and loans linked to Medicare and Medicaid payments
- Funds used to promote greater coordination of care and better sharing of clinical information across treatment settings (care coordination models; patient-centered medical home)
D. Encourage regional, multi-stakeholder approaches to reforming health care delivery
- Developing strategic priorities for delivery reforms – more effective when coordinating with other payers
- Bring all public and private payers to the table to promote more consistent measurement, payment, and benefits that support coordinated care
- Congress should give Medicare and Medicaid greater authority to participate in multi-stakeholder initiatives
E. Support for Comparative Effectiveness Research
- Inventory and analysis of existing comparative effectiveness research
- The development of priorities for better evidence
- Targeting: differentiating the effects of treatments, combinations of treatments, and practices and policies that influence the use of treatments on particular subgroups of patients who may respond differently
- More infrastructure investment to gather evidence from actual practice
Executive Summary - Conclusions
- Clear attributes of different approaches to health care reform that are more likely than others to improve health and slow cost growth
- Targeted interventions typically have a greater impact on quality improvement and cost containment than broader approaches
- Delivery system reforms are most effective when integrated and ensure accountability from both providers and patients to improve results
- Reforms are needed to transition provider reimbursement away from volume and intensity of services toward quality and value
- To be most effective, changes in the delivery system and coverage expansions should be implemented together
Quality of Care - AHRQ
The Quality Indicators (QIs) are measures of health care quality that use readily available hospital inpatient administrative data. AHRQ develops Quality Indicators to provide health care decision-makers with tools to assess their data.
- used to highlight potential quality concerns
- identify areas that need further study and investigation
- track changes over time
- in use in acute-care hospitals only
Prevention Quality Indicators
A set of measures that can be used with hospital inpatient discharge data to identify quality of care for “ambulatory care sensitive conditions.“
Good outpatient care can prevent the need for what?
hospitalizations
Prevention Quality Indicators can provide insight into what?
into the community health system
Prevention Quality Indicators is used as what?
its used as a “screening tool” to help flag potential health care quality problem areas that need further investigation; provide a quick check on primary care access, and help those interested in improving population health
Inpatient Quality Indicators
Provide a perspective on hospital quality of care
- Inpatient mortality for certain procedures and medical conditions
- Utilization of procedures for which there are questions of overuse, underuse, and misuse
- Volume of procedures
Inpatient Quality Indicators: use
used to identify potential problems that may need further study
Patient safety indicators
Provide information on potential in hospital complications and adverse events
Patient safety indicators was developed after what?
comprehensive literature review, analysis of ICD-9-CM codes
Patient safety indicators is reviewed by who?
a clinician panel
Patient safety indicators: use
used to help hospitals identify potential adverse events
Pediatric Quality Indicators are used with inpatient discharge data to do what?
to provide perspective on the quality of pediatric health care
Pediatric Quality Indicators focus on what?
Focus on potentially preventable complications and illnesses caused by physician or medication
Pediatric Quality Indicators: use
screens for problems that pediatric patients experience as a result of exposure to the health care system
Consumer Assessment of Healthcare Providers and Systems (CAHPS®): when did it begin?
Began in 1995 to advance scientific understanding of patient experience with health care
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) conducts research on what?
patient experiences and develops surveys that ask consumers and patient to report on, and evaluate, their experiences with health plans, providers, and health care facilities
what are the components of the patient experience model?
- Providers
- health plans
- physicians
- health care facilities
- this is not the same as patient satisfaction, its about the actual care you receive. for ex. how the food was, the temp. in the room, etc.*
Publicly reporting the patient experience survey findings help consumers do what?
choose among providers and plans
Patient care experience measures are increasingly reported where?
in public reporting and pay-for-performance measures
The ACA mandated that CMS establish several public reporting and payment programs, such as what
CAHPS®
National survey data indicate that ___ Americans are consulting online rankings and reviews of clinicians; ___ for hospitals and medical facilities
1 in 6; 1 in 7
Research – Systematic Review: purpose
To gather information on the associations between patient experience measures and other indicators of health care quality
Research – Systematic Review gathered articles from what years, using which search terms?
1990-2013, using search terms CAHPS, HCAHPS, and Medicare Hospital Compare
Research – Systematic Review: final results
34 studies that met the criteria
Patient Behavior results
Better communication, better adherence to treatment regimens; increased trust
Clinical processes results
Hospitals with higher HCAHPS scores perform better on process of care for AMI, CHF, pneumonia, and surgery
Clinical outcomes results
In AMI patients, better care > better survival after one year after discharge
Efficiency results
- Some aspects of patient-centered care may help to reduce unnecessary health care use
- Children with asthma who physicians had reviewed a long-term therapeutic plan with parents were less likely to visit the emergency department, make urgent office visits, or be hospitalized
Saftey results
Positive patient experiences > lower prevalence of inpatient care complications
Patient experience measures should be collected using what?
psychometrically sound instruments; standardization
Measuring patient experiences of care may help to promote what?
accountability and quality improvement efforts
Better patient care experiences are associated with what?
higher levels of adherence to recommended prevention and treatment processes, clinical outcomes, better patient safety culture, and less health care utilization.
Update on Quality Improvement Efforts: making care safer
Half of all patient safety measures improved; significant reduction in adverse drug reactions
Update on Quality Improvement Efforts: each person and family engages in care
Nearly all measures improved; better communication
Update on Quality Improvement Efforts: promoting effective communication and care coordination
Improved discharged processes and care coordination; increase in the adoption of health information technologies
Update on Quality Improvement Efforts: promoting the most effective and prevention and treatment practices for the leading causes of mortality
Half of effective treatment measures improved for life-threatening conditions; increased attention to prevention efforts
Update on Quality Improvement Efforts: Working with communities
Half of measures of healthy living improved; increased uptake in adolescent vaccines
Update on Quality Improvement Efforts: Making quality care more affordable
affordability has “leveled off”
Only ___ of people with higher BP are receiving the recommended level of care
70%
Disparities in hospice care and chronic disease management has _____.
increased
across all 6 priorities, disparities still exist according to what factors?
income, race and ethnicity
Accessing health services: coverage
gain entry into the healthcare system
Accessing health services: services
ensure that people have usualy and ongoing source of care
Accessing health services: timeliness
provide care quickly after a need is recognized
Healthcare access and utilization compared to 2013:
Percentage who had a usual place to go For medical care increased in 2014 for:
Hispanic Adults and
Non-Hispanic White Adults
No significant change for Non-Hispanic, Black and Non-Hispanic Asian Adults
Compared with 2013, the percentage of adults aged 18-64 who had seen or talked to a health care professional in the past 12 months _____ in 2014 for?
Whereas there was no significant change for who?
increased; hispanic adults
No significant change for:
Non-Hispanic White adults
Non-Hispanic Black adults
Non-Hispanic Asian adults
Improving access to primary care is about what?
maintaining a balance between supply and demand
What does it mean to maintain a balance between supply and demand when talking about improving access to primary care?
- No backlog of appointments
- No delay between when the demand is initiated and the service is delivered
The higher the gap between supple and demand,
the increased delay in meeting patient’s needs, more expensive, and increased waste in the health care system
The demand can be predicted accurately based on:
- The population
- The scope of the provider practice; practice style
Institute for Health Care Improvement – Strategies to Improve Primary Care Access
- Balance supply and demand
- Commit to doing today’s work today
- Create contingency plans
- Decrease demand for appointments
- Do tasks in parallel
- Find and remove bottlenecks
- Improve workflow and reduce waste
- Manage panel size and scope of practice
Match the supply and demand on a ____..
daily, weekly, and long-term basis
To balance supply and demand, what is crucial?
Communication among departments is crucial
Use the opportunity for communication to actually manage the supply and demand – as well as anticipate and plan for recurring seasonal events such as…?
Influenza season
Allergies
Weather-related injuries
To balance supply and demand, what should be apart of a daily schedule?
Commit to doing todays work, today
- A system in place to take care of daily demands when the demand is generated (requires strong commitment from health care team)
To balance supply and demand, No appointments are “held” or “frozen”; this is to maintain what?
flexibility in meeting the daily demand
- improve patient flow
- backlog is eliminated
Variations in demand
- expected (flu season)
- unexpected (more than usual number of walk-ins)
Variations in supply
- vacation
- emergency sick leave leaving lower number of staff
Who are often the end product of the mismatch between supply and demand……
the patients
Contingency Plan: Strategies for Improvement
- establish a policy for late patients
- develop scripts for common occurrences
- plan for a sudden absence of a provider or care team member
- anticipate unexpected increases in demand
- establish vacation plans and policies
Improving access is about increasing the ability of the system to ..?
predict and absorb demand
Improve access to primary care by reducing the unnecessary demand for various services so the patients that do need the service can…?
get it in a timely manner
- Emergent vs non-emergent care (ER, acute care, primary physician)
- Specialized care (primary care physician, specialist)
- Scheduling (longer time between re-checks)
Decrease Demand: Strategies for Improvement
- use alternatives to one-on-one visits
- group appointments for chronic disease patients - Manage and decrease no-show appointments
- reminders - increase return intervals
- use “max-packing” during the visit
- address multiple -or anticipated issues- in one visit
Parallel processing means what?
that the overall process can continue even if one part is delayed
- If a patient provides symptoms of strep throat and provider is delayed, the nurse can perform strep test
To do tasks in parallel, what is needed?
documentation
bottleneck (constraint)
anything that restricts the throughput of patients into and through the clinic system
bottlenecks (constraint) occur when
the demand for a particular resource (e.g., rooms, providers, tests) or part of the system is greater than the available supply (Example: iTriage)
Why must the bottlenecks (constraint) be addressed?
in order to improve parts of the system
“Rate-limiting step”
the step that determines the rate at which work passes through the system
Improving the flow of work and eliminating waste ensures what?
that the clinical office runs as efficiently and effectively as possible.
Some reports estimate that up to 40 percentofclinical officework is what?
redundant or otherwise wasted effort.
Improve Workflow and Remove Waste: changes for improvement
- remove intermediaries
- use automation and technology
- move steps in the system closer together
Panel size
the number of unique patients for whom a care team is responsible; it is a measure of the equity of the work.
How can panel size be measured?
by calculating the number of unique patients seen by a specific provider within a specific time frame — usually the past eighteen months.
The goal to panel size good panel management, meaning what?
clinicians and their care teams being responsible to, and caring for, a designated population of patients.
Progress on Access to Care, 2013-2016; report released by who, and when?
released by the Commonwealth Fund in December 2017
Progress on Access to Care, 2013-2016: goal?
Compare state trends in access to affordable health care between 2013 and 2016
Progress on Access to Care, 2013-2016: methods
Analysis of recent data from the U.S. Census Bureau and the Behavior Risk Factor Surveillance System (BRFSS)
Progress on Access to Care, 2013-2016: indicators
- uninsured rates for children
- uninsured rates for working age adults
- adults access to care
- percentage of individuals under age 65 with high out-of-pocket medical expenses relative to income
for uninsured adults and uninsured children, how many states reported and improvement in the Change in Health Systems Performance, by Access Indicator, 2013-2016
Uninsured adults: 47 states reported an improvement
Uninsured children: 33 states reported improvement
Adults who went without care due to cost: how many states reported improvement
36 states
At-risk adults who went without a doctor’s visit in past two years: ___ states reported
Improvement
30
Dental care: Most states reported what?
no change or access to dental care has worsened
The rate of uninsured working-age adults dropped where? In 47 states, it fell by at least how much?
in all states and D.C; 5 percentage points
In nearly three-fourths of states and D.C., the share of adults who went without care because of costs dropped by how much?
at least 2 percentage points.
The states at the top of the access rankings, as well as those that made the biggest improvements in the rankings between 2013 and 2016, had all what?
expanded their Medicaid programs by January 2016
The medical home is an approach to primary care that is
- Person Centered
- Coordinated
- Accessable
- Committed to quality and safety
- Comprehensive
Defining medical home: Person Centered
supports patients and families in managing decisions and care plans
Defining medical home: coordinated
care is organized across the “medical neighborhood”
Defining medical home: accessible
care is delivered with short waiting times, 24/7 access and extended in-person hours
Defining medical home: committed to quality and safety
maximizes the use of health IT, decision support and other tools
Defining medical home: comprehensive
whole-person care provided by a team
The health system transformation requires what?
- public engagement
- benefit redesign
- payment reform
- delivery reform
Clear communication and effective coordination among health care providers are vital for patient health, but the current primary care structure makes collaboration what?
incredibly difficult
PCMHs serves as what for all health and social support services to achieve care coordination
a central “hub”
PCMH clinical partners
- specialists
- hospitals
- home health
- long term care
- clinical providers
PCMH non-clinical providers
- community centers
- faith-based organizations
- schools
- employers
- public health agencies
- YMCAs
- Meals on wheels
Public health transformation requires public engagement, describe what that means.
Patients, Families & Caregivers, and Consumers must drive demand for the model
One of the most important activities that we engage in at the PCPCC is to what?
communicate with the public at large about primary care and the patient centered medical home.
Public health transformation requires delivery reform, describe what that means
Growing evidence to support that the model works
How does PCMH enhances ability to identify and manage high-risk, high-need populations?
- Risk stratification and diligent monitoring for all patients
- Track care plans and medication adherence
- Proactive outreach from care team with collaboration among specialists and primary care
- Patient engagement and activation
What are the components of how the PCMH uses diverse empowered care teams?
family, clinical staff, health resources, insurance companies, and a social world are all surrounded around the patients and their needs.
How does the PCMH facilitate care that is documented and shared electronically
- Shared with patients through electronic records, portals, mobile apps, email (which includes patient generated data)
- Shared across providers and institutions through health information exchanges
- Shared across public and private payers
How does PCMH support improved access to care and better patient experience?
- 24/7 access to care team (phone or e-consults with nurses, etc.)
- Alternatives to traditional face-to-face visits, including telemedicine, group visits, e-consults, peer support
- Access to electronic health records and patient portals
PCMH includes patients, families and caregivers as…?
part of a care team
For the PCMH, its important to consider experience of care from the _____ – and includes families & caregivers
patient’s perspective
Patients with multiple chronic conditions (and/or their caregivers) often in best position to advise care team on what?
challenges/opportunities to improve care
Through their stories, patients can energize and encourage team to promote what?
compassionate care
How does PCMH include patients, families, and caregivers in practice transformation?
- Invite patients/caregivers into quality improvement efforts from the very beginning
- Invite patients/caregivers that represent the larger patient population (i.e. ethnicity, culture)
- Invite patients/caregivers with experience managing their own condition
- Provide compensation for patients/caregiver advisors
- Invite more than one patient, family, caregiver
Need to integrate behavioral health into primary care: describe the triangle
Level 1: Primary care provider (PCP provides first line treatment
Level 2: PCP receives ad-hoc consultation, usually from an off-site mental health specialist
Level 3: PCP supported by brief intervention from on-site behavioral health consultant
Level 4: PCP supported by a collaborative care team with systematic treatment to target
Level 5: Referral to mental health specialty care
The health system transformation requires payment reforms, describe this.
Necessary to sustain the model and the progress made
“Supply side” reforms
Reimbursement changes that impact health care delivery
Examples of reimbursement changes that impact health care delivery (“Supply side” reforms)
- Increased payment for providers who adopt PCMH model
- Increased use of shared savings , bundled payments, captivated payments
- Alignment across all payers through multi-payer or all-payer initiatives
“Demand side” reforms
Reimbursement changes that impact consumers and employers
Examples of reimbursement changes that impact consumers and employers (“Demand side” reforms)
- Consumers pay less in premiums/copays to use higher-value, PCMH services
- Limit co-pays for wellness visits/primary care
- Use of tiered pharmacy benefits that encourage the use of cost effective prescriptions (including generics)
- Improve consumer understanding of the PCMH model and primary care to better manage health
Reducing Hospital Readmissions: what is in process
reducing costs and improving patient care
how many people discharged from the hospital will be readmitted within 30 days or less?
15-25% - most are preventable
what is a major opportunity for rapid savings in the HC sector?
save billions of dollars in healthcare spending
Weakness of current efforts in reducing hospital readmissions
- Not data driven, in understanding where readmission problems exist or in determining how well interventions are working
- Narrowly focused on hospital-based transitions (home, skilled nursing, rehab, assisted living) and not avoiding readmissions
- Are not supported by payment reforms (such as the State Innovation Model) for physicians, hospitals, and other providers to redesign care to reduce readmissions
Hospital Readmissions Reduction Program (HRRP)
Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program (HRRP)
IPPS
inpatient prospective payment system
Hospital Readmissions Reduction Program (HRRP) requires CMS to do what?
reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012
Readmission is defined as what
an admission to a hospital within 30 days of discharge from the same or other similar hospital
FY 2014 IPPS final rule –
added COPD, total hip arthroplasty, total knee arthroplasty
FY 2015 IPPS final rule –
added coronary artery bypass graft surgery
FY 2016 IPPS final rule –
added aspiration pneumonia, sepsis patients with pneumonia
FY 2018 IPPS final rule –
changed the methodology to calculate payment adjustment factor; hospital CEO or designee may submit ECE (extraordinary circumstances extension)
Hospital Readmissions Reduction Program (HRRP) adopted readmission measures for the applicable conditions of what?
acute myocardial infarction, heart failure, and pneumonia (2012)
When calculating the hospital readmission
rate, CMS uses how many years worth of hospital data?
three-years
Hospitals to incur the largest penalties are those
that have a…
1) higher share of low-income
beneficiaries and 2) teaching hospitals
A high percentage of patients are
staying in hospitals that scored well on what?
on previous measurement period and incurred no penalty or very small penalty
National Medicare Readmission Rates started to fall in 2012,
The decline in hospital readmissions due to:
Hospital Readmissions Reduction Program
Hospitals making concerted efforts to reduce hospital readmissions before the fines began in 2013
IPPS Hospitals
Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute carehospitalinpatient stays under Medicare Part A (HospitalInsurance) based on prospectively set rates. This payment system is referred to as theinpatient prospective payment system(IPPS)
Under IPPS, each case is categorized into what? explain it
into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG
If the hospital treats a high-percentage of low-income patients, what happens?
it receives a percentage add-on payment applied to the DRG-adjusted base payment rate.
The disproportionate share hospital (DSH) adjustment
provides for a percentage increase in Medicare payments for hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients.
For qualifying hospitals, the amount of The disproportionate share hospital (DSH) adjustment may vary based on what
the outcome of the calculation required by law.
If the hospital is an approved teaching hospital it receives a percentage add-on payment for each case paid through what
IPPS.
Direct medical education (DME) adjustment
varies depending on the ratio of residents-to-beds under the IPPS for operating costs, and according to the ratio of residents-to-average daily census under the IPPS for capital costs
Indirect medical education (IME)
residents training in non-provider settings must spend their time in patient care activities in order to be counted. Needed – written agreement between hospital and non-provider setting or hospital pays stipends and fringe benefits of the residents concurrently. (Added on in the ACA)
Reducing Readmissions: Step 1
Analyze data to identity types and causes of readmissions
- Readmissions for complications or infections arising directly from the initial hospital stay
- Readmissions because of poorly managed transitions during discharge
- Readmissions because of a recurrence of a chronic condition that led to the initial hospitalization (asthma, CHF, COPD)
Largest volume of readmissions occur in what patients?
patients with chronic diseases
Reducing Readmissions: Step 2
Reinvent care delivery across the continuum
- Majority of readmission reduction initiatives have focused narrowly on improving the discharge process or the transition
- Difficult to try and prevent initial chronic disease admissions, but…..
- Needs to be a strong focus on improving primary care/outpatient management of patients with chronic disease
Reducing Readmissions: Step 3
Create payment systems that make care changes sustainable
- Under Medicaid, Medicare, and most commercial health plans, primary care practices cannot be reimbursed for providing care management services to patients
- under current payment systems, hospitals lose a significant amount of money when readmissions are reduced, even though they still have to cover the fixed costs of having bed and staff available
- The approach taken by Medicare and many private health plans is to reduce or eliminate payments to hospitals for readmissions
Current procedures for reducing hospital readmissions were based on what
the notion that readmissions reflect the quality of care – but may be a result of the discharge process
Is it clear what proportion of the readmissions are truly preventable?
no - unclear
Hospital readmission rates are not meaningfully related to what
other performance measures of hospital quality
Academic institutions and hospitals in socioeconomically ____ areas are disproportionately affected
disadvantaged
Interventions - Hospital to Home –> types of interventions
- patient education
- discharge planning procedures
- follow-up telephone call
- patient centered discharge instructions
- discharged coaches/nursed interacting with patient before and after discharge
Interventions - Hospital to Home: findings
single interventions unlikely to work but multi-faceted interventions are likely to necessary for substantial improvements in readmission rates
Interventions – Hospital to Post-Acute: Settings
Skilled nursing or rehabilitation facilities
Interventions – Hospital to Post-Acute: population
This population accounts for a substantial portion of overall and disease-specific hospital readmissions (CHF, pneumonia, co-morbidities)
Interventions – Hospital to Post-Acute: how should prevention steps occur and what should they include attention to
early in acute hospital stay and include attention to
- medical reconciliation
- minimize use of urinary catheters, PICC lines and other in-dwelling devices
- include patients in advanced-care planning discussions
When the hospital does not have the capacity to use a multi-faceted approach for all patients, how should they identify those who are more likely to be readmitted?
identify those at high risk of readmission
- use of readmission risk prediction models
When identifying high risk patients for readmission, how should the readmission risk score be calculated?
early enough during index hospitalization to allow time for intervention
- Tailor prediction models to specific patient population or disease
What are potential new frontiers for identifying high risk patients for readmission?
- Telemonitoring for disease management
- Incorporate behavioral therapy in the hospital, during home visits, and ambulatory care setting
- Enhance the discharge process
- Community partnerships
- Create new roles in the health care team such as transition coaches, discharge advocates, and transition care coordinators
Technology has played a role in medical cost ___
inflation
Technology has done with with consumer expectations?
raised
Technology has led to what in specialized medicine
led to increases
Technology and ethics: describe
Technology has raised complex social ethical concerns
What is medical technology?
The practical application of the scientific body of knowledge for the purpose of improving health and creating efficiencies in health care
Physics: how has it impacted medical technology?
(x-ray technology, mammography, ultrasound, MRI)
Chemistry: how has it impacted medical technology?
drug development
Computer science and communication technologies: how has it impacted medical technology?
telemedicine
Bioengineering: how has it impacted medical technology?
robotic systems in surgery; advanced prosthesis
Medical Technology: Diagnostic
- give ex.
Computed Tomography, Fetal Monitor
Medical Technology: survival
- give ex.
ICU, Bone Marrow Transplant, CPR
Medical Technology: illness management
- give ex.
renal dialysis, pacemaker
Medical Technology: cure
- give ex.
hip joint replacement, lithotripter
Medical Technology: prevention
- give ex.
Vaccines, Cardioverter defibrillator Implant
Medical Technology: facilities and clinical settings
- give ex.
Hospital Satellite Centers, Clinical labs
IT Applications: Clinical Information Systems
Process, storage and retrieval of information to support patient care delivery
IT Applications: Administrative Information Systems
Carry out financial and administrative support activities
IT Applications: Decision Report Systems
Information and analytical tools to support managerial and clinical decision making
Health Care Informatics: Defined
“the integration of health care sciences, computer science, information science, and cognitive science to assist in the management of health care information.”
Describe how Health Care Informatics and nursing have turned out
vastly growing field
Health Care Informatics: outcomes
enhanced delivery of care, improved health outcomes, and advanced patient education
Health care informatics help to bridge the gap between
technology, workflow, and the data collection process
American Recovery and Reinvestment Act (ARRA) 2009
Health Information and Technology for Economic Clinical Health Act (HITECH)
Clinics and hospitals are rewarded for using EHR – penalizes them if not being adopted in the near future
Massive amount of data to be managed and analyzed
Policy makers can use the information contained in the EHR to
inform decision making about public health issues
Electronic Health Record (EHR) =
“systematic electronic collection of health information about patients”
Four Key Components of EHR
- Collection and storage of health information on individual patients over time
- Immediate electronic access to person- and population-level information by authorized users
- Availability of knowledge and decision support
- Support of efficient processes for health care delivery
EHR benefits
- Major savings in health care costs
- Reduced medical errors
- Improved health
- Improved quality of care, timeliness, adherence to clinical practice guidelines, and reduce medication errors
EHR Drawbacks
- Changed the emphasis from patient-centeredness to institutional priorities
- Increased time and effort required in documentation
- expensive start-up costs
Smart Card Technology
Pocket-size smart card embedded with a microchip to allow hospitals and physicians’ offices to access personal medical information
Smart Card Technology adoption rate
very slow
Why does the public view smart cards with suspicion and distrust
Information security
Personal privacy
Internet application in the medical world
a. First source of information that patients consult for specific health conditions (70 percent)
b. Physician consultations; online support communities
E-Health
electronic health care; secure patient portals
M-Health
mobile health; wireless communication devices to support clinic practice; most common use is for EHR access
E-Therapy
behavioral support and counseling
Virtual Physician visits
online encounter between patient and physician
Cost effective method to deliver patient care and expand access
telehealth
Connects patients to virtual health care services through videoconferencing and need for reimbursement
telehealth
Medicare lagging behind private insurers for understanding the importance and need for reimbursement
telehealth
Information regarding the benefits of telehealth need to be conveyed to policy makers to support what
incorporation into health care delivery
Interventions – Chronic Disease Management: Congestive Heart Failure
noticeable health improvements, fewer episodes of worsening care, and general improvement in clinical, functional, and quality of life status
- reduction in mortality
- Reduced hospital admissions, re-admissions, length of stay, and emergency department visits
Chronic Disease Management of Congestive Heart Failure improves access to what
stroke specialists in medically underserved areas
In 2016, approximately
___of hospitals are
currently using or implementing
telehealth
65%
Barriers to wide adoption of telemedicine
- medicare limits coverage and payment for telehealth services
- limited access to broadband services (esp. rural facilities)
- challenges of cross state licensure
- Credentialing and privileging, online prescribing, privacy and security, and fraud and abuse
Factors that Drive Innovation & Diffusion: Anthro-Cultural Beliefs and Values
Americans want to be the “best”, reliance on medical model of care
Factors that Drive Innovation & Diffusion: Medical Specializaiton
broad exposure to technology for specialty residency training programs
Factors that Drive Innovation & Diffusion: financing and payment
limits on payments to hospitals for the use of high-tech procedures
Factors that Drive Innovation & Diffusion: Technology-Driven Competition
Insured patients are more likely to seek services from hospitals with “state of the art” equipment
The Impact of Medical Technology: Quality of care
Precise medical diagnoses, quicker and more complete cures, reduce risks
The Impact of Medical Technology: Quality of life
Long-term maintenance therapies, pharmaceutical breakthroughs, pain management
The Impact of Medical Technology: Health Care Costs
Accounted for roughly half of the total rise in health care spending
The Impact of Medical Technology: Access
Mobile equipment can be transported to rural and remote sites
The Impact of Medical Technology: Structure and processes of health care delivery
Medical centers, alternate settings, IT systems, telecommunications
The Impact of Medical Technology: Global medical practice
Medical device companies based in the U.S. exporting to other countries
The Impact of Medical Technology: bioethics
Does medical technology benefit everyone? Who has access?
National Partnership for Women & Families
National, non-profit, consumer organization with 40 years’ experience working on issues
important to women and families
Campaign for better care
Engage patients and consumers in re-design of our health care delivery and payment
system
Institute of Medicine
Care that is respectful of and responsive to individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions.
Planetree
An approach to the planning, delivery and evaluation of care grounded in mutually beneficial partnerships among providers, patients and families. It redefines relationships in health car
Whole person care
clinicians understand the full range of factors affecting a patient’s ability to get and stay well
treatment recommendations align with patients’ values, life circumstances and preferences
Coordination and communication
providers organized in teams and smooth transitions between settings
Patient support and empowerment
expanding patients’ and caregivers’ capacity to get and stay well and support for self- management tools and services
Ready Access
getting appointments promptly and accommodating barriers such as language or physical or cognitive problems
what will happen to the proportion of the worlds population from 2015 2050
the proportion of the worlds population over 60 years will nearly double from 12% to 22%
mental and neurological disorders among older adults account for how much of the total disability for geriatrics
6.6%
about what percent of people 55 years or older experience some type of mental health concern?
20%
The most common conditions for geriatrics include
- anxiety
- severe cognitive impairment
- mood disorders such as depression or bipolar disorder
what are often implicated as a factor in cases of suicide
mental health issues
who has the highest suicide rate of any age group
older men
what is required by the department of human services (state of iowa) to provide psych services to individuals they deem in need (PASRR)
SNF/ICF
