hour 9 Flashcards
Value-based insurance design and Patient-Centered Medical Homes
what are the IOM 6 aims of Health Care Improvement?
that its safe, effective, patient-centered, timely, efficient, and equitable
what do we mean when we say safe in terms of IOM health care improvement?
avoid injuries from care that is intended to help them
what do we mean when we say efficient in terms of IOM health care improvement?
providing services based on scientific evidence to those who could benefit and refraining from providing to those who will not benefit
what do we mean when we say patient centered in terms of IOM health care improvement?
care that is respectful and responsive to patient preferences, needs and values
what do we mean when we say timely in terms of IOM health care improvement?
Reduce and avoid harmful delays
what do we mean when we say efficient in terms of IOM health care improvement?
cost-effective, avoiding waste
what do we mean when we say equitable in terms of IOM health care improvement?
quality does not vary based characteristics such as gender, ethnicity, location or economic status
what are some challenge we face with our current healthcare model?
1) diagnostic and treatment options are expanding and changing
2) chronic diseases and complications are increasing
3) care is fragmented
4) variations in quality among different populations
5) continued cost increases are not sustainable
6) clinical research does not address pressing clinical questions
7) increased drive for information delivery
8) fee for service medicine encourages waste
what can we conclude about the our current healthcare system?
“the complexity of the modern health care is reaching levels that challenge human cognitive capacity.”
whats the evidence behind our conclusion about our current healthcare system?
1) research from biomedical and clinical articles is increasing drastically from 200,000 in 1970 to over 750,000 in 2010
2) physicians spend 8 hours a day on patient care
what are some recommendations by the IOM?
1) Accelerate integration of the best clinical information into care decisions
2) Involve patients and families in decisions regarding health
3) Improve coordination and communication within and across organizations
4) Continuously improve healthcare operations to reduce costs
5) Structure payment to reward the provision of best care
what do we want health policy to achieve?
accessibility, cost, quality, desired outcome=improved health status
what is successful policy?
providing VALUE to patients
so how do we measure value?
quality divided by cost
what is center for value based insurance design?
aligning payment reform with benefit design
what is cost sharing?
Use of deductibles, co-payments and co-insurance to discourage inappropriate utilization of healthcare services
what are some problems with most cost-sharing programs?
1) they do not discriminate between services based on their clinical value
2) cost sharing is regressive - same deductible for people of different incomes
what are the goals of value-based insurance design?
achieve cost savings and maximize clinical benefits
what are the VBID tactics?
1) Provide financial incentives to alter behavior and change utilization
2) Implementation of wellness and disease management to avoid future costly events
in any ideal situation what tactics would be best to implement?
cost sharing through higher co-payments would discourage low value care and absence of co-payments would encourage use of high value care
whats the VBID definition?
“The lowering or elimination of financial barriers to the purchase of “high-value” drugs or services in the hope of raising compliance and avoiding more expensive future medical cost, such as hospitalization.”
what are the V-BID key principles?
1) Value equals the clinical benefit achieved for the money spent
2) Health care services differ in the health benefits they provide
3) The value of health care services depends upon the individual who receives them
what are the VBID objectives?
1) greatest positive health impact for the expenditure
2) change focus of health debate from cost alone to clinical value
3) minimize the lack of patient adherence to evidence based services
T/F, V-BID doe not recognize that reduced utilization, the reason for cost sharing, may not be a desirable goal?
F, V-BID does recognize
what four approaches waive or reduce cost-sharing?
1) select drugs and services for all patients like statins and cholesterol test
2) medications or services for certain clinical conditions like effective medications for diabetes
3) high risk individuals who may benefit by participating in disease management programs
4) high risk individuals who participate in disease management programs within a certain network of providers where they can earn additional financial incentives for healthy behaviors and reaching certain clinical benchmarks
name some VBID examples?
1)Pitney Bowes, a 90-year-old, $5.6 billion company with 33,000 employees was among the first employers to add V-BID to its benefits in 2001. It made headlines in 2004 when it reported $1,000,000 in savings from reduced complications after it lowered copayments for asthma and diabetes medications.
2)State of Oregon
Cost sharing implemented on a tiered basis
Low for preventive services, medications for chronic conditions
High for services recognized as overused such as surgery for back pain that can be treated with physical therapy.
$25 surcharge for smokers
what are the barriers to VBID?
short term increase in utilization and cost, requirement for sophisticated data systems, and privacy concerns because VBID wants to know habits to be able to provide better services; also difficulty in determining value with lack of comparative research in addition to potential for fraud which may encourage providers and patients to misrepresent themselves to qualify for reduced cost-sharing
how effective has V-BID so far?
Measuring outcomes – few studies on the impact of VBID on utilization and patient compliance with recommended treatments
Adverse selection – VBID may attract a large number of “high risk” patients
HOWEVER, health affairs reports:
“Value-based Insurance Design Improves Medication Adherence without an Increase in Total Health Spending”
0.1 to 14.3% improved adherence Associated with no increase in costs
so V-BID and the ACA together work eliminate patient cost of sharing for preventative services receiving an A or B rating from the USPSTF, what is this organization?
USPSTF – independent body of healthcare providers and determine If they are effective (preventative services) and if they are A grade then they are incorporated into the healthcare plan and so if patient is admitted to hospital, then there is no expense or cost sharing
what was the goal both the V-BID and ACA were trying to achieve in implementing the VBID model?
In 2017, CMS began testing a V-BID model in 7 states to see if V-BID is an effective tool to improve quality and lower cost for Medicare Advantage enrollees with chronic conditions
Does the model improve outcomes
Does the model improve satisfaction and out-of-pocket costs
Does the model lower costs and result in savings to Medicare and enrollees
Expansion to three more states in 2018
Through what was VBID able to expand? think Bill and initiatives
2017 Defense Authorization Bill allows Tricare to test V-BID
2018 “American Patients First” drug strongly reflects V-BID concepts
what is the potential impact VBID can have on healthcare providers?
High value services provided by high cost providers will likely be considered low value
$5,000 colonoscopy versus a $1,500 colonoscopy
Physicians providing low-value services will struggle – need to keep up-to-date
what are patient centered medical homes (PCMH)? According to IOM
“Patient-centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients’ wants, needs, and preferences and that patients have the education and support they require to make decisions and participate in their own care”
what are the core components of PCMH?
1) Personal physician
2) Physician directed medical practice
3) Whole person orientation
4) Coordinated/integrated care
5) Focus on quality and safety
6) Increased access
7) Payment reform
what is the personal physician in the core component of the PCMH?
1) Patients value relationships
- Fee-for-service medicine creates barriers to developing relationships
2) Continuous care with one physician is associated with better outcomes and lower costs
what is the physician directed medical practice in the core component of the PCMH?
1) The physician is responsible for organizing and directing the care provided by a multi-disciplinary team
2) Clarifies each team members role and helps to make sure that “issues” do not fall through the cracks
what is the whole person orientation in the core component of the PCMH?
care for all stages of life
deals with the body
deals with the spirit
culturally appropriate
what is the care is coordinated and /or integrated in the core component of the PCMH?
1) coordinated across all health care settings
2) requires efficient transfer of health information
3) poor information sharing can result in poor outcomes and patients are not always the best at communicating information
what is quality and safety in the core component of the PCMH?
1) Use of evidence-based medicine
2) Use of performance measurement tools
3) Voluntary recognition by accreditation agencies – National Committee for Quality Assurance
4) Patient involvement in quality efforts
5) Use of electronic health records
what is the enhanced access in the core component of the PCMH?
1) Expanded hours
2) Patient access to electronic records and ability to schedule online
Do PCMH’s work? What does the five year cohort study say?
A growing body of scientific evidence shows that PCMHs are saving money by reducing hospital and emergency department visits, mitigating health disparities, and improving patient outcomes. The evidence we present here outlines how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.
according to NCQA july 2016
quality measures indicate modest improvements in two areas compared to control, outperformed the control group on two measures and no difference on four measures; utilization measures indicate modest changes and the PCMH allows for more primary care visits and fewer specialists visits with fewer diagnostic tests
