Post Midterm Flashcards
What is Aledade’s model based on?
Focusing on preventative services, improved comprehensive primary care to reduce costs.
Came from the insight that 1 ACO = 100 PCPs who each have 2,000 patients who cost $5,000 per pt per year = massive money if they all buy in for savings.
1. Get Drs to buy in
2. Get payers (accountability for reduced costs, creates incentives)
3. Get savings
4. Get efficiency
Explain the hypertension example.
Controlling hypertension is the best candidate to reduce mortality.
More profitable for hospitals to wait to control b/c more strokes are incentivized b/c that means more $$.
Need to incentivize earlier preventative care.
What does Aledade use to get savings that the quality metrics of CMS don’t capture?
- Access to primary care = telemedicine, scheduler as gatekeeper
- Point of Care = does the Dr know your history/potential health risks/what specialists you’re saying?
- Care compass = someone with very complex health issues or making end-of-life decisions may be out of the PCP’s scope
- TCM (transitional care management) = if a patient goes to the ER will the PCP/other providers have tools/time/workflow to call them and assist in transition/check in?
Has Aledade seen savings?
10-12% savings, working with CMS in the MSSP.
Looking at possible 15% savings for the most successful groups.
How do primary care decisions impact downstream care?
Primary care doctors impact referrals, imaging, procedures.
Providers often don’t think they’re responsible for controlling costs.
What is the burden of sickness like in the US?
Life expectancy is stalling, the burden of sickness is unevenly distributed due to socioeconomic factors.
Health policies need to address factors outside of the medical system that affect health.
How are structural changes in the economy affecting life expectancy?
3 factors driving the declining life expectancy:
- Worse circumstances for low income individuals (wage stagnation, increased inflation)
- Decrease in job opportunities
- Driven by automation, foreign trade, de-unionization
- Manufacturing decline - as plants close see a large increase in opioid deaths mostly among ppl w/ low education
- Unions - increases in unions = wage bump = better economic outcomes and lower mortality risks - Social safety net can’t support everyone
What are a few policy responses to boost health?
- Welfare not relying on employment status but instead poverty status
- Increasing minimum wage and uninsured benefits
- New age job retraining to deal with autonomation
- Environmental regulation
- Educational investments throughout the life cycle
What is Medicare Advantage? What does it cover?
Privately insured medicare, covers Part A+B+benefits and normally D with NO ADDITIONAL PREMIUMS.
Insurance companies contract w/ Medicare and receive payments PER PATIENT.
MA plans have narrower provider network and higher cost sharing but more additional benefits, like vision/dental/etc.
Is enrollment in MA decreasing or increasing?
Increasing, people like the additional benefits it offers with the $0 premiums.
What are a few financing problems the US is facing w/ the aging population?
Increasing beneficiaries for Medicare w/ increased volume/intensity of services for these beneficiaries = Medicare spending growth.
Spending on drugs increasing because of the increased average price for drugs.
What is MedPAC and what is its role?
MedPAC is a nonpartisan congressional agency that advises Congress and CMS on issues affecting Medicare.
- Has obligation to Medicare program
- Influences CMS through “threat of action” where CMS comes to MedPAC with an idea, MedPAC advises = MedPAC shaping executive policy
- House Ways & Means, House Energy & Commerce, Senate Finance
What are several key impacts due to MedPAC proposals (2)?
The inflation reduction act (2022) and the consolidated appropriations act (2021).
Explain the Inflation Reduction Act.
Explain the Inflation Reduction Act.
Restructured Medicare pt D so that plans take on increased insurance risk above the out-of-pocket threshold limit. Shifts the weight from beneficiaries to drug manufacturers, the ultimate goal is to reduce the cost of expensive drugs.
MA ptD beneficiaries will save with the IRA.
Explain the Consolidated Appropriations Act.
New designation for rural emergency hospitals to be critical access hospitals. There have been declining admissions at CAHs and they bill Medicare based on their costs, even if there’s a small number of patients.
MedPAC recommended these hospitals should act as outpatient only, paid on outpatient per service with a fixed subsidy for their operating costs.
Rural Emergency Hospital = critical access hospital w/ <50 beds
CAHs that become REHs can’t go back.
Have high deductible plans increased or decreased in enrollment? Why?
HDHPs have lower premium costs but very high deductibles, so adults enrolled in them are more likely to delay care due to the cost.
They’re increasing but this is employment based - directly purchased HDHP haven’t changed that much.
Which are the dominant employer plans?
PPOs are the dominant employer plans at 49%, and also have the highest premiums.
Larger firms can pay for HC through funds not insurance, smaller firms combine plans with stop-loss plans (re-insurance).
What are the 4 different types of payers?
- Nationals = for-profit, many lines of business, often contract with large employers
- Blues/Regionals = not-for profit, local density
- Local Players = for profit and not for profit, strong local density and community ties
- Specialty = usually not for profit with geographic breadth, focuses on care management for specific populations (ex. Military, Medicaid).
What is the difference between fully and self insured?
Self-insured is when the EMPLOYER bears the risk (ex. re-insurance) and the insurer is contracted for administrative services only.
Fully-insured is when the insurance company/PAYER accepts full risk and management of care costs, usually for smaller employers that can’t take on the risk.
What are the trends involving payers and consolidation?
Payers are more for-profit and are consolidating both horizontally (buying up other companies) and vertically (buying through value chain, not just insurance companies).
LESS regulatory scrutiny for provider consolidations, MORE for payer consolidations.
- If providers consolidate that means they have more negotiating power w the payer and this affects the payer’s profits.
What are private equity trends?
Private equity interest is growing and they are buying up doctor contracts/nursing homes/etc most commonly in the south.
PE buy-outs have corresponded with decreased quality of care.
How is MA enrollment changing?
Grown by 8% since 2014.
How did the government allow for Medicaid changes during COVID?
They allowed for expanded Medicaid enrollment so HUGE increases, but states now going through and disenrolling people.
Disenrollment = ACA exchange plan enrollment at an all time high.
What is driving the transition to EHRs? What are the status quo problems?
Need to limit medical errors and increase healthcare quality.
Status quo had a lot of missing results/lost records or missing problems/history.
What are concerns associated with AI application in HC?
AI has biases, particularly towards certain races/genders. There’s a fear AI may incorrectly label patients or ignore disease, false positives or negatives.
There is a concern about privacy norms and the lack of transparency in AI training and whether the information collected goes to a dataset. It’s hard to explain why certain things are suggested by AI - correlation not causation.
What’s a promising example of digital involvement?
Targeted automatic e-consults (TACo) works combat the resource intensive consult where physician referral triggers a specialist consult - not very efficient.
So identifies patients automatically via the EHR for common conditions that are straightforward for virtual consultation - this is triggered by objective data. Should be started w/ clinicians on limited # of services, then should get feedback and scale up the practice.
What’s the HITECH Act of 2009?
Promote the adoption and meaningful use of technology in health information. Really emphasized the value of the EHR and improved the use of + access to patient EHRs.
What is precision medicine? Give an example of this.
Precision medicine is tailoring care to an individual’s history, behavior, lifestyle, environment, genetics. Involves converting notes to computable data, combining with individual specific data and using AI to include future risks and recommendations.
PREDICT looked at a drug and flagged the patients who may need it, then they were genotyped to see if it would work for them! When they needed the drug it had already been determined whether they could have it - this avoids all barriers with starting a new drug.
Does tech contribute to clinician burnout?
Tech increases clinician burnout - think “click fatigue”. Really dis-empowers physicians and makes it extra work - they’re not able to take notes the way they want, but have to work within a system that’s created by 3rd parties.
What are the 6 elements of transformation for HC delivery?
- Catalyzing crisis - overcomes status quo and compels change
- Leadership pushes change forward - not sufficient to transform alone
- Culture, governance, physician engagement - values for change should be embedded in company culture and leaders should embody them
- Data + access to data
- Physician and management alignment
- Financial incentives - so everyone shares in the risk
How are e-consults beneficial for PCPs?
They’re beneficial for Medicaid patients and rural patients, because specialists are more likely to see them because of cost and access.
PCP can message reviewer who decides on referral = increased efficiency and decreased wait times.
Some PCPs say econsults increase their burden with low reimbursement.
Why should we focus on the physician office and behavioral changes?
Shifting burden to patient (ex. Price transparency) hasn’t worked, patients clearly have skin in the game but shouldn’t be responsible to lower the cost of care (they don’t make a lot of HC decisions, they often think more expensive = better quality).
Need to focus on getting physicians to eliminate low value, high cost care, unnecessary, inefficient. Physicians control referrals, prescriptions, hospitalizations, tests, etc.
How do we change physician behavior?
- Incentives - FFS offers status quo incentives, need financial incentives to counteract
- Infrastructure - need to make low cost/high quality options easier to choose to overcome laziness
- Information - Drs may not know how to change or may not have the information on what certain services cost
What are the key practices that should be changed?
- Scheduling
- Chronic Care Coordination
- Behavioral Health
Explain how scheduling is inefficient as it is, and how it should be changed. Provide 2 examples.
Currently, there’s a large no-show rate, very overbooked, no same-day appointments, long waiting times, limited patient satisfaction, high stress.
By centralizing scheduling to an off-campus handler the doctor/nurse doesn’t have to handle schedules, decreases waiting time, and set number of same-day appointments reserved for walk-in patients.
Ex. Cleveland clinic - centralized, off-campus call center with 14 walk-in clinics = LARGE INFRASTRUCTURE
Ex. Extended office hours - accommodate patients who need care after work/on weekends = reduction in ED visits = INCREASED ACCESS
How was chronic care coordination inefficient?
Hospitals aren’t very good at managing chronic illness, better at acute care management.
- Chronic care management needs many expensive specialists to coordinate and care in the US is FRAGMENTED for sicker patients.
- Patients require adherence to regimen and self management, proactive care, and coordination between providers. Polypharmacy is a HUGE problem with the risk of not taking meds as prescribed increasing with the more meds you take (HUGE for chronic care).
How can we change chronic care coordination? Provide an example.
To reduce chronic care costs:
1. Identify high risk patients
2. Embed care managers in primary care teams
3. Empower care managers to close care gaps
4. Use active outreach to contact the patient and improve compliance/access
5. Educate patients about their illness and how best to use the HC system
Geisinger Health System saved 7% through implementing chronic care coordination with consistent office visits, frequent check ups, education with results explained, contact with care manager to ensure adherence, extended office hours - DECREASED ED VISITS = SAVINGS.
How is behavioral health inefficient?
Behavioral health conditions are very expensive per patient basis and make other illnesses much harder to manage.
These patients can also be more expensive on the non-mental health side because (for example) if the doctor doesn’t soothe patients with anxiety about care/symptoms they may go to the ED to get a second opinion = higher costs.
How can we change behavioral health? Provide an example.
INTEGRATION W/ PRIMARY CARE
Advocate Health practices collaborative care model where primary care is in the same facility as behavioral health specialists and MA patients are screened for behavioral health. If they screen positive they are brought directly to behavioral health for follow up.
- Hard b/c of the shortage of mental health professionals
Why is there no political will to change in the Canadian HC system?
People think the system is just good enough, there’s no real revolt to make politicians change, status quo seems fine.
