US. Health exam 3 nations, literacy, conflict, digit. Flashcards
Germany
Mandatory sickness funds
Predominantly private
Government-mandated, employment-based private insurance
7.3% is employer responsibility; 7.3% withheld from pay; equals 14.6% for each employee
2009-government run health fund distributes health funds based on risk adjustment
Not allowed to exclude, or raise rates according to age or medical condition
Remain in fund if ill, retired, lose job
Higher income can select private insurance
Germany: Medical Care
Appointments with Primary Care is common
Allowed to make appointments with specialists without a referral
Over 40% of physicians are generalists
Little coordination between hospitalists and generalists
Appointments, labs, prescriptions, hospitalization=No bill to the patient
Germany: Payment Structure
Primary physician Bills regional Association of Physicians
- 1986- began to cap spending- Rationing
- Physicians are reviewed quarterly, with each quarter affecting the following quarter
Hospitalists bill via Episode- Based funding or Bundle payment
Germany: Cost Control
Concerted Action
- Guideline Fees
- Hospital Rates
- Pharmaceuticals
Controls physician fees, capping physician fees
Throughout time still Germany has Gross Domestic Product (GDP) that has been rising since 1990
Canada: Overview
Health insurance: show provincial government card
Hospital Insurance Act: Hospital coverage but no MD coverage
Universal medical insurance 1966
Tax financed, public, single-payer health care system
Funded with provincial and federal tax revenues
Not attached to employment at all
Everyone contributes through taxes-everyone benefits
No bill if part of provincial health service
Private insurance allowed for gaps: some pharmaceutical coverage or private hospital rooms
Canada: Medical Care
Family physician referral to specialist
Specialists get paid best if referred
Longer waiting for elective procedures
Less services per capita than US for example: MRIs and surgery
Despite everyone being covered, inequities still happen
US (days) vs. Canada (weeks): Long Waits
canada waits longer
Canada: Payers/Payment
Physician bills provincial government (and the government pays using the taxes!)
Paid in full according to fee schedule
Physicians must agree with payment, cannot bill patient
Blended models
Fee-for-service
Capitation
Hospital services slow-not enough money to pay extra
Hospitals do not need to prepare itemized bills
Approval process for capital projects of hospitals
Regulation of pharmaceutical prices
Canada: Cost Control
Canada vs. US
- Less administrative costs
- Less expensive high tech costs
- Lower pharmaceutical prices
Caps on payment (Similar to Germany)
Changes in 2010 due to lack of confidence
United Kingdom: Overview
Being on the “soil” entitled to receive tax supported medical care through NHS –National Health Service
Private health insurance can compete with NHS
11% buy private health insurance
Private insurance can pay for care of private hospitals not NHS facilities
United Kingdom: Medical Care
NHS – need referral to specialist
Must have general practitioner
GP is primary care, local hospital is secondary care, regional/national hospitals is tertiary care
GPs not in hospitals, but with social services
Home care is highly developed in UK
United Kingdom: Payer/Payment
Capitation for MD
Preventive care fee for service
Home visits, nights and weekends, fee for service
Consultants=Specialists
Quality is awarded
United Kingdom: Cost Control
Queues lengthened
Capitation and salary for physicians
Limited consultant slots- controls supply of personnel and facilities
Fewer surgeons
Fewer meds
Fewer x-rays
More skeptical of new technology than US
Japan: Overview
Large companies- required to operate self-insured plan for employees and dependents
Smaller companies-single national health insurance plan
Self-employed workers and Retirees- National Health
Insurance or Citizen’s Health Insurance
Government workers- society managed insurance
All have standard comprehensive coverage
Mix of employment-based insurance, social insurance, universal insurance
Japan: Medical Care
No pre-authorizations
No restrictions
Less hospitalizations
Less surgery
Longer hospital stays
Japan: Payer/Payments
Fee-for service was the basis
2003 hospitals paid per diagnosis, physicians still paid fee-for-service
Government strictly regulates physician fees, hospital payments, medication pricing, number of expensive services
Physicians have high volume of seeing patients
Average physician visits: 13 per capita in Japan versus 4 per capita in US
Physicians may see 60 patients in a day
Physicians can dispense medications and profit from medications dispensed
Some patients see physicians just for refills
Japan: Cost Control
GDP increasing 7.7% in 2000 to 10.3% in 2012
Healthcare system relies greatly on employer taxes
Low birth rate and longer life expectancy is problematic for this structure
Japan estimated 65 and older population is projected to increase from 12% 1990 to 39% in 2050
US 65 and older population also growing but not as quickly from 13% in 1990 to 21% in 2050
Costs are contained with strict fee schedules but may not be able to sustain with older facilities and potential underfunding of the healthcare system
the U.S is a world outlier when it comes to spending
spends a lot on health care
the U.S is the only high inncome country that does not guarantee health coverage
the U.S spends 3 to 4 times more on health care than south korea, new zealand and japan
the U.S has among the lowest rates of physicians visits and practicing physicians
hospital stays are shortest in the netherlands and the U.S
the U.S has amongst the lowest number of hospital beds
the US spends more on admin. costs but less on long term healthcare than other wealthy countries
Secondary Features of National Health Insurance Plans
Benefit Package: What is covered or what is NOT covered? Just emergency care or is prevention care covered? Are prescriptions covered? Think about discrepancies such as women’s health?
Patient Cost Sharing: What is covered or what is NOT covered? How much are copayments, coinsurance, premiums, deductibles? Is there a maximum out of pocket? ACA has high cost sharing is a criticism of the system. Single-payer models tend to have low cost sharing.
Effects on existing health care coverage: National health care needs to look at all current health care options and understand effects on each type of coverage for example Medicare, Medicaid.
Cost Containment: Many models exist, including patient cost sharing, limiting percentage of health care premiums that can be retained for overhead and profit, review of medical loss ratio, or the amount of claims being paid for actual health services.
Reform Health Care Delivery: Expanding roles of nurses, pharmacists, and other health care providers, development of Accountable Care Organizations, financial incentives for rewarding higher value care.
what were the results of the favorite label survey
patients liked the label with
- largest lettering
- most space
- easy to read directions
things to know abt literacy and numeracy
make everything up to a 5th grade reading level
literacy: reading and understanding
numeracy: able to calculate how much insulin they need or how much sugar they take in from a meal that could effect blood sugar
Patient Literacy Assessment Tools
Diabetes Numeracy Test
REALM-R: Rapid Estimate of Adult Literacy in Medicine, Revised
Short Assessment of Health Literacy–Spanish and English (SAHL-S&E)
Health Literacy Readability Assessment Tools
SMOG (“Simple Measure of Gobbledygook”) Readability Test
- make shorter sentences
- sentences with less syllable
Fry Readability Test
- out of 100 words, how many sentences and syllables are there
Flesch-Kincaid Grade Level Readability Formula
- average number of words used per sentence.
- average number of syllables per word.
SAM (Suitability Assessment of Materials)
- Content
- Literacy Demand
Graphics
Layout and Typography
Learning Stimulation and Motivation
Cultural Appropriateness
Each category rated
Making a Difference
What are some of the issues with over-the-counter labels?
crowded
hard to read
small lettering
Health Literacy and….
Drug Coverage
Prescription Label Instructions
Four Major Actors in Conflicts, Change, Tensions, and Challenges
purchasers
insurers
providers
suppliers
took us through 80 years of healthcare
Conflict of the actors and dollars
Insurers, providers, and suppliers make up the health care industry.
Previously:
Gain for health industry Thought of as an investment in economics of the nation
Now:
Too much to pay, purchasers want to reduce the amount spent while health care wants the number to increase
Provider-Insurance Pact 1945-1970
Alliance of insurers and providers
– Many independent hospitals
– Lack of competition
Hospitals and insurers decided payment provisions of Medicare and Medicaid
– Providers had the “upper hand” in negotiating generous payments
– Insurers paid without much question
* so providers benefitted and insurers did too
Employers paying for insurance and receiving tax benefits; no real complaints of increased costs
Businesses growing and profitable
Able to pay for benefits
Hospitals even charged for facilities and new construction
everyone was benefitting!!!!!
Changed Perception of 1970s
US share of world industrial production decreasing from 60% in 1950 to 30% in 1980–decline!
- Lower profits
- Purchase cash flow decreased
- Inflation and unemployment on the rise
New economic reality of less money for individuals and companies, becomes increased concern for the rising costs of health care
- Hospitals being regulated for new construction
- Government begins health planning agencies
Regulation begins after Blue Cross increase of premiums 25% to 50% in a single year
Utilization reviews begin by insurers
- Provider-insurer tensions rise
- Insurance-provider pact unravels-Blue Cross separates from the AHA
benefitting:
- purchasers are not benefitting
- insurers are benefitting
- providers are not benefitting, things are tightling up for them, more regulation for them. 50/50 benefit
- suppliers are not benefitting
more regulation and more changes
so really insurers are benefitting
1980’s Purchasers Pay Attention
Costs increase for employer-sponsored health plans
By 1989 =20.4% of business expenses (it was a fraction of the cost from1945-1970)
Almost a double increase (from 5% to 9%) of payroll spent on health care benefits
Business more attentive to costs and health care issues
Large companies start self-insurance More companies use managed care options such as HMOs as cost-control Individuals and labor unions see shift of costs to them; complain of health care costs
Rising premiums and policy cancellations for those with chronic illnesses become media headlines; people with cancer get dropped
Selective contracting of purchasers = In-network and Out-of-Network
Insurers choose providers to contract with (those that provide cost containment) Shift from fee for service to capitated reimbursement-causes providers to cost-control as well
Medicare payments are tighter controlled and Medicaid is scaled back
benefitting
- purchasers are not benefitting; speding more and being dropped from coverage if they have cancer
- insurers are benefitting due to HMOs and such
- providers are not benefitting because there are less people covered and sign contracts
- suppliers…not clear but we can guess that there is not a big increase and that they are pretty steady
Coverage Landscape Changes-1990’s
what changed about the plan
what do employers do.
what happened to providers
what did purchasers have
Plan become very specific as to where and from whom care can be provided and covered
Employers shop around more for insurers
Providers would lose contracts due to poor rates and unwillingness of insurers to negotiate
Purchasers had some negotiating power with HMOs and saw a drop in premium growth in the earlier 1990’s
benefit
- purchasers benefit
- insurers 50/50, more competitionn
- providers are not benefitting due to contracts and rating
- suppliers pretty much the same, nothing happenigng for them
2000’s
what do providers and insurers doo
Counter-revolution by providers/Consolidation in health care market
Provider and insurance negotiations are intense
Costs accelerate especially for the individual employee-Premiums and deductibles rise 34%
Large HMOs emerge due to buy-outs and consolidation
Growing power of specialists and specialty services
For-profit services, physician owned imaging facilities
Specialist physician groups grow and negotiate for higher payment rates from insurers
Ambulatory centers for day surgery and clinics grew and are physician owned
Hospitalists are a growing specialty
benefit
- providers finally have the upper hand and are benefitting
- suppliers are benefitting too, more equipement due to more small offices
- purchasers and insurers are not benefittng
2000’s
Pharmaceutical industry criticisms
- 1988 Rx was 5.5% of national health expenses versus in 2009 10.1
- Shift of insurance coverage of Rxs occur; Insurances take notice and begin to challenge pharmaceutical costs; Tiers begin
- Most profitable companies: earning 20% of revenues compared to other Fortune 500 companies that earn 5% of revenues
No regulations by government to regulate prices
Brand to generic tactics to continue market share-Hatch-Waxman Act
- with the act there is 6 months and then manufacturers can add their generic products
Generic manufactures are consolidating driving up generic costs
“Evergreening”- Immediate release vs extended release after/close to 6 monhs time to extend their branding for longer than 17 years
– Rx to OTC
trying to cost control
Pharmacy Benefit Managers (PBM)
- Part of the supply chain and responsible for formularies
- billing
benefitting
suppliers benefit
2000’s
Primary Care Shifts
Primary care practices looking at capitation versus fee-for-service
Choosing Wisely campaign spotlights overuse of health care
- might nt treat an older adult because it is not appropritate to do that
- ex: don't do mammogram yearly for elderly that are 80 y.o +
Payment for value versus volume
Patient-Oriented care on the rise
Primary care teams are forming
The Perfect Health Care System
Noble aspirations but most likely impossible to attain 100%
Important factors of health care system:
- Improve health
- Control costs
- Prioritize allocation of resources
- Enhance quality of care
- Distribute services fairly
everyone would benefit!
Blurring of the Actors
Insurers acquiring Providers: UnitedHealthcare acquired DaVita Medical Group
Providers acquiring Insurers: CVS merging with Aetna
Providers acquiring Suppliers: CVS merging with Caremark
Insurers acquiring Suppliers: Cigna merging with ExpressScripts
Companies moving into health care: Amazon
in US
Shortage of primary care providers with substantial health deserts.
Mental health providers in sharp decline despite a growing need.
Many conditions have increased during the pandemic.
Report Increase in Symptoms
- 67%
Additional Barriers to Care
60% of mental health providers cannot take new patients
Additional Barriers to Care
Travel costs and arrangements
Childcare
Time off work
Therapy costs and insurance coverage
RISE OF HYBRID CARE MODELS
In person care
virtual care
IN-PERSON CARE
- Patients will need care in hospitals, rehabilitation centers
- Majority of diagnostics & acute treatments will be handled in person
- Health systems will adjust what services offered
VIRTUAL CARE
- Expansion of care models to embrace treatment of patients remotely where available
- Scale up the use of technology to triage patients for in-person or remote care where applicable
- Use of technology to collect and measure data remotely or provided digitalized treatment options
HEALTHCARE IS CHANGING
what have patients adopted
what is home considered
how can providers meet patients
Patients have adopted a consumer mentality towards engaging in their health seeking to meet their needs on demand.
Home as the center of health is a quickly growing area of focus in medicine including the ‘Hospital at Home’ model
Meeting patients where they are at is a growing healthcare business structure across multiple care modalities.
progression of health and digitalization
E-Health
- Rise of the Internet
(1990s)
mHealth
- Integration of IoT
(Early 2000s)
Digital Health
- Wearables and more
(2010s to Present)
Why Digitalize Healthcare?
Digital tools are giving providers a more holistic view of patient health through access to data and giving patients more control over their health.
Digital health offers real opportunities to improve medical outcomes and enhance efficiency.
They can help address the following issues:
- Reduce inefficiencies,
- Improve access,
- Reduce costs,
- Increase quality, and
- Make medicine more personalized for patients.
DIGITAL HEALTH TECHNOLOGIES
Enterprise System
& Support
- Platforms for healthcare systems, clinics, and enterprise settings.
Clinician Services & Support
- Platforms for clinicians and healthcare staff such as EHRs (Electronic health record).
Patient-Facing Wellness
& Support
- Products that capture, collect, store, or transmit patient health-related data.
Patient-Facing Diagnostics & Monitoring
- Products that diagnose, guide diagnosis, or actively monitor patients health.
Patient-Facing Therapeutic Interventions
- Products that deliver medically therapeutic interventions for patients.
As of 2021, nearly 4 in 5 office-based physicians (78%) and nearly all non-federal acute care hospitals (96%) adopted a certified EHR. This marks substantial 10-year progress since 2011 when 28% of hospitals and 34% of physicians had adopted an EHR.
TELEHEALTH
where does provider access patient
Telehealth — sometimes called telemedicine — lets your health care provider care for you without an in-person
office visit. Telehealth is done primarily online with internet access on your computer, tablet, or smartphone
.
Talk to your health care provider live over the phone or video chat.
Send and receive messages from your health care provider using secure messaging, email, and secure file exchange.
Majority of payers cover telehealth services for members
Expansion of services available pre-pandemic
Mental and psychological health over state lines
Remote Patient Monitoring (RPM)
what do devices monitor
what can RPM be used for
Devices monitor physiological data from patients
CPT codes for setting up and monitoring data available from CMS
RPM can be used for many conditions that require physiological data indicative of disease management
Some patients will need in-person testing, diagnostics, or monitoring. This depends on their condition, Internet capabilities, or personal preferences and abilities.
But there are many ways that remote patient monitoring can help with chronic conditions, pregnancy complications, and short-term illness.
High blood pressure
Diabetes
Weight loss or gain
Heart conditions
Chronic obstructive pulmonary disease
Sleep apnea
Asthma
Remote Therapeutic Monitoring (RTM)
what is it a combination of
what can it include
Combination of technology like RPM devices and disease management for therapeutic outcomes
This can include medication adherence and physiological data
Interventions can include education and coaching
Currently, CMS covers pulmonary and musculoskeletal conditions
CPT code 98976 - RTM (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days.
DIGITALIZATION OF DEVICES
- Integration of health devices into the ‘Internet of Things (IoT) landscape
Approaches include:
- Integration of Bluetooth to tether to an external device (e.g., smartphone or peripheral)
- Wireless integration (e.g., cellular, WiFi)
Mobile app integration for data collection and user engagement
Enabled the movement towards:
- Remote Patient Monitoring (RPM)
- Remote Therapeutic Monitoring (RTM)
Ongoing Issues:
- Accuracy, data interoperability, coverage, patient education, user adherence
RISE OF CGM
Increased desire amongst PwD to utilize CGM ( continuous glucose monitor) over other BGM (Blood Glucose Meters) interventions due to fewer finger pricks and convenience
Visually impaired patients have benefited from easier BGM
Digital affinity closely related towards acceptance of the use of CGM technologies
This is likely to increase over time with digital natives
Increased recommendation of CGM use in clinical practice guidelines influencing clinician behavior
Limitations still present:
- Cost barriers
- Clinician and patient buy-in
- Technology barriers
SMART BLOOD PRESSURE WATCH
Cuffless blood pressure monitors integrated with a smartwatch form factor have been gaining traction
Some technologies to facilitate BP/HR measurement include:
- Wrist-worn watch-type oscillometric BP monitoring (WBPM)
- Waveform measurement
Accuracy has been a concern and has limited integration within clinical practice guidelines
- Likely due to the variable sensitivity of BP measurement through location and patient difference
Technology continues to evolve and improve
FOOT SENSORS
Utilization of sensors that PwD can utilize to detect the development of foot ulcers in the presence of neuropathy
Several pathways:
- Image capture of the foot (camera)
- Temperature sensor (socks with embedded sensors, smart mat)
Aim to remotely monitor high-risk patients for ulceration and reduction of foot infections
SMART TOILETS
In May 2023, the FDA cleared a smart toilet seat to measure heart rate and SpO2 in adults at least 22 years of age weighing 90 to 350 pounds.
R&D is ongoing to create smart toilets that can measure biometrics, which could also:
- Track renal function
- BGM
- Medication adherence
- BP/HR
Data can be collected via:
- Excretion collection (stool & urine)
- toilet seat sensors
Passive Monitoring vs Active Intervention
Passive Monitoring
- Continuous Patient Outcome Assessment
- Real-Time Patient Adherence Tracking
- Real-Time Patient Data
Active Intervention
- Establish New Patient Goals
- Adjust Care Plan
- Remote Intervention
hospital at home model
ER/Provider identification of valid patients
conditions of defined treatment protocols
- HF, COPD, CAP, cellulitis
patient’s home is within hospital range to provide emergent care
Home as the center of health is a quickly growing area of focus in medicine including the ‘Hospital at Home’ model
home must have space and fit patient needs (ex: food, heat/cooling, water)
health staff visit patient in the home (ex, respiratory therapist, nursing)
tests conducted in the patient’s home and therapy (ex: medications) given as well
RPM will play a significant role
PROGRAM IMPLEMENTATION BARRIERS
Education amongst multiple sites to have a cohesive approach to patient care
Leadership buy-in beyond the idea but providing logistical and staff support to allow the programs to develop (upfront investment)
Time and training for staff (turnover) that had no prior exposure to RPM/virtual care
- As education evolves, it should diminish
Leveraging ancillary staff (CDEs, Pharmacists) can help alleviate cognitive loads and expand workload
Launching RPM/Virtual services requires an initial evaluation of on-site needs and implementation considerations
PATIENT BUY-IN
Modules related to diabetes education be enhanced and personalized for the individual rather than a set approach
Patients have variable health literacy and needs
Technical and physician support when adopting telemedicine
Onboarding patients may be what makes sure that patients will want to commit and engage or abandon
Data use needs to be explained (privacy & security)
Patients also express the importance of having a sufficiently flexible platform that could be adapted to their needs
RPM technology options account for patient diversity and technical support and education
Virtual care will not be for everyone and SDoH may be a barrier that needs to be addressed for adoption
PAYER COVERAGE CONCERNS
Scope of RPM and telehealth services are still in flux post-pandemic
Concern related to reimbursement models and incentives for providers to utilize RPM/virtual care models vs in-person services due to margins
Increased risk of fraud of overbilling for services utilizing RPM and telehealth services
Codes (CPT) for RPM and RTM for diabetes management
Coverage for RPM devices and OOP costs
- Many studies gave devices for free or limited duration
Many employer-based programs are exploring the use of standalone DM-focused programs
what is the difference between remote patient monitoring vs remote therapeutic monitoring
RTM enables patients’ self-reported data and digitally uploaded non-physiologic and therapeutic data.
RPM, on the other hand, requires physiologic data that is automatically transmitted and not manually uploaded.
scenario
Lydia knows she is sick. She doesn’t know what it is, but she wants to feel better. But, how will she seek care?
WHAT ARE LYDIA’S OPTIONS?
Schedule a visit with her PCP
good:
- provider knows her
- prior billing set up
bad
- may not have availability
Go to urgent care clinic
good:
- Increased likelihood of being seen in person
bad
- Likely will have to wait
- Complete medical history may be unavailable
Use a telehealth service
- Can ‘meet’ at her personal convenience
- May only cover certain conditions
- May be referred to in-person
THE RISE OF DIGITAL HEALTH TECHNOLOGIES
- Omnimetrics of Health
- Biosensors and Wearable Devices
- Smart Precision Medicines
- Mobile Integration
- Continuous Feedback Loops
- Scalable Services
Drug Delivery System Milestones
1970 - insulin pumps come to market
1980 - insulin pens come to market
1990 - smart insulin pump development
2000s - rise of med adherence apps, GLP-1 agonist autoinjectors come to market
2010s - 2020s-
- smart insulin pens widley available
- first insulin dosing DTx cleared
- first bluetooth connected BGM approved
- rise of connected CGM devices
STATEWIDE RPM PROGRAM MODEL (SC)
RPM program to improve the management of type 2 diabetes in low-income and rural populations, to identify patient-level variables that influence the likelihood of achieving HbA1c reduction at 6 and 12 months.
Patients included A1c > 8.0% and enrolled in community clinics
RPM Process:
- 2-in-1 blood pressure and glucose-monitoring device (FORA D40g)
- 4G cellular connection
- Central hub (academic center) oversaw training for clinic staff to handle data and adjust therapy
Results (2017-19)
- A1c reduction of 1.8% at 6 mo (n=302)
- A1c reduction of 1.3% at 12 mo
- (n = 125)
- Rural and underserved populations achieved significant improvements in HbA1c
- HbA1c reductions were sustained at 6 and 12 months of RPM program participation
- Patients of varying demographics and clinic types achieved similar clinical benefit
weak AI vs strong AI
used in different areas of medicine
LOOKING TO THE FUTURE
AI INTEGRATION
PAYER COVERAGE EXPANSION
IoT INTEGRATION
RWE INTEGRATION
VR/AR TECHNOLOGIES
DRUG + APP
REGULATORY OVERSIGHT
DIGITAL FORMULARIES
Germany
Payment PCP
Cap spending
Care from PCP
No bill, no referrals
Canada
Hospital insurance act but no MD coverage
Specialty referral and specialists get paid more if they are referred
Long wait
less service per capita
Tax financed insurance
U.K
Staff supported care
Private insurance, private hospital only
Need referral to specialist
Need PCP
Home care is highly developed
Longer queues
Limited consultant slots
Fewer surgeons, X-Rays
More sceptical to new technology
Japan
Pay from employer
Retiree pays a premium
No pre authorization or restraints
Less surgery, less hospital stay
Longer hospital stays
Low birth rate and longer life expectancy
