HCI3 Exam 1 - Value-Based Care

providers, patients, employers, and payers

stakeholders in healthcare service models

25%

amount that waste accounted for of NHE in 2020

payment reform

requires an understanding of the risks and rewards adn knowing who bears the burden of risk between physicians, hospitals, and payers

enhanced patient experience, improving population health, reducing healthcare costs, and well-being of the care team

the four aims of Medicare

value-based care

healthcare delivery framework that incentivizes healthcare providers to focus on the quality of services rendered, as opposed to the quantity

quadruple aim

value-based care that provides better care for individuals, better health for populations, at a lower cost

volume over value

the focus on _____ (value/volume) over _____ (value/volume) has contributed to ballooning healthcare costs in the US

bundled payment

single predetermined payment for an entire episode of care; "controlling expenses impacts profitability"

charges

what practitioners, healthcare facilities, or pharmacists charge for a service, procedure, or product; may be higher than what is received back as reimbursements

reimbursement

payment rates and terms defined by insurers/payers; a negative impact is that this can drive "charge inflation" if it is defined as a "percent of a charge"

out-of-pocket

amount that the patient is charged at the point of care; places a degree of risk on the patient to encourage appropriate use of services

contract rates

determines reimbursement rates

diagnosis-related groups (DRGs)

physician or hospital is paid one sum for all services delivered during one illness; there is a different set case price for each of approximately 750 distinct DRGs

per diem

the hospital is paid for all services delivered to a patient in 1 day

fee-for-service

physician or hospital is paid a fee for each service provided

capitation

one payment is made for each patient's treatment during a month or year

provider

in a fee-for-service model, the ____ defines the charge

payer

in a capitated payment model, the ____ defines the max charge

entities

in a bundled payment model, ____ divide reimbursement

value to payer

in a value-based payment model, reimbursement is driven by the level of _____

true

T/F: employment-based private insurance is a tax-deductible business expense, and therefore subsidized by the government

Medicare Part A

"hospital and inpatient coverage"; at age 65 years and paid SSI for at least 10 years,

Medicare Part B

"outpatient medical services"; insures elderly for physicians' services through federal taxes and monthly premiums from beneficiaries

$147/month

premium that those with Part A can choose to pay for Part B

Medicare Part C

"Medicare Advantage Plans" (senior care) that can enroll in private health plans to receive benefits to cover A, B, and D

Medicare Part D

"medication or drug coverage"; voluntary prescription coverage that is added to original Medicare with deductibles that may not exceed $360/year

Medicaid

federally funded (50-76% of total costs) programs that are administered by the states

Affordable Care Act (Obamacare)

decreased the number of uninsured Americans and reduce healthcare costs through insurance reform

uninsured

not covered by insurance with fewer medical visits, increased mortality, and worse clinical outcomes during hospitalizations

provider

in a bundled payment, the _____ (payer/provider) assumes the risk

Accountable Care Organization (ACO)

network of organizations, facilities, and providers that uses a shared savings/risk approach to set aside financial reward to groups of providers or large healthcare organizations that attain a yearly benchmark spending goal and meet predefined quality standards

patient centered medical home (PCMH)

a model of primary care provider (PCP) coordinates treatment to make sure patients receive the required care when and where they need it, and in a way they can understand

pay-for-performance (P4P)

provides a financial incentive to providers who meet defined performance goals and usually the first step in transitioning toward more value-based care

false (organization or group of providers is better)

T/F: focusing on an individual provider produces improved focus and resources to increase quality of care

financial value

the price or worth of a good or service

utility value

the benefit, impact, or significance of a good or service

beliefs

values like principles or social values

[quality + service] / cost

value V = _______

ROI

return on investment = (net return on investment/cost of investment) x 100%

medication therapy management (MTM)

describe face-to-face patient assessment and intervention as appropriate by a pharmacist; optimizes the response to medications or to manage treatment-related medication interactions or complications

99605

MTM billing code for the initial 15 minutes of a new patient

99606

MTM billing code for the initial 15 minutes of an established patient

99607

MTM billing code for an additional 15 minutes

99496

CPT transitions care management (TCM) code for 7 day FU visit of high complexity

99495

CPT transitions care management (TCM) code for 14 day FU visit of moderate complexity

99490

CPT CCM code for non-complex 20 minutes, non-face-to-face with clinical staff

99439

CPT CCM code for non-complex 20 minute add on with clinical staff

99487

CPT CCM code for complex 60 minutes with clinical staff

99489

CPT CCM code for for complex 30 min add-on with clinical staff

99491

CPT CCM code for complex 30 min with provider

99437

CPT CCM code for complex 30 minute add-on with provider

comprehensive medication review (CMR)

annual, full medication profile review MTM consultation

targeted medication review (TMR)

interim, specific issue resolution MTM consultation

3 or more chronic conditions or at least 8+ medications

MTM eligibility criteria include patient-specific criteria of _______ or are at-risk beneficiaries as defined by 42 CFR statute 423.100

RUC or market valued

code valuations are determined by ______

product or service

CPT coding is used for ______

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-Based Incentive Payment System (MIPS)

transforms the basis of healthcare clinician payment from volume to value, created the Quality Payment Program (QPP) to determine physician and other clinican FFS payment rates in Medicare and created the MIPS

HEDIS

drives provider reimbursement established by the NCQA and focused on the practitioner and organization quality for reimbursement

star ratings

helps patients "select a plan" and is focused on helping the consumer evaluate health plan selection based on quality

prospective DUR

pharmacist reviews teh patient record and each NEW and REFILL prescription presented for dispensing in order to promote therapeutic appropriateness by identifying over-/underutilization, duplications, drug-disease contraindications, drug-drug interactions, incorrect dosage or duration of treatment, drug-allergy interactions, and clinical abuse/misuse

true

T/F: a pharmacist is REQUIRED to take appropriate steps to avoid or resolve problems, including consultation with the prescriber, upon recognition of a problem in a prospective DUR