HCI - M4: Value-based care

What is driving costs in healthcare spending?

Appropriate spending

Poor practice activities

Operational inefficiency

Individual behaviors

What is a payment reform?

A type of payment that that rewards healthcare workers for better patient outcomes and quality of care, instead of paying for the service (fee-for-service)

What does a payment reform require an understanding of?

Risks and rewards of the provider and knowing who bears the burden of risk

What type of care has the lowest risk tolerance?

Fee-for-service with performance incentives

What type of care has the highest risk tolerance?

Full capitation

What is the quadruple aim of Medicare

Patient satisfaction

Outcomes & Safety

Total cost savings

Provider satisfaction

What is value-based healthcare?

A framework that makes healthcare providers to focus on quality of services instead of quantity

What goverment organization supports the quaruple aim?

Centers ofr Medicare and Medicaid Services (CMS)

What has factor has driven the uprise in the costs of healthcare?

Focus on volume over value

What 5 things must you do in order to implement value-based healthcare?

Identify patient population

Design a care model with metrics

Interdisciplinary work

Drive and documentation of outcomes

Quantify impact and continuous improvement

What are charges in health care costs?

What providers will charge for a service; may be higher than was is received back as reimbursements

What are reimbursement in health care costs?

Payment rates that is defined from the insurers

What can reimbursement drive that negatively impacts the patient/consumer?

charge inflation; also defined as a "percent of charge"

What is the Diagnosis-Related Groups (DRG) Health Provider Reimbursement Model?

Physicians or hospitals are paid in one sum for all services that is provided

What is Per Diem in Health Provider Reimbursement Model?

Hospital is paid for ALL services given to a patient in ONE DAY

What examples provide per-diem reimbursement models?

Private insurances, PPO/HMO

What is Fee-For-Service in Health Provider Reimbursement Model?

Physician or hospital is paid a fee for EACH SERVICE

What is capitation in Health Provider Reimbursement Model?

One payment is made for each patient's treatment during a month/year

T or F:

Employment-based Private insurances is a tax-deductible business expense

True

- The gov does not treat the health insurance deduction as taxable income to the employee

Medicare Part A

Hospital & inpatient coverage

Medicare Part B

Outpatient medical services

Medicare Part C

Medicare Advantage Plans (Senior care)

Medicare Part D

Medication or Drug Coverage

Who is included in Medicare Part A?

- > 65 YO patients who paid > 10 years of SSI

- < 65 with permanent disability within 24 onths of disability

- ESRD on HD

T or F:

Medicaid services vary state by state, but it is federally funded

True

What are the two models of bundled payments?

Patient centered medical home (PCMH)

Accountable care organization (ACO)

What are bundled payments?

A single payment to a provider for all services associated with a treatment/condition

- the prices are risk-adjusted

What are Patient Centered Medical Home (PCMH)?

A group of providers that cooperate together

What are accountable care organizations (ACOs)?

A network in an organization that uses a shared savings/risk payments that meets quality standards that was created under Obamacare - example) BayCare Health Systems

What are pay-for-performance (P4P)?

Giving financial incentives to providers who meet performance goals

In a bundled payment model, who assumes the financial risk; provider or the buyer (patient)

Provider

T or F:

When focusing on just the individual provider actually produces a change in the improvement of care for patients

False

How does financial risk shift to the provider in a Capitation reimbursement model?

If a patient happen to have/need more care than the average patient and the services provided exceed the total payment that was reimbursed to the provider

In the shared risk reimbursement model, what are the financial risks and provider integration?

High financial risk and high degree of care provider integration

In the primary care incentives reimbursement model, what are the financial risks and provider integration?

Low financial risk and low degree of care provider integration

Medicare is _____ funded and _____ administered

federally; federally

Medicaid is ________ funded and _____ administered

federally/state; state

Which reimbursement model used to represent HMOs, but are rarely used?

Capitation

What are the qualifications for Medicare beneficiary eligibility for MTMs?

> 3 or more chronic conditions

> 8 medications

Medication costs are ANNUALLY estimated to be more than the MTM services

All "at-risk" beneficiaries with active coverage limitations

In Transitions Care Management (TCM), what are the CPT codes for patients and how many days is it?

99496 - 7 Day FU Visit for HIGH Complex conditions

99497 - 14 Day FU visit for MODERATE complex condition

In Chronic Care Management (CCM), what are the CPT codes for the CLINICAL staff?

Non-complex - 1 chronic condition:

- 99490: 20 mins of non-face-to-face

- 99439: additional 20 mins (max 2xMonth)

Complex - 2 or more chronic conditions:

- 99487: 60 mins

- 99489: additional 30 mins; no limits

Annual Medication Reviews are done....

Annually

Targeted medication reviews are done....

at least quarterly

In the fee-for-service reimbursement model, what are the financial risks and provider integration?

Low financial & low degree of care provider integration

In the capitation plus performance based contracts reimbursement model, what are the financial risks and provider integration?

High financial & High degree of care provider integreation