daniel B mclaughlin guide to healthcare reform

Business in Healthcare class 1

-effects of Obamacare

-looks at prevention not treatment of disease

-clinical prevention KEY in all aspects of nursing

-Lifestyle and Demand Management

-clinical prevention-routine provision of tests and services to prevent disease or uncover in early stages (demand management)-keep individuals well in community

-Individual wellness-maintenance of healthy lifestyle.diet exercise, avoidance of risky behaviors (lifestyle management)

-community building-creating communities that encourage healthy living and strong personal relationships and caring (Lifestyle management)

-educate patients to stay well

-systems view of prevention, wellness, and community

State gov

Executive branch

-governor

-attorney general

-lieutenant governor

-Secretary of state

-auditors

-commissioners

Legislative Branch

-senate

-house of rep/assembly/house of delegates

Judicial branch

-supreme court

NJ only state with Charity care

Prevention services in the ACA-establishes National prevention, health promo, public health council

-school based clinics

-oral health programs

-medicare benefit for an annual wellness visit and personalized prevention plan, removes coinsurance and deductible payments for preventive services of medicare

-preventive services for Medicaid recipients are increased

-elimination of cost sharing for preventative services in private insurance

-communit preventative services task force-focuses on population helath

-preventative services task force continues

Preventative Education

-Healthy behaviors education campaign

-restaurants with more than 20 locations required to post nutritional content of standard menu items

-school-based wellness-meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents

Wellness

-an active engagement in routine exercise

-healthy diet

-avoidance of risky behaviors Ex) smoking, drinking, drug abuse, driving without seatbelts

Biometric-Based Wellness

-allows employers to reward employees who meet goals with refund of up to 30% of premium costs. Can be raised to 50% in future

-Medicaid financial incentive for wellness available

-Goals frequently used by employers

-BMI-Cholesterol levels

_blood pressure

-No smoking

Community Building Transformation Grants

-Healthier school environments: Healthy food options, physical activity opportunities, promotion of healthy lifestyle, emotional wellness programs, prevention curricula, and activities to prevent chronic diseases

-access to nutrition, increased physical activity, encourage not smoking, improved social and emotional wellness, and enhanced safety in community

-work-site wellness programming and incentives

-healthy options at restaurants and other food venues

-reduction in racial and ethnic disparities, including social, economic, and geographic determinants of health

-inclusion of all age groups and invididuals with disabilities, and individuals in urban, rural, and frontier areas

Community Benefit Reporting

ACA requires Tax-exempt charitable hospitals to:

-Conduct community health needs assessment every two years

-adopt a written financial assistance for hospital care

-refrain from taking extraordinary collection actions against a patient until the hospital has made reasonable efforts to determine whether pt is eligble for financial assistance

Population Health and US healthcare

-health is state of complete physicial mental and social well being and not merely absence of disease or infirmity

Pollution health management’s goal is to improve health of population

Case for population Healh management

-Demographics- 1 in 5 Americans will be over 65 by 2030 in US

-Increase in culturally unique communities

-increase in culturally unique communities

-increase in chronic disease

-fragmentation of care system

-emphasis on acute care and fee for service

-payment disconnected from long term outcomes

Population management framework

-find target population

-select strategies

-lifestyle, demenad, disease, catastrophic, and disability

-then execute and monitor

Critical support needed

-incentive alignment

-IT

-Communication and coordination

-committed patients and providers

-excellent clinical acute acre

What is to be managed?

Healthy People 2010 Indicators

-physical activity

-obesity

-tobacco use

-substance abuse

-responsible sexual behavior

-mental health

-injury and violence

-environmental quality

-immunization

-access to healthcare

Goals of Management

-Health as defined by WHO

-Healthy People 2010

qq-Triple Aim

-cost

-experience of Care

-popilation health

Definitions of population

-age, income, geography, community, employer, insurance coverage,

Health status

-utilization patterns

-specific disease

-Site of care

Data for Population Health Management

Sources

-Health plan membership data

-employer data

-administrative and claims data

-clinical data

-electronic records

-individual surverys

Issues

-Ownership

-privacy

-physical access

-integration of access to healthcare

Risk Identification Triggers

-Rate of hospitalization

-Readmissions

-ED visit

-Clinic visits

-Diagnosis and procedure codes

-Repeat hospitalizations within one year

Population health Management

-lifestyle

-demand management

-disease management

-catastrophic care

-disability management

Lifestyle

-prevention

-health behavior change

-education

-motivation-psychological rewards

-financial

-training

-marketing- smoking cessation

-effectiveness of programs

Examples- Smoking cessation, injury prevention, employer-based programs, participation-based, biometric

Demand Management

Goal-reduce level of inappropriate or unnecessary demnd for clinical service Ex) antibiotic use, C section

Issues:

-Morbidity level

-perceived need

-patient preferences

-non-health motives ex) attention

Predication for target populations

-claims data

-clinical information

-patient questionnaires

Demand Management Strategies

-telephone-based triage and decision support

-selfcare via education or internet

Risk and Rewards

Risks-inappropriate redction in needed clinical services

-chronic disease management impaired

-legal issues and accreditation of programs

Benefits-patient empowerment

-clearer expectations of care

-better understanding of system

-cost reduction

Chronic Disease and Need for Management Highest order

-High bP

-high cholesterol

-ischemic heart disease

-arthritis

-diabetes

Disease Management Providers

-Health plans

-providers and related ACOs

-employers

-behavioral health

-medicaid

-stand-alone organizations ex)Optum

Focus on Disease Management

-high volume of services used

-preventable complications (inpatient, ED)

-can be managed as an outpatient

-complex referral patterns, multiple providers

-well accepted care guidelines

Patient issues

-patient engagement and compliance

-education and health literacy

-healthcare beyond clinical services (Skype)

-predictive analytics-how to tell pt they are going to be sick?

Catastrophic Illness Examples

-Cancer

-ESRD

-rare diseases

-ALS

-trauma and severe burns

Catastrophic Care Management

-Immediate referral

-development of a care plan

-medical management by experienced professionals-centers of excellence

-individualized patient management

-patient and program satisfaction

-multispecialty vs. single specialty groups

Disability –physical or mental impairment that substantially limits one or more major life activities

-20% of americans has one or more disabilities

-11 million americans are receiving social security disability benefits

-cost of disability to employers

-medical cost

Disability Management

-ergonomics

-employee assistance

-early intervention to prevent further injury-early retention to work

-case management

-transitional work programs

-onsite rehab

Chapter 4

Wagner Chronic Care Model

-population based outreach

-treatment plans that are sensitive to each pacttttttttttttttttttttttttttttttttttttttient’s preferences

-evidence-based medicine is employed and is aided by clinical information systems with built in decision support

-patients are encouraged to change risky behaviors and to self manage care

Meaningful Use

Stage 1- Use electronic health record and e-prescribing

-use of certified EHR technology for the exchange of health info. Exchanging data with other providers of care or business partners, such as labs or pharmacies

-use of EHR technology to submit clinical quality and other measures to the HHS

Stage 2: Increased data collection and reporting to advance clinical outcomes

Stage 3: improved clinical outcomes

Funding for electronic records provided in ARRA

Financial penalties if MU goals not met

Comparative Effectiveness Research

-challenge of “routine”healthcare and its lack of ongoing research

-patient center outcomes research institute

-PCORI priorities

-assessment of prevention, diagnosis, and treatment options

-improving healthcare systems

-communication and dissemination research

-addressing disparities

Medical Home Features

-Personal physician for each pt

-Dr directed medical practice with a team of practitioners

-whole person orientation

-care is coordinated across all practicioners and systems

-quality and safety emphasized

-enhanced access

-payment that supports cost of medical home

Medical Home Successes

-Keys to success

-individualized and intense caring for patients with chronic illness

-efficient service provision

-careful selection of specialists

-results: total cost of care reduced by 15%

-less frenetic pace for practicioners

ACA Support

-Community health teams to support decision making

Shared Decision making

Facilities shared Decision Making

-Empowers pts and reduces unnecessary costs in the system

-provides funding to create pt educational and decision support materials and to disseminate these aids to providers and pts

-focus of shared decision making:

-arthritis of hip and knee

-low-back pain from a herniated disc

-chest pain

-enlarged prostate

-early stage prostate and breast cancer

Challenge:Study of US regions in US found that the incidence of joint replacement for chronic arthritis of hip or knee and of surgery for low back pain varied 5.6, 4., 5.9 respectively, from lowest to highest region

Chapter 5:

Value Based Purchasing

-hospital value based purchasing program

-redirect funds from DRG payments to quality bonuses in inpatient care

Quality Reporting

-new measures being developed

-health outcomes and functional status of patients

Medicaid Quality Reporting

-improve health outcomes

-implement activities to prevent hospital readmissions

-identify best practices in delivery of healthcare services

-find changes in processes of care and systems used by providers that will reliability result in intended health outcomes

-identify healthcare providers that deliver consistently high quality, efficient healthcare services

Exercise

Identiify local restaurnats that have posted the nutritional content of their menues. Which entry is the healthiest? The least healthy? What are restaurants doing to promote the healthiest entrees?

Chipotle- Posts calories at restaurant and online, build own burrito online to see exact calories

Most calories- burrito

Least Calories- salad??

McDonalds- Posts calories of $ menu but rest you have to go online.

-Big Breakfast with Hotcakes and Large Size Biscuit

Calories: 1,150

-Best thing to get:

Hamburger-250 calories

Starbucks: Posts Calories in restaurant

Worst drink to get at starbucks:White Hot Chocolate-Venti- 620 Calories

Best Drink to Get:

Black Coffee