RESUMO
The COVID-19 crisis has nakedly exposed the problems and huge holes in the health care system of the United States. For today, we need to address the current pandemic from the point of view of both control and suppression. But such efforts could also provide insights into a post-pandemic restructuring of health care. If one or several states succeed in addressing the COVID pandemic together with an associated modest economic resurgence, citizens could develop the trust in state leadership necessary to finally make fundamental changes in our health care system. Such change is a once in a century opportunity.
Assuntos
Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Atenção à Saúde/legislação & jurisprudência , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Política , Prática de Saúde Pública , COVID-19 , Centros Comunitários de Saúde/organização & administração , Busca de Comunicante , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Humanos , Massachusetts/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Saúde da População , Estados Unidos/epidemiologiaRESUMO
Dealing with the COVID-19 coronavirus requires a coordinated transnational effort. We propose a 2-stage state-led effort that utilizes community health workers (CHWs). We spell out what is beginning to occur in states to control and suppress COVID-19. In the second stage, we suggest working with these CHWs as a key element in the next evolution of our health care system: community-centered population health.
Assuntos
Controle de Doenças Transmissíveis/organização & administração , Centros Comunitários de Saúde/organização & administração , Agentes Comunitários de Saúde , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Assistência Centrada no Paciente/organização & administração , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Saúde da População , Prática de Saúde Pública , Pessoal Técnico de Saúde , COVID-19 , Busca de Comunicante , Infecções por Coronavirus/transmissão , Reforma dos Serviços de Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Massachusetts/epidemiologia , Pandemias , Pneumonia Viral/transmissão , Vigilância da População , Estados Unidos/epidemiologia , Washington/epidemiologiaRESUMO
In the wake of the election of Donald Trump, I resigned from my research work. I decided to become politically involved and since I am a health care professional, in June 2018, I started a bipartisan political consulting firm, Ask Nurses and Doctors (AND; www.asknursesdoctors.com). This start-up is focused on electing candidates or incumbents committed to health care reform. There are 2 approaches to universal coverage-either the Affordable Care Act or Medicare for All. To implement either approach, there are 10 lessons from my 30 years of research that may be useful to enact universal coverage.
Assuntos
Reembolso de Seguro de Saúde , Garantia da Qualidade dos Cuidados de Saúde/economia , Instituições de Assistência Ambulatorial , Benchmarking , Participação da Comunidade , Grupos Diagnósticos Relacionados , Liderança , Política , Reembolso de Incentivo , Estados Unidos , Cobertura Universal do Seguro de SaúdeRESUMO
Access to rural health care is an ongoing challenge for those living in America's countryside. Hospital closures, a fragmented and dislocated care delivery system, disproportionate levels of chronic illness, and poverty combine to present significant obstacles to health reform. This article highlights the major challenges in rural health care and specifies financial and delivery policy options that can strengthen rural health care. In particular, this article suggests a return to a prepaid approach within the umbrella organizational framework of what we term "rural convening entities." These entities would serve as the control of telehealth hubs for the communities they serve.
Assuntos
Acessibilidade aos Serviços de Saúde/economia , Hospitais Rurais/economia , Seguro Saúde/economia , Serviços de Saúde Rural/economia , População Rural , Custos e Análise de Custo , Política de Saúde , Humanos , Medicare/economia , Áreas de Pobreza , Saúde da População Rural , Telemedicina/economia , Estados UnidosRESUMO
BACKGROUND: In 2016 the U.S. Congress directed the Centers for Medicare & Medicaid Services (CMS) to implement the 21st Century Cures Act to fix a flaw in the Hospital Readmissions Reduction Program (HRRP). One section of the Act is intended to remove bias in calculating penalties for hospitals treating large percentages of low socioeconomic status (SES) patients. A study was conducted to analyze the effect of the introduction of SES hospital peer groups on the number and distribution of the hospitals being penalized. METHODS: The CMS analysis files for the fiscal year 2017 HRRP final rule and Disproportionate Share Hospital adjustments were used to assign hospital peer groups. The median excess readmission ratios for hospital peer groups were calculated, and the resulting pattern of hospital penalties within peer groups was analyzed. RESULTS: The findings suggest that because CMS assigns individual HRRP penalties on six clinical conditions but proposes to assign hospitals to a single SES peer group based on all admissions, it will ignore substantial differences in the distribution of peer group medians across these conditions. For surgical cases, as expected, hospitals with fewer patients had higher readmission rates, while for medical cases, hospitals with fewer patients had fewer readmissions. These findings may result in distortion of the peer group adjustment intended to correct for SES. CONCLUSION: Hospital peer groups may create unintended redistributions of penalties through distortion of peer group medians. An observed relationship between lower-volume hospitals and fewer readmissions for medical conditions requires additional research to establish its basis.
Assuntos
Benchmarking/organização & administração , Centers for Medicare and Medicaid Services, U.S./normas , Administração Hospitalar/normas , Readmissão do Paciente/normas , Populações Vulneráveis , Benchmarking/normas , Humanos , Indicadores de Qualidade em Assistência à Saúde , Fatores de Risco , Fatores Socioeconômicos , Estados UnidosRESUMO
Medicaid can improve beneficiary health and help sustain its own future by embracing payment for outcomes. Good precedents exist from states such as Florida, Maryland, Minnesota, New York, Ohio, Pennsylvania, and Texas. Medicaid outcome measures include preventable admissions, readmissions, emergency department visits, and inpatient complications; early elective deliveries; infant and child mortality; patient-reported outcomes, satisfaction, and confidence; and reduction in low-value care. Criteria to prioritize initiatives include potential savings, availability of established models, impact on health status, and Medicaid's ability to effect change. We offer 5 principles for success, emphasizing clinically credible initiatives that generate actionable information for clinicians.
Assuntos
Medicaid/economia , Reembolso de Incentivo , Resultado do Tratamento , Controle de Custos , Humanos , Readmissão do Paciente/economia , Qualidade da Assistência à Saúde/economia , Risco Ajustado , Estados UnidosRESUMO
Beginning as early as 2009, Texas began to put the antecedents in place for an effective Medicaid value-based purchasing model. Since those early activities were undertaken, Texas Medicaid is emerging as a national leader in value-based purchasing and has produced exceptional results that clearly demonstrate the value proposition associated with alignment of financial incentives. This article presents several years of data and preliminary results of this effort. This study found significant improvements in a number of outcomes. Further improvement will depend on implementation of financial incentives and ongoing commitment to paying for better outcomes. This ongoing commitment includes many additional programs that hospitals, in particular, have put in place such as improved handwashing techniques.
Assuntos
Melhoria de Qualidade , Qualidade da Assistência à Saúde , Aquisição Baseada em Valor , Bases de Dados Factuais , Definição da Elegibilidade , Medicaid , Texas , Resultado do Tratamento , Estados UnidosRESUMO
The Partnership for Patients (PfP) and the Agency for Healthcare Research and Quality (AHRQ) have reported a 23.5% decline in hospital-acquired pressure ulcers (HAPU) over 4 years resulting in a cumulative cost savings of more than $10 billion and 49 000 averted deaths, claiming that this significant decline may have been spurred in part by Medicare payment incentives associated with severe (stage 3 or 4) HAPUs. Hospitals with a high rate of severe HAPUs have a payment penalty imposed, creating a financial disincentive to report severe HAPUs, possibly contributing to the magnitude of the reported decline. Despite the financial disincentive to report, the number of severe HAPUs found in claims data over the corresponding 4-year period did not decline but instead remained unchanged. The results from claims data, combined with some flaws in estimating HAPUs, call into question the validity of the decline in HAPUs reported by PfP and AHRQ.
Assuntos
Úlcera por Pressão/prevenção & controle , Melhoria de Qualidade/normas , Redução de Custos , Humanos , Medicare/organização & administração , Úlcera por Pressão/economia , Úlcera por Pressão/epidemiologia , Avaliação de Programas e Projetos de Saúde , Garantia da Qualidade dos Cuidados de Saúde/métodos , Garantia da Qualidade dos Cuidados de Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Reembolso de Incentivo , Estados Unidos/epidemiologiaRESUMO
In October 2014, the Centers for Medicare & Medicaid Services began reducing Medicare payments by 1% for the bottom performing quartile of hospitals under the Hospital-Acquired Condition Reduction Program (HACRP). A tight clustering of HACRP scores around the penalty threshold was observed resulting in 13.2% of hospitals being susceptible to a shift in penalty status related to single decile changes in the ranking of any one of the complication or infection measures used to compute the HACRP score. The HACRP score also was found to be significantly correlated with several hospital characteristics including hospital case mix index. This correlation was not confirmed when an alternative method of measuring hospital complication performance was used. The sensitivity of the HACRP penalties to small changes in performance and correlation of the HACRP score with hospital characteristics call into question the validity of the HACRP measure and method of risk adjustment.
Assuntos
Centers for Medicare and Medicaid Services, U.S./normas , Administração Hospitalar/normas , Doença Iatrogênica/epidemiologia , Indicadores de Qualidade em Assistência à Saúde/normas , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Número de Leitos em Hospital/estatística & dados numéricos , Humanos , Qualidade da Assistência à Saúde/normas , Fatores Socioeconômicos , Estados UnidosRESUMO
This Open Forum addresses the challenging situation involving decisions about when to hospitalize patients for psychiatric care. Because the evidence base for when to hospitalize patients is incomplete, current practice is to hospitalize only patients who are in crisis. This Open Forum provides a suggested set of payment options that can provide financial incentives to change practice patterns and lead to better clinical outcomes.
Assuntos
Transtornos Mentais/economia , Serviços de Saúde Mental/economia , Reembolso de Incentivo , Planos de Pagamento por Serviço Prestado , Gastos em Saúde , Humanos , Padrões de Prática Médica/economia , Estados UnidosRESUMO
In this article we propose a new approach to pricing for patent-protected (on-patent) pharmaceuticals. We describe and define limit pricing as a method for drug companies to maximize revenue for their investment by offering budget-neutral pricing to encourage early adoption by payers. Under this approach, payers are incentivized to adopt innovative but expensive drugs more quickly if drug companies provide detailed analyses of the net impact of the new pharmaceutical upon total health budgets. For payers to adopt use of a new pharmaceutical, they would require objective third-party evaluation and pharmaceutical manufacturer accountability for projected outcomes efficacy of their treatments on population health. The pay for outcomes underpinning of this approach falls within the wider aspirations of health reform.
Assuntos
Comércio/métodos , Indústria Farmacêutica , Reembolso de Seguro de Saúde , Patentes como Assunto , Medicamentos sob Prescrição/economia , Garantia da Qualidade dos Cuidados de Saúde/economia , Controle de Custos/métodos , Custos de Medicamentos , Reforma dos Serviços de Saúde , Estados UnidosRESUMO
Risk adjustment accounts for differences in population mix by reducing the likelihood of enrollee selection by managed care plans and providing a correction to otherwise biased reporting of provider or plan performance. Functional health status is not routinely included within risk-adjustment methods, but is believed by many to be a significant enhancement to risk adjustment for complex enrollees and patients. In this analysis a standardized measure of functional health was created using 3 different source functional assessment instruments submitted to the Medicare program on condition of payment. The authors use a 5% development sample of Medicare claims from 2006 and 2007, including functional health assessments, and develop a model of functional health classification comprising 9 groups defined by the interaction of self-care, mobility, incontinence, and cognitive impairment. The 9 functional groups were used to augment Clinical Risk Groups, a diagnosis-based patient classification system, and when using a validation set of 100% of Medicare data for 2010 and 2011, this study found the use of the functional health module to improve the fit of observed enrollee cost, measured by the R(2) statistic, by 5% across all Medicare enrollees. The authors observed complex nonlinear interactions across functional health domains when constructing the model and caution that functional health status needs careful handling when used for risk adjustment. The addition of functional health status within existing risk-adjustment models has the potential to improve equitable resource allocation in the financing of care costs for more complex enrollees if handled appropriately. (Population Health Management 2016;19:136-144).
Assuntos
Indicadores Básicos de Saúde , Risco Ajustado , Medição de Risco , Gastos em Saúde/estatística & dados numéricos , Humanos , Programas de Assistência Gerenciada , Medicare , Vigilância da População , Estados UnidosRESUMO
Rising health care costs will result in reduced payments to providers, but across-the-board provider payment reductions are not the answer. Instead, existing payment systems should be reformed to strengthen value for the dollars spent. This can be accomplished by increasing efficiency, improving quality and outcomes, and lowering costs. Payment system reforms must be practical, transparent, identify opportunities for care improvement, and demonstrate material cost savings. Most importantly, because the current growth in health care costs is unsustainable, these reforms must be able to be implemented today. A set of comprehensive measures is being used by state government and private payers in the United States to adjust payment, based on improved outcomes quality. This article details the use of this set of measures, referred to as potentially preventable events, and demonstrates how they are being applied to achieve health care value.
Assuntos
Informação de Saúde ao Consumidor/normas , Autocuidado/normas , Estatística como Assunto/normas , Centers for Medicare and Medicaid Services, U.S./economia , Centers for Medicare and Medicaid Services, U.S./legislação & jurisprudência , Centers for Medicare and Medicaid Services, U.S./normas , Informação de Saúde ao Consumidor/métodos , Coleta de Dados/métodos , Coleta de Dados/normas , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Readmissão do Paciente/economia , Readmissão do Paciente/legislação & jurisprudência , Readmissão do Paciente/normas , Mecanismo de Reembolso/legislação & jurisprudência , Mecanismo de Reembolso/tendências , Autocuidado/métodos , Estatística como Assunto/métodos , Estados UnidosRESUMO
Lessons from outcomes-based fee-for-service payment models that can be applied to population health management models include the following: Focus on outcomes, not processes. Limit the number of outcomes measures used. Ensure that the amount distributed is substantial enough to motivate behavior change. Communicate results clearly and transparently. Ensure that the financial consequence of poor performance is proportional to the cost increase it generates. Focus on reducing the rate of excess preventable outcomes.