Why is it necessary that risk adjustment incorporate sociodemographic factors for my diabetic schizophrenic patients who have unstable housing?
Healthcare is fundamentally about people. That’s why, at the end of the day, it is the differences and disparities among individuals that are at the heart of the challenge facing the National Quality Forum (NQF) as it debates incorporating sociodemographic factors into risk adjustment.
Here’s a real-life example of the importance of SES factors to risk adjustment: Robert is a diabetic patient of mine who is schizophrenic with episodes of psychosis. He has difficulty with his meds in part because his housing situation is not stable. From time to time he is homeless. If there is any possibility of stabilizing his diabetes, he will need additional case management time over and above a diabetic schizophrenic who does not have the added SES burden. The case manager would not just deal with “medical” issues like making sure that Robert is taking his meds every day but also working with Robert to address conflict with neighbors that in turn are making him extremely anxious. In this case, the neighbors were extremely rowdy with loud music. The case manager was able to defuse the situation – when the neighbors were told by the housing authority to move. The same challenge applies to my asthmatic patients who live in substandard housing and are exposed to different allergens than those impacting middle-class asthmatics. In this situation, the case manager might help with making sure that insects exacerbating the asthma attacks are eliminated from the apartment. Continue reading
Blog post by Krysten Brooks, RN, BSN, MBA
Hospitals across the country have launched a wide-range of initiatives to reduce hospital-acquired conditions (HACs), but despite their efforts, a quarter of the nation’s hospitals face reimbursement penalties according to a preliminary analysis released in June by CMS that scored hospitals based on rates of acquired conditions and patient complications. While Medicare’s HAC Reduction Program plans to release final scores later this year, the healthcare organizations facing penalties can expect to lose approximately one percent of each Medicare payment from October 1, 2014 through September 30, 2015, translating into billions of dollars in lost reimbursement.
The Medicare penalties will undoubtedly hit some organizations hard, and these hospitals are moving quickly to analyze avoidable complications and intervene to improve quality. Facilities are also auditing clinical documentation for completeness and accuracy and examining documentation workflow to analyze process breakdowns and problems. Continue reading
“How do we achieve better population health?”
This is the question on the minds of health care leaders across the country today.
At a recent 3M health care executive conference in Saint Paul, Minnesota, representatives from health plans, hospitals, Medicaid and several non-profit organizations gathered to discuss patient-centered models of care as a way to achieve better population health outcomes.
But attendees didn’t walk away with a clear-cut answer to the question “how do we achieve better population health?” There is no such thing. Instead, they left with affirmation that better population health is going to require (1) new collaborative partnerships and (2) thoughtful consideration of the right metrics for measuring population health. Continue reading
I believe most human beings have some sort of a moral compass, especially in the healthcare arena. I might be naïve in my view but I believe most healthcare professionals choose to work in health care to care for others. As part of that drive, I also believe that we informally and formally have always assessed the care we give and look for opportunities to improve — often acting as a Monday morning arm chair quarterback review. As part of that review, many root cause analyses and written protocols for care and/or critical pathways have been developed to ensure patients received the best quality and most efficient health care. Continue reading
“That’s it baby. When you got it, flaunt it. Flaunt it!”
The famous line is shouted by theater producer Max Bialystock in the 1968 movie The Producers. It could just as easily be the advice of strategists to health systems and hospitals today. When you got good quality, flaunt it. Show it off in the marketplace.
The key is to demonstrate quality—which, like beauty, lies in the eye of the beholder. Some hospitals and health systems might feel they don’t have much to show off, but rankings aren’t the only measure of quality in health care. Continue reading
The concept that payment for health care should be based on quality and clinically meaningful outcomes is not new, but the current breadth, variety and rapid adoption of value-based models is unprecedented. Value-based payment models now include accountable care organizations (ACOs), patient-centered medical homes (PCMHs), bundled and episode-based payments, and pay for performance structures.
There are now more than 600 Medicare and non-Medicare ACOs. This is more than a 300% increase from the end of 2011 when the first 32 Medicare ACOs were announced, at which time there were approximately 160 private sector ACOs. The increase in PCMHs is no less remarkable with a 5-year increase from 28 in 2008 to nearly 6,000 in late 2013 – and that only includes those with NCQA accreditation.
Value-based purchasing further emphasizes the ripple effect and spider web of CDI, HIM and Quality. Everyone “knows” about value-based purchasing, but what is it comprised of?
Value-based purchasing (VBP) is both a broad and narrow quality measurement tool. Broadly defined, pay for performance (P4P)/ VBP is payer-developed metrics to measure value compared to reimbursement given. Two examples are accountable care organizations (ACOs) and bundled payments. A narrow definition is a program mandated by the Affordable Care Act of 2010 and administered by CMS. VBP has been in development for almost 10 years but was formally introduced for FY 2013. Through the Medicare program, incentive payments are made to hospitals based on either how well they perform or improve against their own baseline on each domain comprising VBP. There are four domains: clinical process of care, patient experience of care, outcome (FY 2014 forward) and efficiency (FY 2015 forward). Each domain is assigned an associated weight. For example, in FY 2015 clinical process is 20 percent of the total VBP score, patient experience is 30 percent, outcome is weighted at 30 percent and efficiency rounds it out at 20 percent. Continue reading
Value-based purchasing (VBP), a program authorized by the Patient Protection and Accountable Care Act of 2010, authorizes the Centers for Medicare & Medicaid Services (CMS) to base a portion of hospital reimbursement payments on how well hospitals perform in 25 core measures. The goal of the VBP program is to incentivize hospitals to improve care by starting to base reimbursement on quality of care delivered. This program focused on how patients rate their hospital experience, and how well hospitals follow certain standards of care. Some of the VBP core measures ask the following:
• Were blood cultures performed in emergency department prior to initial antibiotic?
• Were prophylactic antibiotics discontinued within 24 hrs after surgery end?
• How often was pain well controlled? Continue reading
Yes. To achieve real success in population health we need health care consumers to actively engage in the behaviors necessary to secure their health. “Patient” engagement is the holy grail of health care. However, despite decades of research into health behavior and ways to change it, we don’t seem to be any closer. I think that is about to change.
Disruptive technologies are proliferating in response to the new cultural phenomena of the “quantified self.” This movement believes each of us is a rational creature responsive to data and if we can only get enough indisputable facts about our daily life, then we can manage/change our behavior. Therefore, everything in our lives must be tracked. This assumption is debatable — some people do not need a scale to know if they are gaining weight, a look in the mirror will do. However, for others, including myself, we seem to automatically airbrush that image in the mirror, so a little rude data every now and then may be necessary.
Maintenance of Situational Awareness, or SA, is crucial to all of our endeavors. It is the perspective and sense of what is going on around us. One would like to say it is an appreciation and evaluation of all that is relevant to the target pursuit plus extra detail to be stored away for access at a later date – often without a direct application in mind. To appreciate all aspects of an endeavor or project is an aspiration, and, depending on the context, unrealistic. In such cases, we depend on team members to help create a shared mental model. Maintaining SA is an active and incessant process. Common speech recognizes this concept in remarks such as “…missing the forest for the trees” or “…functioning with blinders on.” Continue reading