Fairleigh Dickinson Executive MBA Health Systems Management

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Fairleigh DickinsonExecutive MBAHealth Systems
Management

• Managed Care and Provider Reimbursement
• Robert Eidus MD, MBA

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May 21

• Final Exam
• Population Based Health Management
• Preventive Health Services in Managed Care
• Demand Management
• Case Management
• Case Study- Accordant Health Services-
• Oral Presentations of Project
• Course Summary
• Wrap Up and Feedback

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Case Study

• Merck-Medco Managed Care Michael

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Current Events Analysis
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Simple Rules for the 21st Century

• Current Approach
• Care is based primarily on visits
• Professional autonomy drives variability
• Professionals control care
• Information is a record
• Decision-making is based on training and
  experience
• Do no harm is an individual responsibility
• Secrecy is necessary
• The system reacts to needs
• Cost reduction is sought
• Preference is given to professional roles rather
  than the system

• New Rule
• Care is based on continuous healing relationships
• Care is customized according to patient needs and
  values
• Patient is the source of control
• Knowledge is shared and information flows freely
• Decision-making is evidence based
• Safety is a system property
• Transparency is necessary
• Needs are anticipated
• Waste is continuously decreased
• Cooperation among clinicians is a priority

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Health Care in the 21st Century Should Be

• Safe- avoiding injuries to patients from the care
  that is intended to help them
• Effective- providing services based on scientific
  knowledge to all who could benefit and refraining
  from providing services that will not likely
  benefit them
• Patient-centered providing care that is
  respectful of and responsive to individual
  patient preferences, needs, and values, and
  ensuring that patient values guides all clinical
  decisions

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Health Care in the 21st Century Should Be

• Timely- reducing waits and sometimes harmful
  delays for both those who receive and those who
  give care
• Efficient- avoiding waste, including waste of
  supplies, equipment, energy, and ideas
• Equitable- providing care that does not vary in
  quality because of personal characteristics, such
  as race, ethnicity, geographic location, and
  socioeconomic status

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How is Health Care Rationed in the United States?

• Discussion

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Population based health management
People with complex multisystem illness
25-35 of health care costs
People with chronic illnesses
30 of health care costs
35 of health care costs
Healthy or asymptomatic and at risk for illness
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Population based health management
People with complex multisystem illness
Care management (Catastrophic Case Management
People with chronic illnesses
Disease Management
Preventive Health, Demand Management
Healthy or asymptomatic and at risk for illness
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Typical Prevention Interventions

• Registries
• Reminders
• Educational activities
• Provider incentives

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Barriers to effective managed care preventive
efforts

• Migrating membership
• Inaccurate data bases
• Lack of point of service effectiveness
• Missed opportunities
• Physician overload
• Lack of systems in providers offices

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Demand Management

• Basic Principle
• 70 of illness is self limited
• Much of primary care visits and ER visits are
  patient initiated very often due to lack of
  education/ information
• Giving patients information/ advice/ and
  alternative venues for care can save money

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Typical conditions which can be managed via
demand management

• Colds (avoid a PCP visit)
• Asthma, ear infections (avoid an ER visit)
• Minor strains/ sprains
• Allergies
• Urinary tract infections

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Types of Demand Management Interventions

• Algorithmic books and other literature
• On-line advice systems
• E-health care (future)
• Nurse advice lines (advice and triage)
• Example Access Health
• After hours clinics and urgent care centers

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Does Demand Management Work?

• Probably- but dont believe the press you hear
• Nurse advice lines are well received by patients,
  but
• Most patients dont use them
• They are costly
• Cost savings may be difficult to calculate,
  particularly after year one

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Case Study

• Accordant Health Systems

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Care Management

• Also called case management or catastrophic case
  management
• Operating assumptions
• Suttons Law
• If I can manage the few cases with big ticket
  items, then I can ease off the micromanagement of
  the masses

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Typical Cases Managed

• Transplants
• Parenteral Hyperalimentation
• HIV/AIDS
• Premies
• Traumatic Brain Injury
• Stroke

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Care Management Toolkit

• Discounted contracting
• Home nursing, PT, DME, Rehab., Centers of
  Excellence
• Substitution of benefits
• Coordination of care
• Guidelines monitoring
• Telephonic or on-site support

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Care Management

• The bulk of the services are provided by nurses
  that work for the health plan or an independent
  company that contracts with the health plan or
  employer
• Nurses are specially trained
• Documentation software

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Care Management Problems

• Although most people believe that Care Management
  helps patients and save money, it is hard to
  quantify
• Small numbers and large dollars give large
  amounts of variation
• You are basing savings on what would have
  happened had you not intervened

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Prospective Care Management-A new paradigm

• Basic tenet
• Identify people at risk for high medical
  expenditures before they get sick
• People with chronic illness
• Depressed
• Social Isolation
• Poor self efficacy
• Poor decision-making skills

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Web-Site Analysis
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Course Summary

• Managed Care should be differentiated from HMOs
• Managed care started in response to a societal
  need for access
• In the last 25 years, the growth has been fueled
  by a need to control costs
• Managed care will continue to respond in the
  future to the balancing and changing needs of
  access, coverage, and cost containment

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Course Summary

• Although it seems to be an ideal situation, the
  development of integrated delivery systems has
  been fraught with problems
• Within the sphere of cost containment, the
  general tactics are benefits constriction, cost
  sharing, transfer of risk, incentives, and
  utilization management
• None of these have worked very well alone-
  together they have helped to modify the
  escalation of medical costs
• The basic factors that contribute to cost
  escalation are aging of the population, new
  technology and consumer demand

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Course Summary

• Managed care has made many contributions to
  improving quality of health care. There is little
  evidence that the tactics used to contain cost
  have adversely impacted quality
• Despite public statements to the contrary,
  employers chose health plans based upon cost, not
  quality
• Population based care management has become
  increasingly popular to prospectively influence
  outcomes

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Feedback

• What did you like?
• What didnt you like
• What would you have liked more of?
• What would you have liked less of?
• Value of minipresentations

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Evaluations
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Thank You