PHA 308: Healthcare Delivery Models
The US saw the birth of a ______________________ system after WWII.
As technology advanced, ________________ of medicine escalated.
Government role in healthcare increased with the passage of what acts?
Social Security Act, then Medicare/Medicaid, and Affordable Care Act
Micro level of analysis of effectiveness
Improving the health of individual patients through medical care services
Macro level of analysis of effectiveness
Improving the health of populations and communities through medical and/or nonmedical services
Micro level of analysis of efficiency
Combining inputs to produce services at the lowest cost
Macro level of analysis of efficiency
Combining inputs to produce maximum health care improvements given available resources
Challenges related to healthcare costs continuing to rise
- Cost=Quantity X Price
- Insurance system and technology encourages increased quantity
- Lack of transparency in pricing encourages price disparities
Insurance access is not universal, but healthcare is considered a _____________.
There is universal access to _____________ care.
Services provided are not standardized, therefore there are ________________________ in the quality of care across race, gender, location, type of payment method.
Delivery models for healthcare cost
- Pay-for-Performance (P4P)
- Bundled payments
- Accountable care organizations (ACOs)
- Use either (+) or (-) incentives to get providers to improve
quality outcomes (e.g. Hospital-acquired conditions and hospital
readmissions for Medicare patients)
- Medicare Star Rating System
- The outcome has been mixed. Some studies found improvement in quality outcomes and others did not see any
- Leapfrog group uses positive incentives to reward providers who attain certain thresholds
- Fee-for-value system aimed at efficient care
- Goal is to pay a single fee for a ‘bundle’ of related services during an episode of care
- Will reduce duplication (an inefficient treatment) and get providers to take ownership of the service
- Also to foster coordinated care
- Offer standard discount to Medicare for inpatient care-redesign care and therefore share in any gains
- Or give a lump-sum prospective payment to the provider for the entire episode of care
Accountable Care Organizations (ACO)
- Championed by the ACA as a VBP system but it already existed
- Defined by CMS as groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to Medicare fee-for service beneficiaries
- Group takes the financial risk of providing efficient care to an assigned group of patients to achieve cost reduction and quality of care
- Becomes eligible to share in the savings achieved if they meet spending and quality targets negotiated with the payer (benchmark)
There are more than _____ public and private ACOs in the United States (managing the health care costs of ~32 million Americans).
ACOs are a reimbursement model where ___________________________________________________________________________. If successful, they receive higher reimbursement.
healthcare organizations strive to meet cost and quality targets
There are 4 domains within ACOs, with 31 performance and quality measures (22 are related to pharmacy). What are the 4 domains?
- Patient/Caregiver experience
- Care coordination/Patient Safety
- Preventative health
- At-Risk Population
True or False: ACOs are not required to include pharmacy/pharmacists as providers.
ACO models that incorporate pharmacists
- Employed Model (clinical staff member)
- Embedded Model (partnership)
- Regional Model (works in health system)
- Shared Resource Network Model (contracted by provider group-visits to patients)
Half of all Americans take at least _____ prescription drug(s) per-month, whereas almost a quarter take at least _____ prescription drugs (s) per-month.
To deliver cost-effective quality healthcare, ACOs need to manage _________________.
_____________ costs are expected to rise faster than any other medical expenses.
According to a study in the AMCP’s Journal of Managed Care and Specialty Pharmacy, ACOs that employ or contract ______________ are better at managing medication costs while delivering value.
Opportunities to leverage Pharmacist services in APMS
- Limited interoperability inhibits PCP coordination
- Need to communicate Pharmacists value proposition
- Lack of standardized billing methods describing what pharmacists do
- Need for recognized role as providers
Medicare Star Ratings
- 5-point scale, 5 star (excellent) to 1 star (poor)
- Highly rated plans (4 or 5 stars) are rewarded by CMS (Quality Bonus Payments)
- 5 star plans (Can enroll year long and plans are highlighted)
- <3 star plans (over 3 years) can’t enroll through the Medicare website
Medicare Part C and D
- Medicare Advantage plans + Rx Drugs = MA-PDs
- Stand alone Rx Drug plans = PDP
Pharmacy Quality Alliance
A consensus-based, multi-stakeholder membership organization committed to improving health care quality and patient safety (with a focus on the appropriate use of medications)
PQA was established in 2006 as a _________________ with over 100 member organizations.
PQA membership includes
- Health plans
While there has been a total reduction in __________________, the number of lives covered under these models has continued to grow.
The new ACO program ___________________ has been implemented, and dropouts were significantly less than feared, while new organizations moved into the program, even with the enhanced risk requirements.
Pathways to Success
There has also been an increase in __________________________________, and they have moved to downside risk at a slightly higher rate than ACOs with hospitals.
the number of physician-led ACOs
Beyond the ACO models, there have also been significant new programs announced which will ______________________________________ to move toward managing the care of populations.
increase the opportunities for providers