Health Care Euphoria
Revolution in Care: See New MN web site for links to
informationhttp://www.ci.minneapolis.mn.us/dhfs/toolkit.asp#P66_4020
Researched the following - National Alliance for Health Reform
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ICSI- Framework for Guidance in procedures and practice
RHIC- Alignment of Health Care Coalitions - Standardize quality of
service
QASC- Quality Control benchmarking association
Change in Focus-Quality of Service, Benchmarking and Education
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Service and Delivery Clinician Model Change
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Follow up and transformation of support services
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Quantitative research on best clinical practice based on results
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Creation of consultation service added to the clinician care model
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Delivery of education on health care - Full circle of care
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Moving preventive care upstream as a social factor from a
downstream medical model
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Moving wellness program from backburner to center stage
Research completed in following Areas – Investigated health reform
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Corporate America- Wellness Programs
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Wellness/Fitness benefits specifically targeted for Health Reform
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Medicare Health System - Preventive care services – know 100%
coverage
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Long Term Care - Coverage and services - Utilized for active life
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New evidence based testing techniques - Applicability
benchmarking
Health Reform vs. Policy, Practice
Trends in America Today
• Medical Industry – Researched and created agencies for standardization
of practice, delivery and quality, Nationwide
• Insurance Industry – Embraced wellness programs, education,
participation in telephonic services – through policy plan and specialty
providers
• Research Industry -National effort, involvement in Patient Education –
Improvement in ways to provide quality control measurements, drive
services for elimination of barriers to consulting using best practice tested
formats
• Movement towards a healthier nation, based on wellness sponsored
programs directed by Corporate America and Communities
• Medicare-Health platform expansion for preventive care and standardized
plan designs (% close of drug donut hole) for the disabled and retired
(A+B+C+D) formula
• Long Term Care – Looking at aging as a unique adult segment with
Increased health care needs, services and support for assisted living
• Patient Responsibility for selection of care - Make choices based on
quality, outcomes and price. provide tools to rank providers of medical
services
Improve the Health and Quality of life through National, Regional and Community involvement
via improved clinical procedures, electronic medical records and informed users by moving the
nation from a focus on sickness and disease to one based on wellness and prevention.
Changes in Health Care
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Education of Policy Owners on Benefits – Revision to four
page Summary Plan Description with preventive care being
most important. Priority ranking given to Heart, Cancer,
Diabetes, Obesity screenings
Complete Change in Medical Focus – Education on health
care –Consultation and counseling for improved result
outcomes –Quality and payment based on outcomes, not
procedures
Service and Delivery Clinician Model Change
Follow up and transformation of medical services - National
Non-Profit Collaborative
Consultation after the preventive care & testing results Connecting the entire Medical Network to patient
Moving Preventive Care upstream and combine social factors
from a downstream medical model
Deliver wellness program not only to Corporate America
but to all Americans
Focus on driving up participation rates in exercise, activities
and eating more nutritious foods
Paying for Wellness – Monitor the 85% of Medical Loss Ratio
with claims statistics. Use evidence base benchmarked results
HHS-National Prevention Strategy
Provide a vision, goals, recommendations, and action items that
public, private and non-profit organizations and individuals can meet
to reduce preventable death, disease and disability in the U.S.
Draft Goals
• Healthy Communities
• Preventive Clinical and Community Support
Draft Strategy Directions (SD) and Recommendations (R)
• SDI1 Healthy Physical, Social and Economic Environment
• SDI2 Eliminate Health Disparity
• SDI3 Prevention and Public Health Capacity
• SDI4 Quality Clinic Preventive Services
• SDI5 Tobacco Free Living
• SDI6 Reduce Alcohol and Drug Abuse
• SDI7 Healthy Eating
• SDI8 Active Living
• SDI9 Injury Free
• SDI10 Mental and Emotional Well Being
Goals of the New Health Preventive Care Strategy
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Saving the “Obese Child Generation” – Add nutritional eating habits,
structured activity, “monitoring- breakfast through dinner”, Understand
the Nation of Food Allergies (body overload), develop new school
cafeteria menu programs
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Age 20 to 40 - Promote and train on nutritional eating habits, cooking,
foster life, work, & health balance, spend quality time with children,
teach better shopping & eating habits, increase time for exercise
activities, games
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Ages 41 to 64 – Focus on keeping active middle generation free of
chronic disease, preventive testing and active exercise built into an
active social life. No longer full time care givers to parents.
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Age 65 -90 - Medicare, LTC have improved preventive care payment
guidelines focusing on understanding needs and utilization of benefits
– trend to keep active while adding support, nutrition, weight
maintenance and strength building exercise, home and in institutions.
Institute for Clinical Systems Improvement (ICSI)
Framework of Health Care Guidelines
Area of Effective Audience
Mission of our collaboration is to champion the cause of health care
quality and to accelerate improvement in the value of the health care
we deliver to and for:
• Public Policy
• Family and Social Network
• Physical and Social Environment
• Community Support for Healthier Lifestyles
• Educators and Schools
• Employers and Workers
• Health Plan and Payers
• Faith Based Organization
ICSI Guidelines – Designed to assist clinicians by providing an
analytical framework for Evaluation and Treatment of Patients
Not intended to replace judgment or protocol -see
http://www.icsi.org/guidelines_and_more for Guidelines
Regional Health Improvement
Collaborative (RHIC)
www.nrhi.org for more details on their goals and objectives
RHIC Footprint-40 Regional Health
Improvement Collaborative in the U.S
(RHIC )Regional Health Improvement
Collaborative
Goals & Outcomes
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Performance Measurement: provide actionable information about the cost and
quality of healthcare services, the health of the population, and/or the extent to
which state-of-the-art methods of delivery, payment, and health promotion are
being used in their community.
Payment and Delivery System Reform: serve as neutral planning and problemsolving forums where win-win multi-payer, multi-provider payment and delivery
reforms can be designed.
Training and Assistance in Performance Improvement: operate programs which
enable physicians, nurses, hospital administrators, and other healthcare
professionals to obtain affordable training, coaching, and technical assistance on
ways to analyze problems in care delivery and ways to design and successfully
implement solutions.
Patient Education and Engagement: help citizens in their communities (a)
understand and actively engage in activities that will maintain and improve their
health, (b) choose providers and services based on their cost and quality, and (c)
support the delivery of higher quality, more coordinated care.
Strategic Planning and Coordination: can play critical planning, coordinating, and
support roles that will ensure that healthcare reform efforts are designed and
implemented successfully in their community
Why RHIC is Collaborative Body
Neutral, Trusted Mechanism for Transformation of Health care System
Key Health care stakeholders effected in each Community by RHIC
– Health care providers, i.e., hospitals, physician groups,
physicians, home health agencies, nursing homes, clinics,
etc.;
– Healthcare payers, i.e., health insurance plans, public
programs such as Medicaid, and employer groups that
directly contract with providers;
– Healthcare purchasers, i.e., employers who purchase
health insurance for their employees; and
– Healthcare consumers or consumer organizations
Objective is to plan, facilitate, and coordinate the many different
activities required to change Social Mindsets
Quality Alliance Steering Committee(QASC)
National Quality Control Arm
MN Community Measurement
• Aimed at implementing measures to improve the quality and efficiency of
health care across the United States.
• Measurement of the follow includes medical groups, clinics, physicians,
hospitals, health plans, employers, consumer representatives and quality
improvement organizations.
• Mission to accelerate the improvement of health by publicly reporting
health care information
• Ensure that quality measures are constructed and reported in a clear,
consistent, and person-focused way
• MN Community Measurements QC project – Mine data submitted directly
by more than 300 medical clinics statewide
• MN Community Measurements (QASC Project) Over the next three and a
half years we will add 11 new measurements, including six new measures
of specialty care-See D5 Diabetes project- http://www.thed5.org/
QASC Involved in existing and emerging sector-specific quality alliances
http://www.healthqualityalliance.org/about-qasc or http://www.mncm.org/site/
QASC National Collaboration
The High-Value Health Care (HVHC) project
Quality of Care Initiative Guidelines
• Help health care providers improve the quality of
patient care.
• Help consumers make informed choices about health
care providers.
• Help provide payments that support provider efforts to
improve quality and efficiency, rather than simply
paying for more intensive treatments.
• Help reduce large racial and ethnic disparities in care.
The QASC and HVHC Project are supported by staff at the Engelberg Center for Health Care
Reform at the Brookings Institution.
Corporate Wellness Programs and Services
Provided by Insurance Carrier or Third Party
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Health Risk Assessments
Employee Health Screening and Biometric Testing
Wellness Coach / Health Coach Programs
Employee Wellness Newsletters
Custom Wellness Programs
Corporate Wellness Incentive Plans, Points-based Tracking Systems,
Gym Discounts
Interactive Online Wellness Tools, i.e., health calorie counters
Follow-up and counseling employees
Follow-up with physicians
Health improvement and disease prevention programs
Organized worksite-wide wellness program activities.
Wellness Council of America (WELCOA) is most respected resource for
workplace wellness in America, with a membership in excess of 3,200
organizations: http://www.welcoa.org
Top 10 Benefits of Corporate Wellness Programs
1. 3 to 1 return on investment. This means that for every $1 spent on Corporate Wellness Programs, corporations
save an average of $3.
2.Are an absolute necessity for self-insured companies as every dollar saved goes directly toward the bottom
line. A million dollars saved is literally a million dollars left over in self-funded health care accounts.
3. Add to the longevity of each and every employee. An investment in Corporate Wellness Programs is an
investment in the health of your co-workers and employees.
4. Can now be monitored using ROI Tracking systems in order to show direct savings off of ICD-9, CPT-4, and
Pharmaceutical codes in order to accurately show where cost savings are occurring and identify other health
areas that savings can be achieved.
5. Viewed by employees and potential new hires as an employee benefit. Some employees will not work for a
company that does not offer Corporate Wellness Programs.
6. Are fun and motivating. Although there can be a “shock factor” associated with beginning Corporate Wellness
Programs, most employees come to look forward to Biometric Testing, Health Challenges, Health Fairs,
Promotional Materials, and other key elements of Corporate Wellness Programs.
7. Improve the health status of employees, thus reducing absenteeism in the workplace.
8. Have a lasting effect upon reduced sick leave.
9. Can help identify the problem areas such as cardiovascular diseases, muscular skeletal problems, diabetes,
cancers, and other health areas. Using this information, specific interventions can be created within Corporate
Wellness Programs in order to improve health and reduce short-term and long-term health costs.
10. Can utilize high-tech devices and services such as Health Stations, KAM Devices, and ROI Tracking in order to
help each employee on their road to better health and track the financial efficacy of each and every intervention
being used within the Corporate Wellness Programs.
National Health Care Wellness
Sample of 3,200 Wellness-Fitness Companies in U.S.
WELCOA's Premier Provider Network-members
• Advantage Health
• Optum Health
• Health Fitness
• Health Designs
• BioIQ
• Staywell Fitness
• HealthSource Solutions
• Global Fitness
• WellSource Inc.
• Hallmark Business Connections
Paul Zane Pilzer: “A growing industry racking up $200 billion dollars a year in Sales,
growing by 12% annually, all mostly involved with employers having more than 1,000
employees” (Creating a have and have not society)
Medicare- Standard Coverage
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Medicare Part A covers inpatient hospital care, skilled nursing facilities and some
home health care. The benefits start once you've paid your Part A deductible,
which for 2010 is $1,100 for the first 60 days of hospitalization, plus an additional
$275 per day for days 61 through 90 and $550 per day for days 91 through 150.
You are responsible for all costs beyond 150 days.
Medicare Part B is an optional premium-based plan that covers physician services
and outpatient hospital care. You must be enrolled in Part B to be eligible to
purchase a Medicare supplement plan. For new enrollees in 2010, the Plan B
monthly premium is $110.50 for individuals earning $85,000 or less and couples
earning $170,000 or less. Those with higher incomes pay Part B premiums ranging
from $154.70 to $353.60 per month. Medicare imposes a $155 annual deductible
on Part B enrollees, after which it pays 80 percent of the Medicare-approved
amount for health care services
Medicare Part D - prescription drug coverage is insurance run by an insurance
company or other private company approved by Medicare. There are two ways to
get Medicare prescription drug coverage: (Donut Hole closed 50% 2011)
a. Medicare Prescription Drug Plans
b. Medicare Advantage Plans
Medicare –Additional Coverages
Medigap Vs. Part C -Medicare Advantage Plan
• Medigap plans all pay 100 percent of your Medicare Part A coinsurance and 100 percent of your Medicare Part B co-insurance for
preventive care, at least 50 percent of your Part B co-insurance or
co-payment for services other than preventive care, and at least 50
percent of the first three pints of blood for a transfusion. The plans
vary according to whether and how much they pay of other costs
such as the Part B deductible, Part B excess charges and foreign
travel emergencies.
• Medicare Advantage Plans must cover all of the services that
Original Medicare (A & B) )covers except hospice care. Original
Medicare covers hospice care even if you’re in a Medicare
Advantage Plan. Medicare Advantage Plans aren’t supplemental
coverage (Medigap Plans). Medicare Advantage Plans may offer
extra coverage, such as vision, hearing, dental, and/or health and
wellness programs. Most include Medicare prescription drug
coverage (Part D).
U-Care –Carrier Plan Design analyzed for Advantage Plan 2011 Services
Medicare Preventive Health Care Health Reform Check List
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Abdominal Aortic Aneurysm Screening
**Bone Mass Measurement
Cardiovascular Screenings
Colon Cancer Screening (Colorectal)
Diabetes Screenings-risk factors must be present
Diabetes Self-Management Training
Flu Shots
Glaucoma Tests
**Hepatitis B Shots
HIV Screening.
**Breast Cancer Screening (Mammograms)
**Medical Nutrition Therapy Services must have exclusion
Pap Tests and Pelvic Exams (includes clinical breast exam)
Physical Exam
**One-time “Welcome to Medicare” physical exam
**Yearly “Wellness” exam
Pneumococcal Shot
Prostate Cancer Screenings
** Smoking Cessation (counseling to stop smoking)- Preventive
** effective 2011, 20% Co-Insurance/B Deductible removed for Preventive Services many have age restrictions
https://www.cms.gov/MLNProducts/35_PreventiveServices.asp for information
Decline in # of Long Term Care Providers
Major Carriers
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Berkshire Life Insurance Company of America
Genworth Life Insurance Company
Great American Life Insurance Company
John Hancock Life Insurance Company
Metropolitan Life Insurance Company
Penn Treaty Network America Insurance
Company
• Prudential Insurance Company of America
Source: Newman Long Term Care largest Long Term Care agencies in the United
States-http://www.newmanlongtermcare.com
Long Term Care Policy Care Settings
Help with Activity of Daily Lives, Help with Additional
Services, Help with Care Needs in:
• Home Health Care
• In-Law Apartments
• Housing and Aging Disabled Individuals
• Board and Care Homes
• Assisted Living
• Continuing Care Retirement communities
• Nursing Homes
Third Party Full Service Administrator-Univita Health,Long term
care insurance companies rely on Univita for complete outsourcing of
key support services listed above. http://www.univitahealth.com/our-
business
What types of services are covered by
Long Term Care Insurance
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Nurses
Certified Nursing Assistants
Physical, Occupational or Respiratory Therapists
Home Health Aides
Homemaker Services
Transportation Services
Home Modifications
Medical Alert Systems
Some LTCI policies even allow for Family and Friends to
provide your care
A Long-Term Care Ombudsman:
Watch Dog for LTC Care Patients
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Resolves complaints made by or for residents of long-term care facilities
Educates consumers and long-term care providers about residents' rights and good
care practices
Promotes community involvement through volunteer opportunities
Provides information to the public on nursing homes and other long-term care
facilities and services, residents' rights and legislative and policy issues
Advocates for residents' rights and quality care in nursing homes, personal care,
residential care and other long-term care facilities
Promotes the development of citizen organizations, family councils and resident
councils
Long-Term Care Ombudsman efforts are summarized in the National Ombudsman
Reporting System (NORS 2008 data) to include the number of facilities visited, the
types of complaints handled and the kinds of complaints filed with ombudsmen.
Data has been collected since 1996 and gives a good picture of the extent of
ombudsman activities nationally and in every state. A 2001 report compares
national data from FY 1996-2001.
The National Long-Term Care Ombudsman
Resource Center
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Provides consultation and information and referral for ombudsmen and for the
residents, families and others who use ombudsman services;
• Provides training opportunities and training resources for state and local
programs;
• Promotes public awareness of the role of ombudsmen in long-term care;
• Works to improve ombudsmen effectiveness in meeting the needs of residents,
including those served by managed care organizations and those in alternative
settings, such as Medicaid waiver programs;
• Identifies research needs and promotes research on issues which affect the
ombudsman programs or their constituents;
• Supports the ombudsman volunteer component through work with AARP and
other national or state-wide efforts to recruit volunteers for the program;
• Works cooperatively with all organizations and agencies which have as their
mission the protection of the frail elderly who reside in long-term care settings and
• Promotes understanding and cooperation between ombudsman programs and
citizen advocacy groups.
National Long Term Care Web Site http://www.ltcombudsman.org/about
Applicability Statistical Sampling New
Benchmarking Technique
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Step 1. Determine the most important factors that may affect Applicability
Identify potential factors
Table 1. Characteristics of individual studies that may affect applicability
• Population
• Intervention
• Comparator
• Outcomes
• Setting
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Step 2. Systematically abstract and report key characteristics that may affect
Applicability in evidence tables; Highlight any effectiveness studies
Step 3. Make and report judgments about major limitations to Applicability of
individual studies
Step 4. Consider and summarize the Applicability of a body of evidence
Table 2. Elements to be included in a summary table characterizing the applicability
of a body of studies
Source: http://www.learn-medical-statistics.com/index.asp
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Results of an Applicability Study for
Postpartum Depression (PPD)
• A more systematic approach to diagnosis and treatment in
general.
• Increased effectiveness of teamwork and communication.
• Adapting and extending the structured tools used in the PPD
study to the care of other patients with chronic disease.
• Greater feelings of professional self-worth, combined with
increased community recognition of the practice.
• Added opportunity and support for practice staff to move into
new roles or learn new skills.
• Increased understanding of research and its benefits.
3-year trial comparing usual care for PPD with standardized, two-step
screening and a recommended therapy and follow-up program
Conclusion on Health Collaborative Initiatives
• Patient Centered Care-Creates a model of an active participant, but few
tools or resources exist to help patients make the change
• Patients in General- Have not been told that they are supposed to change
but no clear time line or one voice to listen to. Needs to be the Clinician
• Patients-Have been asked to participate in process design, but first need
to be taught and trained in how to talk to Clinicians
• Patients are Strapped with High Deductible Health Plans (HDHP) and are
afraid to see a Physician, for they lack clarity in cost of Services – They do
not know if services are covered. System needs to clean payment reform
and have price transparency prior to delivering clinical service.
• Collaboratives-Need to take a lesson from drug companies: Generic drug
prescription refills today are a commodity market. Wellness preventive
services, testing and counseling should be priced based on evidence based
results and become a commodity retail service, just like buying a set of
tires.-rating of success by clinic and physician
• Create a Medical Health Coalition who works with Patients, cradle to
grave, linking their previous Health Care Plan to their Medicare coverage,
to their Long Term Care Plan, for a lifetime of support. Electronic medical
history-records are a start