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Policy changes to address readmission in healthcare ghi cbp emblemhealth

Policy changes to address readmission in healthcare

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Find a doctor or medical office. Access the EmblemHealth Portal. Sign In. All Rights Reserved. Only in this way will the value delivered for every patient count, including individuals who are currently poorly served. Value in healthcare delivery is largely unmeasured, a striking fact about healthcare delivery not only in the United States but around the world. Failure to measure value is the most serious self-inflicted wound of the medical profession and the broader provider community, because it has slowed innovation and brought about micromanagement of physician practice.

Measuring value depends first and foremost on properly measuring health outcomes. Patients have some initial or preexisting conditions. Services are delivered through processes of care delivery that reflect medical knowledge and are affected by patient initial conditions.

The care delivery process should strongly influence the outcomes achieved. Measuring value in health care. Some of the current challenges in measuring value are highlighted by Figure First, there is a great deal of confusion about the distinction between processes and outcomes.

Many participants in the healthcare system, and most quality measurement systems in health care, confound processes and outcomes or treat processes and structures as if they were outcomes.

While structural factors, protocols, guidelines, and practice standards are partial predictors of outcomes, they are not outcomes themselves Brook et al. Adherence to these types of measures is an imperfect indicator of outcomes. Process guidelines are invariably incomplete and omit important influences on the value of care Krumholz et al. Practice standards often fail to adapt care sufficiently to individual patient circumstances—standardized processes do not guarantee standardized outcomes.

Experience also shows that providers following identical guidelines achieve different results. Process guidelines also fail to cover the full cycle of care that actually determines value.

Thus, process measurement alone will not assure that results will improve for all patients. Moreover, process guidelines can slow innovation, because agreeing on guidelines is inevitably slow and invariably political. Medicine is constantly being refined, and guidelines can lag best practice or, conversely, lead to undue attention to processes that have yet to be definitively proven with a sufficient body of evidence. For example, best practice in treatment of post-menopausal women with estrogen has changed several times in the last decade alone, as new evidence has become available about the risks and benefits of the treatment for particular patient subpopulations.

Process control alone, then, is a risky and ultimately flawed approach to improving outcomes and increasing patient value. In any complex system, attempting to control behavior without measuring results will tend to limit progress to incremental improvement.

Without a feedback loop involving the actual outcomes achieved, providers are denied the information they need to learn and to improve their care delivery methods. Process control is a tempting shortcut because processes are easier to measure and less controversial than outcomes, but there is no substitute for measuring both Birkmeyer et al.

Another important distinction is that between health indicators and levels outcomes as shown in Figure Indicators, such as hemoglobin A 1c used in diabetes care as biological markers of blood sugar control, should be highly correlated with actual outcomes such as acute episodes and complications de Lissovoy et al.

However, such biological indicators are still predictors of results, not results themselves. To improve value in healthcare delivery, it will also be necessary to measure true outcomes and not rely solely or even predominantly on such indicators. Figure also includes patient compliance as an essential factor contributing to health outcomes.

There is compelling evidence that patient compliance with recommended preventive measures, preparations for treatment e. Yet there is a glaring absence of systematic measurement of patient compliance, a major gap in measurement. Focusing on adherence to provider practice guidelines without measuring compliance merely obscures the link between process and outcomes.

Failing to measure compliance also absolves providers and health plans of responsibility to treat compliance as integral to care delivery. There has been growing attention to patient satisfaction in health care, but sometimes in a way that obscures true value measurement.

Figure separates two roles of patient satisfaction in measurement: patient satisfaction with the process of care including hospitality, amenities, etc. There has been a tendency to rely too heavily on patient surveys in quality improvement programs, and surveys have focused mostly on the service experience. These surveys rarely cover patient compliance, a major gap. Many surveys also fail to address what is most important for value measurement, the actual health outcomes as perceived by the patient.

While the service experience can be important to good outcomes, it is the outcomes themselves that constitute value. In the absence of true results measurement, patients will tend to default to friendliness, convenience, and amenities as proxies for excellence in healthcare delivery. Providers cannot rely too heavily on service satisfaction surveys as measures of outcomes, or the value delivered.

An important corollary to defining the value proposition in health care is the definition of quality. In health care, the whole notion of quality has become a source of confusion and sometimes a distraction from genuine value improvement.

Quality ought to refer to patient outcomes. Quality relative to cost determines value in health care, as it does in any field. In health care, however, most quality initiatives are focused on processes of care and compliance with evidence-based guidelines. For example, of the 71 Healthcare Effectiveness Data and Information Set measures, the most widely used quality measurement system, only six are outcomes or health indicators and the balance are process measures.

Of the comprehensive collection of quality measures found in the National Quality Measures Clearinghouse, the overwhelming majority are not outcomes AHRQ, The quality movement in health care is on a dangerous path by trying to measure and control physician practice directly, rather than measuring outcomes.

While outcome measurement is difficult, process measurement is not a substitute. There has also been a tendency to equate safety and quality. The proliferation of safety initiatives is laudable, and has produced genuine improvements for patients.

However, safety is just one aspect of quality and not necessarily the most important aspect. To say it another way, doing no harm is important, but improving the degree of recovery or the sustainability of recovery are just as important, if not more so.

As I will discuss below, too much focus on safety instead of overall outcomes and value may lead to incremental process improvements affecting safety, rather than rethinking the overall delivery of care to improve total outcomes including safety.

To understand value in any field, the unit for which value is measured should conform to the unit in which value is actually created. The unit of value creation should define organizational boundaries in care delivery, which is a central tenet of organizational theory.

In health care, however, both measurement and organizational structure are misaligned with value creation. In fact, one of the principal reasons why value is mismeasured in health care, or not measured at all, stems from faulty organizational structures for healthcare delivery.

A medical condition is an interrelated set of patient medical circumstances best addressed in an integrated way. Care for a medical condition, such as breast cancer, diabetes, inflammatory bowel disease, asthma, or congestive heart failure, will normally require the involvement of multiple specialties. The definition of a medical condition includes the most common co-occurrences , or diseases that occur together.

Caring for the medical condition of diabetes, for example, needs to integrate the care for hypertension and vascular disease. The unit of value creation in health care delivery—care for a medical condition encompassing the cycle of care—collides with the way delivery is currently organized in the United States and in virtually every other country.

Health care today is organized by facility e. This means that both outcomes and processes tend to be mismeasured. Also, faulty organization of care creates many hurdles to actually achieving excellent outcomes. Measurement today usually focuses on the individual providers or specialists, despite the fact that the intervention of one provider is not the sole or even the primary determinant of the overall outcomes.

Measurement focuses on the discrete intervention, despite the fact that the intervention is one of many that determine outcomes. Measurement covers short episodes, which tells an incomplete story in understanding the overall outcome.

Outcomes from a few discrete interventions, or in a few medical conditions, tend to be used as proxies for the overall outcomes of the provider. Current organizational structure in healthcare delivery makes it difficult to measure value correctly.

Indeed, this is one of the most important reasons why it is poorly measured, or not measured at all. Providers, particularly, have a tendency to measure only what is under their direct control in a particular intervention, even if this is not what actually determines value. What is measured is what is easy to measure, rather than what matters for outcomes.

What is measured is also what is billed, even though the unit of reimbursement is misaligned with overall value. Gathering long-term, longitudinal data on outcomes is surely challenging, but the cost of doing so is unnecessarily high because of the current organizational structures and practice patterns. If practice structures were realigned to cover the care cycle, the cost of long-term outcome measurement would fall dramatically. Moreover, the assumption of joint responsibility for outcomes would be natural.

All these observations also apply to measuring costs. To understand the true costs of heath care delivery, one must measure the costs of all the interventions and services involved in determining the outcome.

Today each unit or department is seen as a separate revenue or cost center; no one measures the cost of the entire care cycle. Entities such as rehabilitation centers and counseling units are all but ignored in cost analysis. Many costs, such as those borne by the patient or within primary care practices, are not counted in measuring procedure-centric care. Treating drugs as a separate cost, for example, only obscures the overall value of care.

All costs must be included to measure the total cost of delivering outcomes, and overall value. While the unit of value creation is the medical condition over the cycle of care, a given patient may have multiple medical conditions. This often occurs, for example, in older patients who might have congestive heart failure and breast cancer and osteoarthritis of the hip. Such patients are best cared for by integrated practices for each condition that coordinate with each other. Value is best measured for each medical condition, with the presence of other medical conditions a risk factor in each one.

The alternative, defining a different measure of value for each patient, defeats the whole purpose of measurement. Outcomes are the core of value in healthcare delivery.

There is growing attention to measuring outcomes, which is a most welcome development. However, the practice of outcome measurement suffers from a number of problems. One of these is a tendency to look for a single ideal outcome measure for a given medical condition. However, there is never one outcome measure in any field or endeavor, and health care is no exception.

For every medical condition, there are multiple outcomes that collectively define patient value. One commonly measured outcome is survival or death. This is just one outcome, albeit an important one. Outcomes related to safety, such as the incidence of medical errors along with their consequences, are an additional type of outcome measure. To think holistically about outcome measurement for a medical condition, outcomes can be can be conceptualized in a hierarchy, with the most fundamental outcomes, survival and patient health, achieved at the top, and other outcomes arrayed in a natural progression, such as those related to the nature and speed of the recovery process and those related to the sustainability of the results.

Although there is not time to explore the details in this discussion, it should be possible to characterize the set of outcomes for a medical condition in a fashion that lends to objective and quantitative outcome measurement. For many patients, trade-offs may exist among individual outcomes.

For example, a more complete recovery could require treatment with a greater risk of care-induced illness. Or, more complete recovery could require treatment that is more discomforting. Where there are trade-offs, individual patients may differ in the weight they place on different levels of the hierarchy, and on specific measures. The discomfort of treatment willingly endured will be affected, for example, by the degree and sustainability of health achieved.

For example, cosmetic considerations may weigh heavily against risk of recurrence, such as in the choice of the amount of the breast resected for breast cancer patients, or long-term sustainability of recovery may matter less to older patients. A complete understanding of all aspects of such an outcome hierarchy matters more, not less, when different groups of patients value individual outcomes differently.

Thus, the first step to a systematic approach to value improvement is a disciplined approach to defining and describing the total set of outcomes.

In most fields, including medicine, progress in improving value is iterative and evolving. Excellent performance on one quality attribute leads to attention on improving others although improvements may also occur simultaneously. Over time, innovations seek to relax trade-offs among quality dimensions. In healthcare delivery, the concept of an outcome measures hierarchy emphasizes that progress can be made at different rates at different levels.

As survival rates improve, for example, more attention can be focused on the speed and discomfort of treatment.

Once effectiveness in recovery reaches an acceptable level, attention can shift to relaxing trade-offs between effectiveness and risk of complications, as in cancer therapy. By measuring the entire outcome hierarchy, such improvement is not only encouraged but made more transparent and systematic. And viewing outcomes in a hierarchy reveals opportunities for dramatic value improvements in existing therapies as well as in the development of more cost-effective therapies that address disease earlier in the causal chain.

This is a potential source of great optimism for the future in terms of cost containment. If we posit a hierarchy of outcome measures for a medical condition, this raises the question of how the importance of each one should be determined. These are important questions, which can easily derail outcome measurement.

They have led to the effort to monetize outcomes by, for example, calculating the value of human life or measuring the monetary benefits of improved productivity. If outcomes can be monetized, they can be aggregated and directly compared to costs to determine benefit-cost of value. Seeking to monetize individual outcomes is tempting, but unnecessary and even misleading and distracting in value measurement. Monetizing even tangible outcomes such as improved survival is fraught with complexity, and often arbitrary.

Monetizing more subjective or intangible outcomes is problematic. How should less arduous or less discomforting treatment be monetized?

How should cosmetic or appearance improvements be valued? With multiple outcomes, as we have noted, the value and weights will also vary by patient. Attempting to calculate a single aggregate outcome measure for all patients, or for each patient, is not the right approach to outcome measurement, at least given the current state of practice. Instead, the focus should be on improving the set of outcomes and value in the sense that some outcomes improve without sacrificing others.

For this purpose, outcomes need not be monetized, and individual outcome measures need not be aggregated. Similarly, factoring initial health state into outcome measurement is an important issue. Several efforts to gather and report outcomes have failed because inadequate risk adjustment led to resistance and rejection by the medical community Porter and Teisberg, Even in its current imperfect state, however, getting on with understanding the relevant initial conditions and adjusting for them is essential to improving value itself.

For example, the lack of case adjustment methods is a root cause of the underpayment of providers for more complex cases, both in the United States and elsewhere. Finally, the task of appropriately measuring costs requires close attention. Cost measurement needs to follow some essential principles, including: measuring the full costs of care, not the portion of costs borne by any one actor or the portion of costs taking any one form e.

Value must be the fundamental goal of any healthcare system. Measuring value, and improving it, must become the driving force for every participant in the system. Today, in the U. The fact that healthcare delivery is not organized around value impedes excellent care and drives up its cost.

The fact that reimbursement is not aligned with value cripples the process of value improvement, and renders the profit motive a destructive force rather than a value driver. Proper measurement of value is the single most powerful lever for improving healthcare delivery.

While current organizational structures and practice standards surely create obstacles to value measurement, there are promising efforts to overcome these obstacles. While current measurement efforts are highly imperfect, at least the process of measurement has begun. Health plans, providers, employers, and government policy can all contribute to making measurement of value in health care a reality.

This article draws heavily on joint research with Elizabeth Teisberg Porter and Teisberg, I am grateful to her for her fundamental contribution to the line of thinking discussed here. The same is true for health plans, who can profit through shifting costs and restricting revenues to providers, patients, or the government without actually offering patient outcomes or true efficiency. See below. This does not imply, for example, that all efforts at prevention will lower costs or even improve value.

However, focusing on outcomes as a way to reduce long-term costs will spur innovations in better and more cost-effective forms of prevention as well as other value improvements.

Note that the set of specialties required to care for a medical condition may differ across patient populations. The IPU structure dramatically reduces the complexity of coordination and facilitates the true medical integration of care. For these reasons, the use of claims data in outcome measurement can be misleading unless it aggregates claims at the medical condition level. See Michael E. Turn recording back on. Help Accessibility Careers. Show details Institute of Medicine US.

Search term. Shalala, University of Miami Any discussion of incorporating EBM into the current healthcare system should include an examination of the role of government and regulatory agencies.

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Healthcare readmission address policy in to changes como saber si amerigroup cubrio mi parto

Healthcare Informatics: Analytics for Readmissions, Length of Stay, CMI, Core Measures, EBM

WebCopyright United HealthCare Services, Inc. Inpatient Readmission Review Policy, Facility IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are . WebHRRP is a Medicare value-based purchasing program that encourages hospitals to improve communication and care coordination to better engage patients and caregivers in . WebCopyright United HealthCare Services, Inc FD Readmission Policy, Facility IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for .