Transcript Systems Based Practice - Dr. James Rohack

SYSTEMS BASED PRACTICE
Part I
Dr. James Rohack
General Competencies
• Medical knowledge
• Patient Care
• Practice-based learning
• Interpersonal skills and communication
• Professionalism
• Systems-based practice
The medical profession has long
subscribed to a body of ethical
statements developed primarily for the
benefit of the patient. A physician
must recognize responsibility not only
to patients, but also to society, to
other health professionals and to self.
The Competent Physician
• Possesses medical knowledge,
judgment, professionalism, clinical
and communication skills to provide
high quality patient care
• Evidence of professional standing
• Evidence of commitment to life-long
learning and involvement in periodic
self-assessment
• Evidence of cognitive expertise
• Evidence of evaluation of performance
in practice
You don't know what you
know until you know
Systems-Based Practice
• Awareness of and responsiveness
to the larger context of the system
of healthcare
• Ability to call on system resources to
provide care that is of optimal value
Traditional Fee-For-Service
Revenue
Net Income
Total Cost
$
Variable
Fixed
n1
Volume
Annual Cost of Medical Care in USA
• $ 949.4 Billion/Year
• 50% has minimal or no value
• 31% for administrative costs
• 25% of medical disability due to behavior
or environment
•
•
•
•
•
Smoking
Diet
Alcohol
Stress
Noncompliance
(NEMJ,2003, 349,8,768-775)
HealthCare
Privilege versus Right
Insurance versus Coverage
• MANAGED CARE is the process of the
application of standard business practices
to the delivery of health care in the
traditions of the American free enterprise
system.
Funding Streams
• Individual
• Employer
• Government
Medical Profession
Government
Capitalists
Employers/Wall Street/
Insurance
Capitation
NET INCOME
VARIABLE
COSTS
REVENUE
FIXED
COSTS
n
VOLUME
PMPM
• Per Patient Per Month
• Used to calculate required capitation
rates, based upon utilization and cost
per unit for specified items.
Paradigm Shifts
Traditional Focus
Managed Care Focus
Treat sickness
Maintain wellness
Fee-for-service
Capitation
Solo practice
Group practice
Indemnity insurance
Managed care
Super specialists
Primary care
Paradigm Shifts (cont.)
Traditional Focus
Managed Care Focus
Inpatient care
Ambulatory care
Profit centers
Cost centers
Individual patients
Populations
Fragmentation
Integration
Bricks and mortar
Networks
IPAs
(Independent Practice Association)
• Set up to accept risk, manage and
distribute share of premium
• Either "professional risk only", or "global
risk"
• Global risk IPAs often partnered with
hospitals
Humana/PCA Health Plans 1997
PPO
(Preferred Provider Organization )
• Network of MDs and Hospitals who agree to
"discount" in return for prompt payment and
steerage
• Individuals choose to use or not use
• Individuals choose to use or not use the
network at each incident of care
• Financial incentives to use the network
• Lower deductibles
• Lower co-insurance
Humana/PCA Health Plans 1997
Capitation
NET INCOME
VARIABLE
COSTS
REVENUE
FIXED
COSTS
n
VOLUME
 Utilization Rates among California
Cardiologists and Gastroenterologists
Following Capitation
Sigmoidoscopy
Diagnostic
Upper GI
Endoscopy
Colonoscopy
with Lesion
Removal
Diagnostic
Caths
Angioplasty
0%
-20%
-40%
-12%
-37%
-60%
-62%
-80%
-70%
-77%
(The Health Care Advisory Board Company, 1995)
Managed Care
Reduces Costs
Legislature
• Unfunded mandates
• Impact of premium increases
• Rise of uninsured
Examples of
Legislative Mandates
•
•
•
•
•
•
•
Newborn hearing screening
Mastectomy reconstruction
Prostate cancer screening
Maternity length of stay
Serious medical illness coverage
TMJ coverage
Craniofacial abnormality treatment coverage
Market Forces: The Economic Drivers
Employers seek less
expensive health care
Reimbursement
decreases
Collaborations/Mergers/
Acquisitions escalate to
enhance power and
efficiency
Non-Profits
become alarmed
Develop purchasing
consortia
Providers affiliate to
increase bargaining
power and protect
patients
Predators discover
profits in medicine
Result: Providers lose control of medical enterprise
Factors Driving Up Costs
•
•
•
•
Growth in pharmaceutical expenses
Expensive new technologies,
Aging of the population, and
Increased consumer demand
Utilization Management
• Prescriptive
• Capitation
• Integrated Healthcare System
Utilization Management
Prescriptive
• Preauthorization for:
• Referrals
• Expensive Tests
• Hospital Admissions
• Length of stay guidelines (concurrent review)
• Definition of benefits
Utilization Review
• Formal assessment of the medical
necessity, efficiency, and/or
appropriateness of health care services
and treatment plans on a prospective,
concurrent or retrospective basis.
Medically Necessary
Health care services that are
1) essential to preserve the health of the member
2) consistent with the symptoms or diagnosis and
treatment of the member’s condition, disease,
ailment or injury
3) appropriate with regard to standards of good medical
practice in the community
4) not solely for the convenience of the member,
physician or provider
5) the most appropriate supply or level of service which
can be safely provided to the member
Prior Authorization
• Process of obtaining prior approval to the
appropriateness of a service or medication.
Prior authorization does not guarantee
coverage.
Case Management
• Process whereby covered persons with
specific health care needs are identified
and a plan designed to efficiently utilize
health care resources is formulated and
implemented to achieve the optimum
patient outcome in the most cost-effective
manner.
Financial Considerations
Strategies to Control Costs
• Shift to ambulatory care
• Streamline all care
• Limit unnecessary care
• One third of primary care visits are
unnecessary
• Half of the surgeries performed are
inappropriate
Financial Considerations
Strategies to Control Costs
• Use Urgent care
• Use of the emergency facilities for non-urgent
care is estimated to comprise 40% of all
visits,and such visits are 2 to 3 times more
costly than a primary care office visit
• Manage chronic disease
Over half of chronic illness is preventable.
AHRQ User Liason Program 2001
Payment Mechanisms
For Hospitals
• Per Diem
• DRG
• Capitation
Payment Mechanisms
For Physicians
• Discounted fee for service
• Discounted fee schedule
• Capitation
Marketplace “Drivers”
60%
Purchaser Demands
40%
Traditional
Transitional
Discounted
FFS
Capitation &
Case Rates
Mature
20%
0%
Value-Based
Selection
Value =
Quality
Cost
Ways Others Are Reducing
Resource Utilization
• Develop practice guidelines to reduce
variation
• Shift care to alternate, less costly
providers
• Reduce numbers of procedures
• Limit hospital costs
Managing the Cost of Primary Care…
Health Care Shifting Left
Patient
Self-Care
Telephone
Triage Nurse
Physician
Extenders
Primary Care
Physician
Cost of Routing Care Episode (e.g., cold, flu)
$40
$1
$50
$5
(The Health Care Advisory Board Company, 1995)
Cost to HMO
ER versus Clinic
•An average visit to an emergency room costs $383 –without
physician fees. (2001 www.appleton.org)
•The average physician's office visit costs $60. (American Medical
Association, "Physician Socioeconomic Statistics," 2001.)
High Cost Encourages
Adverse Selection
Cost/Quality
Enrollment
Low
Healthy, Younger,
Less Concerned
High
Older, Sicker,
More Concerned
Uninsured 14.3% Population
Probability of persons under age 65 being
uninsured, by state, 1997–1999.
Texas Leads Nation in
Uninsured Children
Center Public Policy Priorities, 2002
Hispanics in Texas
According to the 2000 Census, Hispanics now comprise 32
percent (6.7 million), while white non-Hispanics constitute
53 percent. The rate of growth for Hispanics in the 10-year
period was 55 percent. Although most Hispanics are of
Mexican descent, the numbers and percentage that are
Puerto Rican, Cuban, and Central American are increasing
throughout Texas.
Health coverage for Texans
Who Pays – You Do
Consumers Want:
• Choice
• Control
• Customer service
• Brands
• Information
Future Funding Problems
• Spreading risk
• Individual responsibility
• Genomics
• How to say NO
Future Directions
Enhance
Service
Reduce Costs
Improve
Quality
Compassion
(advocacy)
Balance
(tension)
Excellence
(quality)
Efficiency
(stewardship)
Part I
The End
Post Test I
Please print page, take exam, send hard copy to
Dr. Sandra Oliver OME
1. When a physician orders a test that is
unnecessary to make a diagnosis or
treatment plan, all the following occur
EXCEPT:
A. increases the premium for health insurance the
following year
B. may result in more tests ordered based on
results
C. increases financial reimbursement under
capitation
D. may decrease liability risk
Question 2
2. Which funding source for medical
care is most impacted by political
influence?
A. individual fee for service
B. private Insurance
C. employer self insured
D. government
Question 3
3. Which of the following does not
reduce resource utilization?
A. Develop practice guidelines to reduce variation
B. Shift care to alternate, less costly providers
C. Increase numbers of procedures
D. Limit hospital costs
Question 4
4. Which method of controlling
medical costs is being abandoned
by some insurance companies?
A. co-pays
B. gatekeeper for specialty referrals
C. chronic disease management
D. practice guidelines
Question 5
5. Which of the following medical
delivery systems is at greatest risk
for ethical problems of performing
unnecessary tests?
A. health maintenance organizations
B. fee for service
C. medicaid
D. primary care case management
Question 6
6. Which of the following medical delivery
systems would have the least likelihood
of a common electronic medical record?
A. Independent Practice Association (IPA)
B. Preferred Provider Organization (PPO)
C. Physician-Hospital Organization (PHO)
D. Integrated Medical Delivery System (IMS)
Question 7
7. Which mechanism is most likely to
influence your physician practice?
A. discussion of a new treatment by a
colleague
B. practice guideline described by a
national physician organization
C. practice guideline placed on a electronic
physician order entry system
D. elimination of reimbursement for a test
by a payor
Question 8
8. Which of the following is false
about Texas ?
A. Highest number uninsured children
B. Highest percentage of elderly
C. Physicians subsidize 26% of
uninsured health care
D. Lower insured rate than nation
SYSTEMS BASED PRACTICE
PART II
Dr. James Rohack
Systems-Based Practice as manifested
by actions that demonstrate an
awareness of and responsiveness to the
larger context and system of health care
and the ability to effectively call on
system resources to provide care that is
of optimal value.
Medical Profession
Government
Capitalist
Employers/Wall Street/
Insurance
Professionalism
• Subordinate self-interest to the interests
of others
• Adhere to high moral and ethical
standards
• Respond to societal needs, reflect a
social contract
• Commitment to scholarship and
advance-ment of one’s field
Quality
Scientific
Approach
All One
Team
Value =
Quality
Cost
There's another way
to measure quality.
It's health care quality
from the
patient's point of view.
Quality
HEDIS
JCAHO
TQM
Report Cards
NCQA
FACCT
Profession
State
Capitalists
HEDIS Data
Quality of Care
•
•
•
•
Childhood immunization rate
Cholesterol screening rate (age 40-64)
Cervical cancer screening rate (age 21-64)
Percent patients receiving prenatal visit,
first trimester
• Percent infants below birth rate
Acute
Care
Costs
Soaring
Reduction in process
variation and multi system
interactions reduces Risk
for failure
Physicians Control Two-Thirds
of Inpatient Costs
Controlled by
Physicians
30-35%
Controlled
by Hospitals
65-70%
(Health Care Advisory Board, 1995)
"80% of future cost savings will come
from modified physician conduct - not
hospital efficiency, etc."
(Advisory Board, Washington, D.C., 1993)
Resource Utilization
• Waste occurs
• Eliminate unnecessary and
duplicative services
Primary Care Physicians
“Population” Managers
Specialists
“Event” Managers
Variation in Cost per Episode for Orthopedics
Physician
Cost per Episode ($)
280
Jones
Tier I
297
D alton
(Data not severity adjusted)
305
Smi th
Average cost Percentage below
per episode
IPA average
R eaves
314
Star kman
319
Li ncoln
322
Levi tt
323
Adamson
329
$315
D onahue
345
O'R eil ly
346
H arri ngton
350
Tier II
Schmi dt
369
Pier ce
372
IPA Average cost
per episode
391
Snyder
20%
Wel ls
415
Bixby
417
Farg oe
432
Klei n
434
Alber tman
435
$392
449
R osenberg
Tier III
497
Brown
C arter
550
C ohen
552
Phil ips
555
Average cost Percentage above
per episode
IPA average
$611
56%
635
C hu
643
R il ey
859
Fri sman
943
Slater
0
10 00
(The Health Care Advisory Board Company, 1995)
Inpatient Costs Controlled
by Physicians
• Admissions/Location Within Hospital
• Length of Hospital Stay
• Utilization of Supplies and Services
• Lab/Radiology
• Pharmacy
• Consults
You cannot improve what
you do not measure
Patient Safety
Principles for Patient
Safety Reporting
1. Create an Environment for Safety
2. Data Analysis
3. Confidentiality
4. Information Sharing
Culture - the set of shared attitudes,
values, goals and practices
that characterizes a
company or corporation
Culture of Safety
• Highly reliable organization
• Key components
• Non punitive reporting
Error - the failure of a planned action
to be completed as intended,
or the use of a wrong plan to
achieve an aim
No one admits an error if
you punish them for it
Big Errors Result
from
Little Errors
Root Causes of Errors
• Insufficient information available to
those who need it
• Insufficient or inadequate
communication
• Insufficient or inadequate monitoring
Humans are the adaptable
element of complex systems
Normal Human Error Rates
Probability
• Error of commission
0.003
• Error of omission
0.01
• Error in high stress
with rapid activities
0.25
“Man- a creature made at the
end of the week, when God
was tired.”
Mark Twain
Safety is made and broken in
systems, not individuals
Culture of Safety does NOT
Mean:
• Abandonment of professional accountability
• Anonymity
• Disregarding
• gross incompetence
• gross procedural violations
• gross insubordinations
• illegal activity
• practicing under the influence
Plan
Act
Do
Check
Value =
Quality
Cost
Patient Satisfaction
• Trust is key
• Patient satisfaction at individual
physician level now being tracked
High Quality Practice
• Measurement
• Outcomes cannot be measured
easily or accurately
• Current strategy is to measure
process
Future Directions
Purchasing Information Employers
Plan to Use in the Future
Treatment outcom es
NCQA accreditation
Report cards
HEDIS
Em ployer-specified
standards
CQI
> 1,000 em ployees
< 1,000 em ployees
0% 5% 10% 15% 20% 25% 30% 35%
Percent of Employers
(368 companies surveyed, Washington Business
Group on Health/Watson Wyatt Worldwide, 1995)
Vertical Integration of Hospitals and Physicians
PHYSICIANS
Solo
Office Share
IPA
CWW
INSURER
Group
Capitation Joint Venture Ownership
Physician-owned
Foundation
MSO
Closed PHO
Open PHO
Service Bureau
HOSPITAL
Staff
Success and Failure Flow
from Same Sources
• Understand technical work
• Dynamic process
• Design tasks and processes that
minimize dependency on weak
cognitive functions
eg: hurry, fatigue, anger, anxiety,
boredom, fear, interruptions
Change introduces new
forms of failure
U.S. Public Opinion Definition of a Good Doctor
• Taken for granted was medical
knowledge and experience
• Quality defined as doctors who care,
communicate and take time to listen
• Treat patients as customers
• Recover from mistakes quickly
• Communicate genuine interest
• Provide recognition and understanding
• Show compassion
Quo Vadis?
The Art of Caring for Patients
is Caring for Patients
Post Test II
Please print test pages, take exam, send hard copy to
Dr. Sandra Oliver OME
1. When you find the medical care your
patients receive is not of high quality,
the following are actions of advocacy
you can take EXCEPT:
A. create a practice guideline
B. lobby for passing a law
C. ask your patients for their expectations
D. refer to a different physician group
Question 2
2. How Is Value defined?
A. Quality/ Cost
B. Cost x Quality
C. Quantity/Cost
D. Cost x Desirability
Question 3
3. When one of your patients requires a
medication to treat a disease that they
cannot afford, all of the following are
reasonable actions you can take EXCEPT:
A. write a letter to their insurance company for
an individual case review for coverage
B. write the pharmaceutical company for help
through an indigent program
C. lobby for the state to mandate as a benefit
D. encourage the patient to take a family
member’s unused medications
Question 4
4. The way to improve patient care is by
improving the safety of the medical delivery
system. The following are ways that that
can be accomplished EXCEPT:
A. measure process of care
B. measure outcome of care
C. increase variation of care
D. decrease variation of care
Question 5
1. The most common reason for system
error when dealing with humans is:
A. fatigue
B. complexity of task
C. number of individuals involved
D. number of times a computer is used
Question 6
6. One percent of individuals consume 25
percent of medical costs. All the following
are potential partners to improve care while
decreasing costs in the short tem EXCEPT:
A. social workers
B. insurance companies
C. funeral directors
D. government
Question 7
7. In a medical system that is owned by a
investor based for-profit system,
decreasing medical costs will result in:
A. decrease in stock value
B. increase in stock value
C. decrease in quality of care
D. increase in equitable distribution of
services
Question 8
8. Big changes in medical systems can be
made by which of the following
A. Small changes in physician processes of
care
B. Changes in public opinion of medical care
C. Changes in legislative reimbursement of
medical care
D. All of the above