Capita Cost Of Care Research Articles

A Hexagonal Aim as a Driver of Change for Health Care and Health Insurance Systems.

Improving health systems, such as the U.S. or French, requires simultaneous pursuit of a patient centered approach aligned with the health professional: improving the experience of care, improving the health of populations, reducing per capita costs of care - Triple Aim - and improving the work life of the care providers, including clinicians and staff - Quadruple Aim -. While these aims are already ambitious, they may be insufficient when considering the economic, social and environmental challenges to the health of our communities in the near and long term. A conceptual framework to provide additional ethical guardrails for health systems. Recently, authors have articulated a Fifth Aim and we propose to add a Sixth Aim to the Quadruple Aim model. These additional aims are meant to account for our growing knowledge around the determinants of health and the challenging processes and structures of governance across a wide range of sectors in society including healthcare. We are strengthening the Fifth Aim defined as equity through "health democracy" to represent the wants, needs and responsibility of the population in taking care of their health and their healthcare. The Sixth Aim is to account for the increase in risk to population health due to climate change as well as the impact our health systems have on the environment. As social tension and environmental changes seem to continue to impact the structure of our society this "Hexagonal Aim" taken together might provide additional ethical guiderails as we set our healthcare goals.

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

Perioperative Medicine: What the Future Can Hold for Anesthesiology.

Wildfire Response and Recovery: The Importance of Coordinated Care and Social Support

Summary A decade ago, the Oregon legislature created coordinated care organizations (CCOs) through a Medicaid 1115 Demonstration waiver as a way of integrating physical, behavioral, and oral health in a single funding stream. The intent of the legislation was to facilitate the development of regional organizations that would coordinate comprehensive care for their Medicaid populations. AllCare Health, through AllCare CCO, serves approximately 61,000 members in the Southern Oregon region by partnering with providers and community organizations and stakeholders. As a participant in this community network beginning in the mid-1990s, prior to CCO legislation — and having developed the infrastructure to support community development and the trust to reinforce relationship management — AllCare Health was able to help facilitate the local response to the destructive wildfires affecting Southern Oregon in the fall of 2020. Using geographic information systems technology, AllCare Health identified members at risk in the fire zones and coordinated evacuation, health care services, and social needs in the immediate crisis. AllCare Health’s experience with integrating social determinants of health (SDOH) and preexisting relationships developed over many years allowed the organization to be a catalyst in the community response to the wildfires, which, given the changing climate, have become more frequent. Further, the CCO model supports care delivery that recognizes SDOH and supports the Triple Aim of improved patient experience of care, improved health of populations, and reduced per capita cost of care.

Prediction of the Number of and Care Costs for Disabled Elderly from 2020 to 2050: A Comparison between Urban and Rural Areas in China

An aging population and an increase in the proportion of elderly people who are disabled have created an unprecedented global challenge, especially in China. This study aimed to predict the number of, and the care costs for, disabled elderly from 2020 to 2050 in China. A comparison was made between urban and rural areas, and we analyzed what must be done to maintain the sustainable development of China’s long-term care insurance (LTCI) system. An overall simulation model and a Monte Carlo simulation were used to estimate the number of disabled elderly and their related care costs, in both urban and rural areas. According to the forecast, the total disabled population will increase rapidly, rising from 43.75 million in 2020 to 91.4 million in 2050. Of that total, 69.7% are expected to be urban elderly. Starting in 2020, the growth rates of the elderly with mild, moderate, and severe disabilities will be 108%, 104%, and 120%, respectively, by 2050. Accordingly, the total care costs will increase from 538.0 billion yuan in 2020 to 8530.8 billion yuan in 2050, of which 80.2% will be required in urban areas. In addition, the per capita costs of care in urban and rural areas in 2050 will be 6 times and 11 times higher than in 2020, respectively. The predicted results show that the number of disabled elderly and the related care costs will increase sharply from 2020 to 2050, especially the growth rate of the number of severely disabled elderly. This study provides strong evidence of the need for the establishment of a unified national LTCI system in China.

Psychiatric inpatient cost of care before and after admission at a residential subacute step-up/step-down mental health facility

Background: Residential step-up/step-down services provide transitional care and reintegration into the community for individuals experiencing episodes of subacute mental illness. This study aims to examine psychiatric inpatient admissions, length of stay, and per capita cost of care following the establishment of a step-up/step-down Prevention And Recovery Care (PARC) facility in regional Australia.Methods: This was a pragmatic before and after study set within a participatory action research methodology. The target sample comprised patients at a PARC facility over 15 months. Six-month individual level data prior to study entry, during, and over 6-months from study exit were examined using patient activity records. Costs were expressed in 2015–2016AU$.Results: An audit included 192 people experiencing 243 episodes of care represented by males (58%), mean age = 39.3 years (SD = 12.7), primarily diagnosed with schizophrenia (48%) or mood disorders (30%). The cost of 1 day in a psychiatric inpatient unit was found to be comparable to an average of 5 treatment days in PARC; the mean cost difference per-bed day (AU$1,167) was associated with fewer and shorter inpatient stays. Reduced use of inpatient facility translated into an opportunity cost of improved patient flow equivalent to AU$12,555 per resident (bootstrapped 95% CI = $5,680–$19,280). More noticeable outcomes were observed among those who stayed in PARC for longer during index admission (rs = 0.16, p = 0.024), who have had more and lengthy inpatient stays (rs = 0.52, p < 0.001 and rs = 0.69, p < 0.001), and those who stepped-down from the hospital (p < 0.001). This information could be proactively used within step-up/step-down services to target care to patients most likely to benefit. Despite early evidence of positive association, the results warrant further investigation using an experimental study design with alongside economic evaluation.Conclusion: Efforts should be directed toward the adoption of cost-effective alternatives to psychiatric inpatient facilities that provide comparable or improved patient outcomes.

System-Level Reform in Healthcare Delivery for Patients and Populations Living with Chronic Disease.

Healthcare in Canada has generally not kept pace with the evolving needs of patients since the creation of medicare in the 1960s. Budgets for hospitals, physicians and prescription drugs make up the bulk of spending in health, despite the need for better prevention and management of chronic disease, the needed expansion of home-based care services and the call for reform of front-line primary care. Over the past decade, a number of Canadian health authorities have adopted the US-based Institute for Healthcare Improvement Triple Aim philosophy (better population health, better patient experience and better per capita cost of care) in order to build system-level change. The Atlantic Healthcare Collaboration was one attempt to initiate system-level reform in healthcare delivery for patients living with chronic disease.

Sharing care to achieve the triple aim of health care delivery.

patients cared for by oncologists alone are less likely to be managing these comorbid conditions or receiving indicated preventive care. In contrast, when patients are seeing both primary and oncologic care providers, they are more likely to be managing the comorbid conditions and receiving indicated preventive care. To achieve the second aim of improving the care of patients, we need to manage the whole constellation of medical problems people face; we need to think about sharing care among providers and taking care of people, not diseases. Sharing care makes sense both medicallyand financially. The Ben-Ami et al study asked whether people on chemotherapy wanted their primary care physician to be involved in their oncologic care. The three most common comorbid conditions among individuals ages 65 are high blood pressure (58%), high cholesterol (45%), and ischemic heart disease (31%). 8 These are not oncologic problems, and they are managed well by primary care. Even if oncologists managed them well, the costs are much higher than in primary care because salaries are substantially higher. 10 Having people seek care for nononcologic conditions in primary care makes good medical sense and will help reduce per capita costs for care. However, the Ben-Ami article has limitations. We do not know the applicability of findings from Israel to realities here in the United States. The Israeli system is based on primary care, and 96% of the patients undergoing chemotherapy stated they

Interprofessional Clinical Experiences in Dental Education

Interest and activity in interprofessional education (IPE) has grown substantially in recent years across the health professions, driven by the belief that more effective interprofessional collaboration among providers will contribute to realization of the Triple Aim objectives articulated by the Institute for Healthcare Improvement—better individual care experiences, better population health, and reduced per capita cost of care. In dental education, new standards from the Commission on Dental Accreditation (CODA) in 2013 require that dental schools demonstrate that graduates are competent to communicate and collaborate with other health professionals, requiring dental educators to develop IPE curricula and assessment at their institutions. One of the more challenging aspects of IPE curriculum development is to provide meaningful interprofessional clinical experiences for students. The purpose of this paper is to review selected examples of interprofessional clinical experiences involving dental students and to describe an interprofessional clinical experience implemented at the authors’ institution.

Population Health Management and the Journey to Medical Home Certification in a Rural Community

WHY ADOPT POPULATION HEALTH MANAGEMENT?Population health management has been the focus of many studies and articles as a critical strategy for success as the healthcare delivery system changes in response to government regulations and insurance industry shifts. It also is frequently cited as a tool to manage costs. Zenty and Bieber's feature article discusses how University Hospitals Health System's (UH) population health management initiative evolved through the experience of its various accountable care organizations (ACOs), which were formed to address the rising costs of their self-insured plans.In the other feature article for this issue, Kindig and Isham discuss the need to improve the health of our communities and close the lag in health outcomes across the United States compared to most developed countries. I believe their message that the challenge of population health improvement cannot be the sole responsibility of the healthcare industry is critical to understanding how we move forward.A recent article in the Journal of the American Medical Association, by Friedberg and colleagues (2014), complicates this discussion, however. Those authors suggest that the care offered in a patient-centered medical home (PCMH) environment, which is designed to coordinate resources to improve patient care, offers little benefit to the outcomes experienced by the patient or in reducing the cost of care. One might conclude from Friedberg and colleagues' findings that if a PCMH or another population health management tool produces no cost management or patient outcome benefits, why invest in the effort?These authors directly or indirecuy link population health management to the Triple Aim as articulated by the Institute for Healthcare Improvement (IHI): improvement of individuals' experience of care, improvement of the health of populations, and reduction of per capita cost of care for populations. Of these, in my opinion, that improvement of the individual experience of care could be the most significant factor influencing the achievement of health improvement and, eventually, cost management.The Perspective of a Critical Access Hospital/Rural Health ClinicYuma District Hospital and Clinics (YDHC) consists of a 12-bed critical access hospital and two rural health clinics offering family medicine, a specialty clinic that brings a variety of medical and surgical specialists to the community throughout the month, and a PhD-degreed psychologist and licensed professional counselor. We offer post-acute care through our swing-bed program and a home health agency. Our ten primary care providers are employees of the organization. Consider us a micro-integrated healthcare delivery system serving a population of approximately 14,000 people spread across a wide geographic area.In 2008, YDHC was invited to participate in an initiative led by the Commonwealth Fund, Qualis Health, and the MacCoil Center for Health Care Innovation at the Group Health Research Institute. The objective of the initiative was to develop and demonstrate a sustainable model to transform primary care safety net practices into PCMHs, thereby achieving the IHI Triple Aim goals. (For more detail about the initiative, refer to www.safetynet medicalhome.org.) We eagerly agreed to participate, with the simple thought that this would be a tool to improve patient care in our rural health clinic. The timing seemed right: We had recently moved into a newly constructed replacement facility to house our hospital and our main clinic, and we were midway through the rebuilding of our medical staff. It was our feeling that this would not be a long journey and that the care provided in our facilities was already close to that of a medical home environment. It did not take long for us to realize that we were just beginning.At the same time as we were moving forward with this initiative, we were faced with a population of patients who believed that their experience of care was not satisfactory. …

Behavioral health in the Department of Defense Patient-Centered Medical Home: history, finance, policy, work force development, and evaluation

Integrating behavioral health services into the patient-centered medical home (PCMH) is an important component for meeting the goals of easy access, whole person, coordinated, and integrated care. Unlike most PCMH initiatives, the Department of Defense's (DoD) Military Health System (MHS) launched its PCMH initiative with integrated behavioral health services. This integration facilitates the MHS's goal to meet its strategic imperatives under the "Quadruple Aim" of (1) maximizing readiness, (2) improving the health of the population, (3) enhancing the patient experience of care (including quality, access, and reliability), and (4) responsibly managing per capita cost of care. The MHS experience serves as a guide to other organizations. We discuss the historical underpinnings, funding, policy, and work force development strategies that contributed to integrated behavioral healthcare being a mandated component of the MHS's PCMH.

Health Care Change Ahead: Are You Ready?

Health Care Change Ahead: Are You Ready?

Integrating behavioral health services within military health system: a model for opportunities and challenges

Background–The 2010 Department of Defense Quadrennial Defense Review report was the impetus for a review of strategies, programs and resources including healthcare. A section of this report focused on lowering military health systems cost, while striking a balance with the “Quadruple Aim” (1) maximizing readiness, (2) improving the health of the population, (3) enhancing the patient experience of care, and (4) responsibly managing per capita cost of care. The Patient-Centered Medical Home (PCMH) was a primary target to reach the goals of the Quadruple Aim. What is the basis for integration of behavioral health services into Department of Defense Military Health System (MHS)?–The PCMH is an initiative to reorganize primary care to improve health outcomes. The implementation and evaluation of transformed primary care systems into PCMHs across the USA is also taking place in the Department of Defense MHS. Unlike most PCMHs, the MHS effort considered the integration of behavioral health services essential to PCMH implementation. Although the Navy, Air Force, and Army all have integrated some aspects of behavioral health into their models, there was a need for an overall MHS systemwide vision and implementation. A 2007 Taskforce on Mental Health recommended the integration of mental health professionals into primary care settings to improve the access and outcomes of behavioral healthcare within MHS. In response to this recommendation, A Mental Health Integrated Working Group (MHIWG) established recommendations for integrating behavioral health providers and care facilitators into primary care that included staffing, evidence-based assessment and treatment, and workforce development. How was the policy for integrating behavioral health services developed?–Once funding was secured, the recommendations from the MHIWG were transformed into a Department of Defense policy. This policy ensures minimum standards, competencies, and evaluation of impact within and across the services. Although currently in draft form, it is estimated that after a 12-month coordination process, it will be formally published. How will the workforce be developed to facilitate this implementation?–Behavioral health professionals are often trained for assessment and intervention in specialty clinics where appointment length and reporting are longer and more detailed than in other health care settings, particularly PCMH. The difference in culture, clinical setting, and the unique delivery system warrants minimum training criteria and core competencies for behavioral health providers consistent with Air Force, Navy, and Army publications. Training will include didactic and experiential training prior to seeing patients. How will the integration of behavioral health services be evaluated?–Evaluation of this initiative is imperative for long-term sustainability and effectiveness. Because behavioral health providers and care facilitators were not part of overall PCMH evaluation outcomes, separate evaluation variables are being planned. These include patient, provider, and clinic, and system level, process, measures that align with the Quadruple Aim. Research questions, methods, data collection, and statistical analysis are being proactively determined and they will correspond with measures collected. Bottom line: The development, implementation, and evaluation a policy to integrate behavioral health services into Military Health Service is complex but has the potential to improve care while lowering military health systems cost and striking a balance with the goals included in the Quadruple Aim. This initiative can be used as a model of behavioral health services integration in other PCMHs. Policy implications: It is necessary to involve many different groups in policy development and implementation strategies. These stakeholders should be engaged at all levels and leaders and champions identified and utilized. Specific rationale for the policy needs to be clear and evidence-based. Evaluation needs to be considered in the planning stages of a policy to integrate behavioral health services to gain robust measures that demonstrate policy effectiveness. Research implications: It is necessary to identify expected impact from integration and develop a set of quality metrics and effective evaluation design that will allow scientifically robust conclusions to be drawn. Developing these measures and using them consistently across care systems can help build the evidence of the importance of behavioral health services integration.

Medicare Head Donald M. Berwick, MD, Takes on Mission of Health System Reform

CHICAGO—Donald M. Berwick, MD, MPP, has devoted much of his professional life advocating for improving quality and outcomes of health care through evidence-based reform of the nation’s health care delivery system. Now, in his new role as administrator of an agency spending more than $800 million to cover health care costs of about 100 million individuals, the Centers for Medicare & Medicaid Services (CMS), Berwick hopes to implement such reform. The effort will have implications for physicians, health care workers, and hospitals across the country. Before becoming CMS administrator on July 7, Berwick, a pediatrician, cofounded the independent and notfor-profit Institute for Healthcare Improvement (IHI). The institute uses evidence-based research to quantify measures aimed at improving quality of medical care and then disseminates the findings of such research to the health care community. As IHI’s president and CEO, Berwick, who was also a professor of health policy and management at the Harvard School of Public Health in Boston, helped develop IHI’s Triple Aim initiative (Berwick DM et al. Health Aff [Millwood]. 2008;27[3]:759-769). The initiative calls for redesigning the health care delivery system to simultaneously accomplish 3 primary objectives: improve the health of the population, enhance patient care (including quality of, access to, and reliability of care), and reduce or at least control the per capita cost of care. Triple Aim builds off the Institute of Medicine’s 6 aims for improvement in the delivery of health care in the United States as outlined in a 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century” (http://bit.ly/b3BZ84). Although physician and consumer groups such as the American Medical Association, the Association of American Medical Colleges, and AARP applauded Berwick’s appointment by President Barack Obama and the passage of the Affordable Care Act by the US Congress, some critics charged that the reform advocated by Berwick and the passage of health reform legislation would lead to rationing, dissolution of the patient-physician relationship, and onerous involvement of the federal government into the care setting. Berwick, who was in Chicago on October 13 as part of a tour of every CMS regional office, stopped by the JAMA offices to visit with former colleagues (he was a JAMA editorial board member for 8 years) and to lay out his vision as to how he would like to see his agency’s role in health care delivery reform unfold. JAMA: What is your top priority? Dr Berwick: Improving care. I see CMS as a partner, a trustworthy partner, and also a force for the continuing improvement of health care for our beneficiaries. But it is not just for beneficiaries. We will be partners in the change of care for all Americans, changing it so it is safe care, better care, more patient-centered, timelier, and more effective. I am also convinced we can do that while controlling costs. Through innovation and change, we can discover ways to deliver care in which care gets better at the same time as it gets less expensive.