De Marco, MA, CMC Performance-Based Medicine

Creating the High Performance Network to Optimize Managed Care Relationships
Erscheinungsjahr 2012
ISBN: 978-1-4398-1289-1
Verlag: Taylor & Francis
Format: PDF
Kopierschutz: 0 - No protection

E-Book, Englisch, 294 Seiten

With healthcare making the transition from volume-based reimbursement programs to value-based approaches, understanding performance measurement is vital to optimize payment and quality outcomes. Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care Relationships guides readers through the maze of definitions and discussions related to value-based purchasing, healthcare delivery, and pricing. It tackles the question of how hospitals, HMOs, physician groups, and employers can arrive at an optimized reimbursement cost and coverage access decision that is attractive to consumers yet fulfills the need for a working margin.

The book begins by looking at HMOs and the three key factors—reimbursement, coordination, and performance—that have led toward performance-based contracting. Laying the foundation for clearer communication between physician hospitals and purchasers, the author defines important concepts in the discussion, from efficiency and cost effectiveness to quality. He focuses on key issues of organizational structure, management, and measuring the outcomes of quality.

Discussing pay-for-performance, the book examines programs in the US and offers case studies of countries succeeding in the development of care management. It explores options for reengineering the healthcare delivery system, among them transitional case management programs and specialist data sharing. It also covers the use of information technology in healthcare delivery.

This timely book will be of interest to managers, vendors, employers, and insurers who have tried everything to lower cost but are discovering that all care is not equal and that matching the right doctor with the right service for the right patient can be done. Helping readers build a path between where they are and where they want to be, it offers an outline of tasks to move from a disorganized collection of care components to a seamless arrangement of high-performance care-givers.

The book is directed at the senior management level for those who are learning metrics and are trying to define performance to become more sophisticated in monitoring and leveraging this vital data in a complex marketplace of contradictory terms and ill-defined outcomes.

Autoren/Hrsg.

De Marco, MA, CMC, William J.

Fachgebiete

• Wirtschaftswissenschaften Betriebswirtschaft Management
• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Gesundheitssystem, Gesundheitswesen

Inhaltsverzeichnis

Introduction
Integration and HMOs: How Did We Get This So Wrong?
Reimbursement
Coordination
Performance
Performance Measurement: A Science with No Followers
Furthering Measurement and Informed Purchasing

Reimbursement: From Fee for Service to Risk Adjusters
More Than a Trend
The Current Status of P4P

Early Pay for Performance
Decile Thresholds
More Than a Trend
The Current Status of P4P
Performance Language and Practice
Where Health Care Delivery and Information Technology Intersect
The Solution Is within Our Four Walls
Can We Get Our Terminology Correct First?
Short Term vs. Long Term
Efficiency
Effectiveness
Grades and Effectiveness
Risk Adjusters and Comparative Effectiveness
Organizational Issues of Planning and Control
Quality Data
Outcomes Data
Evidence-Based Outcomes Data
Lean Engineering
Six Sigma
Learning Organizations
Reengineering
Early Guidelines
Savings Estimates
Summary of Selected Savings Options
Guidelines and Episodes of Care
Grouping Bundles of Services
Value-Based Purchasing and Performance-Based Contracting
Setting Benchmarks and Attainment Thresholds
Small Numbers on Individual Performance Measures
What the Regulations Are Saying about Pay-for-Performance

Challenges
The Pay-for-Performance Rumors and Issues
What Types of Performance Targets?
Cost Effectiveness
Commitment
The Vision
Just Another Program
Lean Engineering
International Classification of Diseases
Web-Based Processing
Comparative Effectiveness and Ethical Limitations
Lung Volume Reduction Surgery as a QALY Example
International Reform
Competition through Improved Performance
Results
Getting Started
Introduction to Planning
Environmental Scan
Managed Care’s Involvement
Feasibility and First Steps
What Are We Trying to Prove?
Legal Issues That Might Affect What You Are Trying to Do
Tasks to Move toward an Integrated Care System
Feasibility Study for Nonaligned Hospitals and Physicians
Financial Steps
Planning Steps
General Issues to Avoid
Issues to Decide upon Early On
No Guarantee That Any of These Steps Will Produce a Result

The Future of Performance-Based Medicine
Once We Have Baseline
Operating Your Performance-Based Strategy
Episode Treatment Group
Sharing Benchmarks and Eliminating Unhealthy Conflict
Normal vs. Abnormal Conflict
Constructive Conflict
Gap Analysis as an Ongoing Operational Management Goal
Disease Grouping Connected to Delivery Systems
Patient Health Status Improvement
Building the "Front End" and the "Back End" of the Patient-Coordinated System
Patient Health Records
Gain Sharing and Risk Management
Community-Based Analysis versus National Standards
Payment as a Meaningful Driver of Permanent Behavioral Change for Physician and Patient
Managed Care Opportunity to Share or Suppress Data
Decision Tools and Artificial Intelligence
Building a Collaborative Model
Deinstitutionalize the Institutional Services
Moving Toward Life Sciences Approach to Managing Care
Appendices