Perceptions of Health Insurers Towards Pay-For-Performance as a Cost Control Model for Hospital Services

Hospital costs are the most significant portion of health-related costs incurred by non-profit health insurers registered as medical schemes in South Africa. Medical schemes continue to use retrospective reimbursement models for hospitals despite general acknowledgment that these models do not limit hospital costs and utilization. Although medical schemes are interested in implementing alternative reimbursement models, such as pay-for-performance (P4P), they are uncertain about which P4P models they can use to reduce hospital costs, resulting in their inability to make critical changes to their costs from traditional fee-for-service models. This qualitative exploratory multiple case study used 17 open-ended case interviews to explore the perceptions of seven South African medical schemes regarding P4P as a cost-control model. The participants confirmed they were not satisfied with how their current reimbursement models control hospital costs and outcomes. They perceived P4P could result in better cost-control and better-quality outcomes. The participants acknowledged P4P is a complex model with significant implementation barriers, and they were also concerned that hospitals could manipulate the model to their benefit. The participants described the enabling factors that could facilitate their selection of P4P as a cost-control model. The participants recommended a patient-centric P4P model that encompasses five broad principles: (1) Paying for measured outcomes, (2) paying specialists for the coordination of care, (3) rewarding hospitals for excellence by directing patient volumes, (4) measuring patient-reported outcomes, and (5) relegating the hospital’s role to that of a supplier rather than a coordinator of care. The study provided a recommended framework that may assist medical schemes in selecting and implementing P4P models

Effect of the Affordable Care Act on utilization of emergency and primary care

The Affordable Care Act (ACA) has considerably reduced the uninsured rate nationally through availability of guaranteed issue private plans (Marketplace) and Medicaid expansion. However, expanding access to health insurance coverage may not be a sufficient incentive for consumers to change their usual setting for care, reduce avoidable use of emergency departments (ED), or increase use of preventive care. One of the core arguments for expansion has been that individuals without coverage may forego preventive care, delay treatment, and subsequently overutilize the ED––leading to worse health outcomes and higher long-run health expenditures. The objective of this dissertation is to investigate the effect of the ACA on substitution between ED and primary care among the newly insured (aim 1), potential delayed effects of coverage gains on avoidable use of the ED (aim 2), and whether high deductibles serve as a barrier to the use of no-cost preventive services (aim 3). Aim 1 uses the linkage between the 2012 National Health Interview Survey and 2013 and 2014 Medical Expenditure Panel Survey to quantify substitution between the ED and primary care settings using linear and multinomial logistic regression models. Aim 2 uses the Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases for 2008 to 2016 to identify the effect trajectory of coverage gains on avoidable ED use using county-level fixed effects and spatial regression models. Aim 3 uses insurance claims from IBM Health® MarketScan® for 2008 through 2016 to estimate the effect of high deductible health plan enrollment on use of high-value preventive services using difference-in-differences models. This project will provide new understanding of how consumers respond to coverage gains at both the individual and population level with a focus on emergency and primary care services—two ends of the health care spectrum that can often be substitutable, particularly for the newly insured. It will address if and when consumers substitute towards a more appropriate setting for care and also how eliminating cost sharing affects use of preventive services. These insights can be used to refine benefit design, consumer education, and expectations about the costs and health benefits of future reforms.Doctor of Philosoph

Improving Integrated Care for Medically Underserved Patients at a Texas FQHC using SBIRT and PHQ-9

Integrated Care, under provisions of the Affordable Care Act (ACA), aimed to reduce fragmented care for Medically Underserved Populations (MUPs) who depend on community-based centers for their health care needs. Well-defined by the World Health Organization, social determinants of health such as low socioeconomic status, low educational attainment, and housing instability often contribute to health disparities, making it difficult for MUPs to achieve optimal health outcomes. The purpose of this study was to gather preliminary data indicating the need to integrate a social work program at a Texas Federally Qualified Health Center using the Screening, Brief Intervention, and Referral to Treatment Model and the PHQ-9 Depression Scale. Using a study sample of n=100, the findings suggest MUPs benefit from co-located care. Aggregated scores from the AUDIT report past or current drinking patterns (60%) and scores from the PHQ-9 indicate mild to severe depressive symptoms (56%). Of the 56% who reported having depressive symptoms, 33% went untreated during their first office visit accentuating the need to have treatment modalities focused on co-occurring diagnoses. Imperative to the field of social work is the adage, “meeting the client where they\u27re at.” Medical social workers may need to assess a patient’s level of understanding of symptoms, concurrent diagnoses, and treatment options to increase commitment to retention care, compliancy, and recovery. Implications for social work practice, as well as, future research are also discussed

Adviser\u27s Guide to Health Care, Volume 2: Consulting Services

https://egrove.olemiss.edu/aicpa_guides/2721/thumbnail.jp

The Private Option

Health care reform is once again in the air. Virtually all Democrats favor some meaningful expansion of public insurance, whether through single payer or the creation of a “public option” that would allow consumers dissatisfied with the private market to buy into a public program. Republicans, not surprisingly, have pushed back, not only against single payer, but also against the public option, saying it will drive private payors to extinction. All the political jousting implicates a larger and serious policy question; namely, what should be the role of private payors in the nation’s health care system?Arguments to date on that subject have largely overlooked two crucial realities. First, payors (public and private) perform multiple functions regarding health care delivery. That the government is better at one function does not mean, or even imply, that the government is better at all of them. By disaggregating the services payors render in connection with health care financing, debates about the ideal roles for public and private payors — as well as whether one of them will or should compete the other into extinction — can be had on understandable terms.Second, although frequent references to the competitive virtues of a public option have been made, insufficient thought has been given to the conceptual specifics of why and how private payors faced with a public option might evolve. In terms of improving care delivery, observers have underexamined how private payors might serve as welfare-enhancing big data digesters, care evaluators, choice intermediaries, and incentive innovators — all proficiencies that not only rate to improve the cost and quality of care, but are entirely harmonious with modern experience about where private actors often create value: by collecting, analyzing, packaging, presenting, and deploying information.Once these two significant theoretical refinements are brought to bear, a richer analysis of the public-private question emerges — and one that supplies good reason to doubt that private payors should or will (at least in the short term) be put to the sword by either Congress or public-option-armed consumers

Adviser\u27s guide to health care: Volume 3, Consulting with Professional Practices

https://egrove.olemiss.edu/aicpa_guides/1802/thumbnail.jp

European governance challenges in bio-engineering : making perfect life : bio-engineering (in) the 21st century : final report

In the STOA project Making Perfect Life four fields were studied of 21st century bio-engineering: engineering of living artefacts, engineering of the body, engineering of the brain, and engineering of intelligent artefacts. This report describes the main results of the project. It shows how developments in the four fields of bio-engineering are shaped by two megatrends: "biology becoming technology" and "technology becoming biology". These developments result in a broadening of the bio-engineering debate in our society. The report addresses the long term views that are inspiring this debate and discusses a multitude of ethical, legal and social issues that arise from bio-engineering developments in the fields described. Against this background four specific developments are studied in more detail: the rise of human genome sequencing, the market introduction of neurodevices, the capturing by information technology of the psychological and physiological states of users, and the pursuit of standardisation in synthetic biology. These developments are taken in this report as a starting point for an analysis of some of the main European governance challenges in 21st century bio-engineering

European governance challenges in bio-engineering : making perfect life : bio-engineering (in) the 21st century : final report

In the STOA project Making Perfect Life four fields were studied of 21st century bio-engineering: engineering of living artefacts, engineering of the body, engineering of the brain, and engineering of intelligent artefacts. This report describes the main results of the project. It shows how developments in the four fields of bio-engineering are shaped by two megatrends: "biology becoming technology" and "technology becoming biology". These developments result in a broadening of the bio-engineering debate in our society. The report addresses the long term views that are inspiring this debate and discusses a multitude of ethical, legal and social issues that arise from bio-engineering developments in the fields described. Against this background four specific developments are studied in more detail: the rise of human genome sequencing, the market introduction of neurodevices, the capturing by information technology of the psychological and physiological states of users, and the pursuit of standardisation in synthetic biology. These developments are taken in this report as a starting point for an analysis of some of the main European governance challenges in 21st century bio-engineering