Although the PCMH is routinely confirmed as a viable reform strategy, there is still resistance to adoption By George Martin, MD - Senior Medical Director for Health Integrated
By way of introduction, my name is George Martin, MD. I am the Senior Medical Director for Health Integrated. I have the pleasure of accepting the responsibility and to have tag teamed with Jay Pomerantz, MD on our Health Executive Leadership Blog. As one who has spent the past 15 years managing and consulting on the implementation delivery, coordination and payment for healthcare, I am passionate about healthcare reform and see how an increased focus on primary care and being able to address some of the other challenges facing health plans and other stakeholders in the healthcare community will help to improve outcomes while reducing overall cost. I am excited to be facilitating your communications on these relevant topics.
As was mentioned last week, one of the sessions in the upcoming Health Integrated Fall Executive Leadership Series Event in Chicago on September 22 - 23, will allow detailed discussion concerning the world of reform and the healthcare landscape.
Healthcare reform is upon us - what will be affected? By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
The healthcare reform bill passed and was signed into law in March. As it comes to fruition over the next decade, there will be many different changes. I have spent much of the last 6 - 8 months talking to various aspects of healthcare reform, all of which have the potential to dramatically affect the manner in which care is doled out, to whom and the subsequent outcomes achieved. Let’s talk about this further.
I wanted to note though, change is afoot, and it has not taken the legalities and formality of the recent bill to catalyze reform within our healthcare system. It has been reforming in a variety of ways over the last several years. Many of the changes have been initiated by progressive health plans which are always seeking new ‘out-of-the-box’ approaches to both improve the overall health services and outcomes provided, while simultaneously reducing the cost footprint. Programs like the patient-centered medical home (PCMH) are one such program. At last count, there are over 27 multi-stakeholder pilots underway in 20 states. Other programs like Accountable Care Organizations (ACOs), Utilization Management (UM), Population Health Management (PHM) and others continue to contribute to the evolution of our healthcare system. I believe that the market will continue to drive better outcomes and efficiencies in tandem with any legislative changes that are implemented. Collectively, this will help the system equilibrate to meet the changing landscape.
Although costly on the surface, addressing mental health has benefits far exceeding the costs to both employers and health plans By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
Mental health parity is the term that describes the practice of managing any ailment termed ‘mental health’, in the same manner as any other physical ailment. Mental health parity is not new though. The Mental Health Parity Act (MHPA) was signed into law in 1996. This law required that any annual or lifetime limits and other financial requirements on benefits paid be no different than the similar dollar limits for other medical benefits offered by health insurance or group health plans[1]. In 2008, mostly under TARP[2], the MHPA was extended and added to with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 signed into law by then President Bush. The MHPAEA preserves the key aspects of the MHPA, but adds some new protections as well. The program was further supported with the issuance of new rules by President Obama in January of this year for all employers with 50 or more employees and choosing to offer mental health coverage as part of their insurance package. This program amends both ERISA[3] and PHSA[4] and was effective as of July 1, 2010.
Can health plans drive the collaboration between physicians and other clinical stakeholders while maintaining a focus on the patient? By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
It seems that healthcare continues to make the headlines on many fronts and hence there are great topics to write about. I continue to be intrigued about healthcare reform and the direction it will take. Several weeks ago, I wrote about whether Accountable Care Organizations (ACOs) could deliver healthcare reform. In a recent blog post from National Journal.com[1], the question is asked, “ACOs: Who’s the Boss?” Interesting question since it implies who is in control. Since an ACO can be defined as a local healthcare organization and related group of providers that can be held accountable for the cost and quality of care delivered to a defined patient population[2], maybe the question is valid, but not in the sense of control, but more in the context of collaboration and direction in meeting a common goal. So the ACO in practice then will perform as we hope all of healthcare reform does - improve outcomes while reducing cost.
Collection, analysis, centralization and access make the EMR an essential component in optimizing utilization By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
It seems intuitively obvious that in order to drive optimum utilization, you need to have systems for data collection, analysis, dissemination and access. We’ve been talking about the vital role of utilization management (UM) in advancing healthcare reform. It would seem that to drive fundamental changes to our healthcare system, the first goal would be to make sure the system is running optimally efficient. Simply put, preventive care would be the standard discipline, effective triage and the subsequent doling out of the right care for the right patient at the right time (and precisely no more), would be routine. These practices would not only streamline the system, but save resources and time. Ah, the Utopian society.
Information and informational access is critical in optimizing utilization in healthcare By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
As I have shared with you the last couple of weeks, utilization management (UM) is a key to achieving the top goals in healthcare reform - improving patient outcomes while reducing overall cost. The interactions between the physician and the patient are a critical part of the process, particularly in a time where information is free flowing and readily accessible. Both physicians and patients have access to more data than ever before, and it has the potential to help steer and navigate decisions.
All of the stakeholders have a responsibility and thus will share in the clinical and financial benefits as utilization is optimally managed By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
Newsflash - healthcare costs keep rising.
No surprise there. It is also no surprise that payors will have to take the lead in bending the cost curve if we are to both continue to improve the quality of care and reduce the associated costs. It makes sense since they are the one link between all of the stakeholders in healthcare’s macro environment. In the past, the burden of increased healthcare costs could be pushed to the employer. 2009 figures show that on average, corporations will spend $9,552 per employee for health benefits, up 6% from 2008[1]. But the current economic situation has exacerbated a more aggressive stance taken by the employer in their relationship with payors.
Optimum utilization management is best driven through evidence-based medicine which is fed by vast and readily-accessible patient data By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
When you stop and think about the available tools and resources for clinicians today, it is somewhat mind boggling. The clinical resources and study data, ready access to health records, vast networks of physicians from general through specialty and so many other resources are available. For a clinician, these resources are augmented with a more sophisticated patient population who also has access to much broader medical and healthcare databases than any time in history.
The latest approach of utilizing evidence-based medicine may be a key in further advancing healthcare reform By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
Utilization management, by definition[1], could be defined as, “The evaluation of the appropriateness, medical need and efficiency of healthcare services, procedures and facilities according to the established criteria or guidelines and in a cooperative effort with other parties, including members, groups, providers and payers to optimize the appropriate placement of patients to receive the appropriate services/supplies.” Quite a mouthful. This is but one definition, but it contains the key elements. Simply put, the goal of utilization management (UM) is to provide the most appropriate care based on case-by-case assessments. If accomplished, costs can be optimized as well.
PCMH is but one element of the changing landscape – we’re broadening the view to cover a broader range of key issues facing health care executives By Jay I. Pomerantz, MD - Executive Medical Director for Health Integrated
We have had such a good response to the PCMH Community Blog since its inception last June. Thank you all for reading and sharing your thoughts. The comments and feedback we have received from you and others have been very positive.
Over the last year, we have facilitated the discussion around the PCMH and how this program could positively affect a health plan in today’s environment. There is no doubt that the potential impact of PCMH on health care remains strong. That said, you have asked that we address other key issues that you face on a daily basis in the constantly changing and dynamic healthcare environment we are all a part of today. We have heard your request.
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