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17 Delivery System Integration
Pages 517-534

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From page 517...
... ThedaCare's Collaborative Care Unit lowered inpatient care costs 25 percent. Gunderson Lutheran's care coordination process included a focus on end-of-life care, resulting in costs per Medicare enrollee that were 
From page 518...
... When discussing evidence demonstrating that care coordination can improve quality, he suggests that Medicare must develop new payment methods that will reward efficient use of its limited resources and encourage the effective integration of care, such as reducing preventable hospital readmissions, increasing the use of bundled payments, and holding accountable care organizations (ACOs) responsible for the cost and quality of the care that their patients receive.
From page 519...
... The results of this fragmentation are evidenced by patients waiting weeks for routine appointments, using emergency rooms for primary care, driving miles between doctors' offices for a single condition, and having little understanding of their disease condition or their plan of care. The outcomes of this fragmented system include major defects in care.
From page 520...
... Medicare Payment Advisory Commission (MedPAC) The healthcare delivery system we see today is not a true system: care coordination is rare, specialist care is favored over primary care, quality of care is often poor, and costs are high and increasing at an unsustainable rate.
From page 521...
... However, it found that fundamental payment and delivery system reforms could improve quality, coordinate care, and reduce cost growth. MedPAC has made numerous recommendations to accomplish these objectives, but the discussion here focuses on a few approaches to payment that would encourage greater coordination of care, resulting in higher quality and lower Medicare spending: • Reducing preventable hospital readmissions; • Increasing the use of bundled payments; and • Holding ACOs responsible for the cost and quality of the care their patients receive.
From page 522...
... MedPAC recommends that CMS conduct a voluntary pilot program to test bundled payment for all services around a hospitalization for select conditions. Candidate conditions might be those with high costs and high volumes.
From page 523...
... Accountable Care Organizations As part of a broader discussion of options for reforming Medicare's healthcare delivery system, MedPAC and others have introduced the concept of holding a set of providers responsible for the health care of a population of Medicare beneficiaries (CBO, 2008; Fisher et al., 2009; MedPAC, 2008)
From page 524...
... Under this model, ACOs with high cost and low quality scores would in effect receive lower Medicare payment rates. ACOs should be viewed as just one tool that can be used to induce change in the healthcare delivery system.
From page 525...
... MedPAC believes that reform of Medicare's payment systems is essential to help bring the healthcare delivery system into the twenty-first century. PAYMENT REFORM TO PROMOTE INTEGRATION AND VALUE Harold S
From page 526...
... With insurance that lowers the patient's cost for services at the margin, the stage is set for increased use of relatively low-value services. Our current fee schedules markedly undercompensate time spent with patients relative to physician compensation for tests, procedures, and imaging that also involve additional costs for staff, supplies, equipment, and facilities.
From page 527...
... For ambulatory care, however, a formal CDT is impossible outside of a large group practice, but virtual, nonexclusive provider networks can be formed around each primary care physician. Paying separately for inpatient episodes markedly reduces the variability in chronic illness costs (Luft, 2008)
From page 528...
... Medicare can begin to implement such changes with demonstration and pilot projects offering various levels of bundled payments for selected sets of admissions and procedures. Preference should be given to organizations that can eventually take on a broader range of cases.
From page 529...
... Much of what integration yields, however, is better coordination of care and more effective use of resources. Improved payment incentives, coupled with accessible data and extracting information from the data can also increase efficiency and value.
From page 530...
... Promote Electronic Health Records So, if HIT is not the magic bullet, then what is the strategy that will get our healthcare systems to become more like the integrated systems that produce better outcomes for patients? Even though it is not sufficient for reform, promoting HIT by deploying electronic health records is a wise course suggested by the American Recovery and Reinvestment Act (ARRA)
From page 531...
... Strategically Target EHR Deployment Electronic health information databases or exchanges are not necessary at a national level. Citizens are wary of nationally integrated health information systems, where the notion is one of a single repository of health information that could be violated, putting everyone's data at risk.
From page 532...
... Integrated healthcare delivery systems are not born from HIT; they are developed from difficult, challenging, and long institutional change processes. By realigning incentives and technical assistance and support, we can start the movement down that road.
From page 533...
... . MedPAC (Medicare Payment Advisory Commission)
From page 534...
... 2008. The partnership care delivery model: An examination of the core concept and the need for a new model of care.


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