Tuesday, September 30, 2014

Bundled Payment for Care Improvement Initiative Essay


Bundled Payment Program Essay
The United States is in great need of health care reform.  I don’t know if there is a more cogent statement in all of healthcare.  Something most involved would agree on is that we cannot sustain the current fee-for-service system.  Health care costs have risen over the last decade and are predicted to rise over 6.8% in 2015 once again out pacing inflation according to Pricecooper waterhouse’s recent survey.

Offering health care to everyone is both necessary and ‘the right thing to do.’ But some of the programs embedded in the law are fraught with missteps.  Whereas, there are many, there is one in particular.  The Bundled Payments for Care Improvement Initiative .  According to the Centers of Medicare and Medicaid Services, “the bundled payment program is a program where organizations will enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality, more coordinated care at a lower cost to Medicare.” This is fallacious, note in the quote the word “may”.  Healthcare systems were interested in this new approach until after careful vetting where they could see the lack of feasibility.

The current fee-for-service program functions as payment for services rendered by each individual entity.  Essentially, this means for a fee is charged/paid for every service:  x ray, hospital stay, surgery, office visits, (even down to the last aspirin). The bundled payment program, especially core model 4 will function as one payment for the service rendered.  That means CMS will pay one payment (historically to the hospital system) that will cover the total cost of care including up to 30 days after admission for the procedure.  As of the latest publication there are 48 eligible procedures everything from insertion of a pacemaker to a joint replacement or stent surgery.   
Let me give an example:  It would be like a mechanic is contracted for X amount of dollars to replace radiators in cars, any make or model is included.  If it costs less to replace, the mechanic would keep the difference, if it cost more, he would take the loss.  After careful research the mechanic learns that a 2012 Ford Taurus has not only the cheapest replacement parts but is the easiest to repair.  It doesn't a rocket scientist to determine that  the more appealing and most lucrative repair would be the Ford.  
The Bundled Payment program has the same potential.             

The program has been incredibly unsuccessful. There are currently only 18 sites participating in the model 4 section, which is closely linked to surgical procedures. First, just like the initial health care enrollment program, we weren’t prepared for the health systems to participate administratively.  IT programs weren’t set up properly to receive this type of claims, the different entities weren’t educated properly to understand how to bill or where to get their portion of the reimbursement.

Most importantly however, the patient care is at risk of being diminished. Let me explain, If there is a patient with illness or disease that will increase the complexity of their care, the hospitals are inclined not to accept them.  This could be anything from a co-morbidity such as obesity, diabetes or heart disease, age no matter how healthy, to a co-dependency on drugs related to the very surgery the patient needs. 

Social factors come into play also. A patient whose lifestyle, living conditions, nutrition, etc. is than optimal has more potential for an unsuccessful outcome. There is the chance that they may be limited or denied care.

There is also the risk of using inferior supplies.  If item A is great and clearly the best thing for the patient and item B is OK but costs much less, the inclination could be to use the inferior product.  This could be anything from a heart stent, to medications, to a joint prosthesis, to the type/quality of skilled nursing facility and rehab.  The proposal also includes saving money by limiting re-admissions.  This is a great goal but my concern is: will be so wrapped up in cutting the costs that patients won’t be re-admitted when needed and will care be compromised?  When focusing on the data to the degree bundled payments would, outcomes become the goal not the patient.

Do we as patients need to assume more responsibility for our health and well- being? Absolutely!   We need to be healthier and more engaged in our well-being to perpetuate better outcomes. But bundling payments and potentially limiting care to the less healthy population is not the best approach.


Monday, September 29, 2014

The First Constructive- Healthcare Reform Outline


Dori Beaumont
Comm 1270

The First Constructive (Prima Facie)
Health Care Reform

Introduction – Health care reform is necessary.  Healthcare costs continue to rise.  According to Forbes magazine, in 2012 healthcare cost rose almost twice as fast as the average consumer good.  Some of the new programs included in the Affordable Care Act are lacking in reaching the goals and objectives set by the Obama administration.


Thesis Proposition
 - The United States is in critical need of health care reform. Offering healthcare coverage to everyone is both necessary and “the right thing to do.”  But, some of the current programs imbedded in the Affordable Care Act are fraught with missteps. Specifically, the current Bundled Payment program needs to be reconsidered.


Define key terms:  bundled payment  A single comprehensive payment made to healthcare providers—hospitals and physicians—for a group of related services, based on the expected costs for a clinically defined episode of care.


Issue A: The bundled payment plan proposed by Obamacare is laden with missteps from unprepared administration of the program to potentially compromising the care of the patient.

Claim 1: The bundled payment program is unsuccessful.

Warrant 1:  The bundled payment plan is one reimbursement/payment to one entity for all services related to that condition for a specific period of time. The payment is generally made to a hospital system and then dispersed to the individual entities including:  physicians, therapists, pharmacies, skilled nursing facilities etc. Currently, there are 48 qualifying episodes for the CMS trial.  This could be anything from pacemaker implementation, stroke, joint replacement, to artery bypass graft surgery. Patients with certain co-morbidities (diseases) who are at a greater risk of readmission after a surgical procedure will find it hard to get care.  The options become:  refusal of care, decreased reimbursement for the hospital system distributing the payment, or considering using lower cost, possibly inferior equipment, medications or facilities.

Claim 2: Bundled payment program could use substandard products or technology.

Warrant 2: The bundled payment program opens the possibility of using inferior products or services.  With cost of care being so paramount to the success of the organization, consideration of using inferior or less effective product is a possibility. The long term effects are less successful outcomes, decreased patient satisfaction or quality of live or even death.

Immediate harms include patient dissatisfaction with the care provided. Patient’s expectations for care could not be met.  The possibility of limiting access to care may be a real issue. 

For example, the CDC  states that the costs of patients with chronic illness account for 75% of US healthcare costs.   Since 2000, health insurance premiums for a typical family of four have increased by 114%.  We cannot sustain these costs and we cannot spend valuable dollars on ineffective programs. The long term harm could be waiting too long for a procedure and jeopardizing health, health care systems being financial unstable and without funding we will see a decrease in progressive technological advancements.

Underview or Conclusion:  There has to be continued health care reform.  Currently costs are predicted to rise over 6.8% in 2015 once again out pacing inflation according to Pricecooper waterhouse’s recent survey. The bundled payment program has been unsuccessful.  As with the Obama care insurance registration, the program was not prepared for roll out. IT programs were not properly set up  to receive this type of claims, the different entities weren’t educated properly to understand how to bill or where to get their portion of the reimbursement.  CMS wasn’t prepared for the appropriate negotiations with the health care systems.  Reimbursement for outcomes can cause patient care to be diminished i.e. lack of appropriate re-admission or appropriate treatment options. There is also the risk of using inferior supplies. The Centers for Medicare and Medicaid have been piloting this program for almost two years and they are still finding it very difficult to get participation from various health care systems.  Currently, there are only 18 sites that are participating in the model 4 portion. Community hospitals are closing at an increased rate leaving patients without health care. We are at a critical state in the health care realm.  The Bundled Payment program of the Affordable Care Act is ineffective, too many resources have been spent trying to keep the program going with too little preparation for implementation.


Thursday, September 25, 2014

Up, Up and Away

I recently returned home from a vacation on the east coast.  The destination is a little island off the coast of South Carolina and requires several airplane connections.  The worst part of traveling can be getting from one gate to the next in time to board, load your bag in the overhead compartment, fasten your seat belt and get settled in.  As I experienced that six times in less than a week, it was fresh on my mind as I read an article on flying restrictions for obese travelers. Chances are you are going to sit next to someone you don't know as most planes have a minimum of three seats across.  This is becoming more of a hot topic as more and more lawsuits are being filed.  I've read several articles online and newspapers.

The irony of flying is that the airplane seems to be getting smaller while the average American is getting larger.  Should there be weight restrictions on air planes?  If so, how would they be managed? Is that a question that should be asked at the time of booking or would we have a "mock" seat for everyone to sit in prior to boarding? The need is cogent but it seems fallacious to be able to make the assessment via a phone call or online booking. There have been several stories recently online.  One being a woman who flew to Hungary and then was unable to board to fly back.  She passed away in the 9 days it took to try to find a suitable flight.  I believe this is fallacious, the article states she was able to fly to Hungary but could not board a plane to get home.  It seems if she was able to fly out, there should have been accommodations to get her home.

There is an article in NY Daily News about a 340 pound man who was flying Southwest Airlines and was asked to leave the plane on a Chicago to Denver flight.  The reason for his removal was the "flight was overbooked".  The man was eventually allowed to return to his seat but only after a 30 minute delay.  I can't imagine how uncomfortable he must have felt boarding the plane while the other passengers watched.  The need to handle these situations better is cogent.

Southwest and Delta as do many other airlines have their own "customer of size" policy. The policy states that you can't infringe on the arm rest or the seat next to you.  As measured by what?  You don't always know until you sit down. There is even a website discussion board, like a blog, for people to try to find the best airline available for larger individuals. Air Canada has made certain concession by determining obesity as a medical condition. Ultimately, most airlines are leaving the decisions to the gate attendants whether to let the passenger board or not.  Again, this seems fallacious. This decision should be made prior to booking.

Whereas, I definitely believe the experience for the man flying from Chicago to Denver that was removed from the flight was wrong, having size restrictions is cogent. Policing it seems to be a challenge and based on some of the comments associated with these articles, consumers are not very tolerant of larger travelers.

Wednesday, September 24, 2014

Black Bear Killing


Recently, a 22 year old man was killed by a black bear while hiking with friends in New Jersey.  There was an article in Field and Stream that states a group of 5 hikers started to run when they noticed a bear was following them.  When the hikers reconvened, they realized one was missing.  Darsh Patel had separated from the group and was found dead 2 hours later by search and rescue 30 yards from the 299  pound bear.  I received this information via email and was intrigued by the title.  The part that was fallacious was that the article stated "a police office euthanized the animal with two shots from a shotgun."  The meaning of euthanized is to put to death humanely.   Is blasting it with a shotgun humane?  

Animal rights is a constant topic in the media, facebook and online.  There are however extremes. Currently there is a youtube video made by a woman named Kelly Atlas.  She entered a restaurant and started a monologue about how someone had "harmed her little girl."  In the end you were able to ascertain that it was actually a chicken.  She raved on and on about how she wanted to save her and her sisters.  The video went viral and has been to topic of several newscasts.  I realize people love their pets but this seems fallacious.  

As I looked further clarity in the bear attack article, there were several items that got me thinking.  The first being the fact that the body was found being circled around by the bear as if he was protecting it or protecting his food source. The bear refused to move even when search and rescue tried tactics that had been successful in past encounters.  I believe this is cogent.  I am sorry a man lost his life, but I don't believe we respected the bear's right to protect his territory and search for food.

Next, according the US Newswas the fact that this season there was a limited supply of berries and acorns.  Kelcey Burguess, a black bear project leader at state Division of Fish and Wildlife, has said that a necropsy would reveal whether the bear had diseases.  He said, "the indication " was the bear saw Patel as food, perhaps because , he added, "acorns, hickory nuts, black walnuts" throughout the state have been in low supply recently. This information and caution had not been passed on to the many hikers that are frequently in the area. To assume the hikers would know there was increased danger is fallacious. 

The report in Field and Stream states that if after they complete the testing  and it proves this bear killed Patel, it will be the first bear fatality in 150 years.  Is the bear guilty without proof and the fate is punishable by death?   I am truly sorry for the loss of a young man just out doing what appeared to be enjoying nature. But, I also feel for the bear who was perhaps just trying to survive. Several articles I read stated that people who live in the area are cautious and carry the appropriate equipment like bear spray. 

After attending class on Tuesday, I am much more aware of the “trolling” comments and was appalled by several.  As I read some, I could honestly envision the exact stereotype we spoke about in class.  Could I be generalizing??