Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Reform Issues

The Nexus of Quality and Cost

The quality improvement movement has changed its focus from improving the health of patients to obtaining the greatest return for the investment.  Why? Because experience has shown, time and again that the former is beyond our abilities, beyond any 'carrot and stick' approach to patient care, and beyond any contrived incentive realignments.  When it comes to lifestyle management, we fail, miserably.  For instance, getting people to stop smoking... Read more Tags: quality improvement, value, value equation, MACRA, health care reform, healthcare reform, value-based, value based, purchasing, cost, quality, access, the elephant in the room, affordability Read more articles about: quality, cost and/or access

The 4 Main Reasons We Fail Reforming Health Care: Cost Fears, Variation, Poor Collaboration and Understanding

Approximately 2/5 persons don't understand their insurance coverage, i.e., which healthcare services are being covered under their current plan and, 1 in 5, "have avoided visiting a doctor for a general health concern within the past 12 months because of cost concerns." Read more Tags: Health Information Exchange, ICD-10-CM, HIE, heterogenity, uncertainty, HIT, structure, process, outcome, ICD, granularity, Donabedan, feedback, variation, analytics, data Read more articles about: communication/knowledge

Data Science Strategy; the Managed Care Method

Healthcare reform is really about managing the care so that it is optimally accessible, reasonable and reliable quality (esp. less variation), and is more efficient and cost-effective.  Here's what a fellow Medical Director and I wrote about this in 1994, still very relevant: Read more Tags: care redesign, accountability, incentives, data science strategy, leaning in, categorical, predictive analytics, managed care, quality, cost, outcome, efficiency, effectiveness Read more articles about: measurement & management

When's "Good" Quality, Good Enough?

"The current system is a mess because payment in the private sector is related to competition, contracts, etc. One gets paid a different amount by each. A single payer would have lower per episode payment, but would cover all and make billing simpler and more reliable." Read more Tags: health status, engagement, AI, value-driven outcomes, potentially preventable events, PPE, information, quality, empathy, actionable, patient welfare, access, value, shell game, shared decision making, artificial intelligence Read more articles about: quality, cost and/or access

Enhancing HealthCare's Worth

It's disheartening; the cure for the ills of U.S. health care lies within our grasp, yet it eludes us. We cannot answer basic questions–What works?  What we are paying for? Are we getting what we need?  Are we getting the right care at the right time and place? Read more Tags: quality of care, home care, population analytics, outcomes, teaching, teach-back, silos, affordable, affordability, health literacy, analytics, transparency, acuity, incentive alignment, informatics Read more articles about: communication/knowledge

Waste Less; Add Value

To make health care reasonably profitable for private payers and more affordable for patients, those who are responsible for managing the care must concentrate on reducing cost (which, by the way, is far easier than increasing the health benefit or favorably affecting the medical loss ratio).  Read more Tags: waste, triple aim, value-based, over treatment, care coordination, outcomes, Population Health, risk adjustment, fraud and abuse, ​Coordinating, Communicating, comprehensive care Read more articles about: waste

The EHR—on the Road Where a Cottage Industry Lived

Technology and automation are facilitating healthcare reform.  Meaningful communication is required at all levels and settings and that means interoperability is a must! Read more Tags: interoperability, electronic health record, EHR, FHIR, EMR, episode, meaningful use, cost, quality, value, value-based care, feedback, communication, health information exchanges, HIE Read more articles about: communication/knowledge

Opportunity for Real Reform

We are now having an unprecedented opportunity for change, but Robert H. Brook, MD, ScD [The RAND Corporation] warns that simultaneously improving health care coverage, the affordability of health care and its quality is challenging.  Read more Tags: health care reform, fee-for-service, fee for service, payment reform, marketplace, coverage, health insurance, spending, benefit, FFS,, Luft, Brook, colonoscopy Read more articles about: Reform Issues

Real Reform...A Bird In the Hand Is Worth 2 In the Bush

The strategic agenda for real reform lies in creating a value-based health care delivery system. As stipulated by Porter and Lee in 2013, health care will be organized and paid for differently in the near future.  Six critical steps in reform as as follows [modified]: Read more Tags: health care reform, health insurance, exchange, cooperative, Certification and Standards Criteria, meaningful use, Core Measures, public option, student, student health insurance, outcome, systems, information technology, bundled, episodes of care, longitudinal view, cost, quality, access Read more articles about: insurance and coverage issues

Who's the Keeper of the Commons?

Recognized as one of their “Top 9 Most Talked About Blogs of 2016,” reports style="font-size: 12px; font-family: verdana, geneva, sans-serif;" target="_blank">Who is ruining the healthcare system?” Medical Economics, 3/26/16.  "This exploitation is analogous to what happens when incentives are not aligned in healthcare: payers, practitioners and patients at the commons are doing what they feel they must without... Read more Tags: home care, communication, top blog, The Tragedy of the Commons, outcome, keeper of the commons, bio-psycho-social, responsibility, equitable, health care system, genetics, vulnerability, adverse childhood experience, epigenetic, mental health Read more articles about: responsibility