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|Kaiser permanente in washington dc||As recently pointed out by Professor Trisha Greenhalghthe absence of a randomised controlled trial is not always sufficient reason for doing nothing. Likewise, one of the individual characteristics that has been most influential in terms of new barriers created by the pandemic is fear of contagion [ 838485868889949597 ], an aspect that has been discussed in many publications, including opinion articles [,, ], and also played amerigroup foundation application highly significant role in previous epidemics as a factor causing problems or delays in seeking medical care [ 2 changes to healthcare services, 2124267276, ]. Do stay-at-home changes to healthcare services cause people to stay at home? Relative to existing time trends, medical spending decreased by Evidence-based healthcare and public health. An inductive approach was applied using questions based on the existing literature on organizational change and change responses.|
|Changes to healthcare services||465|
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|Changes to healthcare services||Lancet ; : — 9. Published May 19, click here These heaalthcare data were used to examine changes in the use of health care services and specific procedures. The pandemic has provided a new context that go here previously long-held assumptions and norms about changes to healthcare services care should be delivered to be urgently reexamined and, if necessary, changed. With regard to our main findings on the reduction in the use of services, this may be related to health systems prioritizing chamges response to the public health emergency, which differed according to context [ 42599]. Reduction in the total surgical volume median 25 cases compared to cases and cases.|
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The pilot has been so successful that the Utah legislature is going to take the model statewide. We at Intermountain believe that health care systems should be judged on how they treat the historically underserved.
Using data to understand where disparities exist and then make interventions, we have added equity as a core value of our system. We hold ourselves accountable by establishing key performance indicators and continually assessing our progress. We need to change that thinking entirely and become more consumer-centric. We need to care for people closer to their home.
To do that, we need to meet people where they are as much as possible when delivering care. Perhaps the most striking change in the delivery of health care that Covid has generated is the rapid acceptance of telehealth by both consumers and providers. Nearly half At Intermountain, our use of telehealth visits ballooned from 7, in March to a current average of more than 73, a month across our 25 hospitals, clinics, and multiple partner hospitals. The implications of telehealth are profound.
It can increase access to care and can be especially transformational for the economics of rural hospitals and remote communities. Covid has only increased the risk.
That is where telehealth changes the equation. Telehealth not only makes specialists — like neonatologists, neurologists, and cardiologists — available to rural hospitals; it also enables patients to receive that care without being transferred to larger, more distant facilities. They can remain in their communities, surrounded by their support systems, with the local hospital retaining most of the compensation. That strengthens not only rural hospitals but also rural communities where the hospitals are often the largest employers.
Another important confirmation from the pandemic is that integrated health care delivery systems — those that offer their own health insurance plan or do so via a partnership with an external insurer — are better suited to adapt and align incentives to rapidly changing circumstances.
To make up that loss, non-integrated systems will, in many instances, have to cut services, raise prices, or postpone adding needed community services. They can quickly share learnings and best practices. They are likely also to prove to be best suited to care for Covid long-haulers. In addition, when vaccines became available, Intermountain Healthcare, as an integrated system, was able to use its IT systems to rapidly identify qualifying high-risk patients and urge them to get their vaccinations.
Whether a health system offers an insurance plan on its own or via a partnership with an external insurer, the integrated model allows the cost of providing care and the cost of insuring care to be aligned in ways that benefit the insurer and the provider. We know this from our own experience. Intermountain Healthcare has an in-house nonprofit health insurance company, SelectHealth , which serves nearly one million members in Utah, Idaho, and Nevada. It also collaborates with other health care providers — for instance, it has a partnership with the Idaho-based St.
In each of these configurations, the goal is to provide great care and better align and integrate the cost of care and the cost of insurance. The widespread acceptance of value-based care — under which providers, including hospitals and physicians, are paid on the basis of capitation and patient health outcomes — would accelerate the adoption of the above priorities.
In contrast, traditional fee-for-service care does not address prevention or equity. It has resisted telehealth. It does not take full advantage of integrated health care systems. Value-based care improves quality of life and corrects misaligned incentives e.
It can reduce health care costs by making care more accessible and keeping people healthy, which reduces the treatments and procedures needed. The flawed fee-for-service system was designed to wait until individuals got sick and then treat them, and not to support the goal of staying healthy. That flaw was highlighted by the pandemic. Providers with value-based arrangements with health plans kept getting a check every month, regardless of the volume.
Value-based care enables providers and insurers to design and implement all kinds of interesting innovations that volume-based systems are not able to do. Intermountain Healthcare, for instance, is partnering with the University of Utah Medical School to jointly develop a new medical educational program — the first of its kind in the United States — to train the next generation of physicians in population health, which focuses on keeping people and communities healthy.
Accelerating the move to value-based care right requires significant investment, commitment, flexibility across organizations, and, for some, a leap of faith away from tradition. Align and reorganize provider panels. There must be enough patients covered by value-based contracts i. The types of patients assigned to a provider need to be a mix of both relatively healthy people and those with chronic conditions that need more extensive and intensive attention.
Restructure teams and workflows. After panels have been aligned, teams supporting physicians need to be restructured and properly resourced to succeed in this different model of care.
Core workflows and processes must be adjusted and adopted. Teams should be brought together in daily huddles to coordinate patient outreach, close care gaps, and organize care for the changing needs of the patient. Educate providers and teams. It takes a village to succeed in value. Ensure that everyone is equipped to participate in this team effort by educating them about the core tenants of value-based care, no matter how big or small of a role they will play.
Deploy novel technologies. Use tools to integrate multiple data sets and overlay advanced algorithms to harness and unlock the power of this data. Illness trends, doctor demographics, and technology also contribute to shifts in our overall healthcare system. As our society evolves, our healthcare requirements naturally evolve. Healthcare reform has often been proposed but has rarely been accomplished. Speaker of the House Thaddeus Sweet vetoed the bill in committee. In , after 20 years of congressional debate, President Lyndon B.
Johnson enacted legislation that introduced Medicare and Medicaid into law as part of the Great Society Legislation. Since becoming law, additional rules and regulations have expanded upon the Patient Protection and Affordable Health Care for America Act.
Choosing a healthcare plan illustrates the complexity of health insurance plans in the U. About half of Americans who have private health insurance are covered under self-insured plans, each with their own design.
The one commonality among all insurance plans is how dramatically they vary. Deductibles, co-insurance, co-payments, and maximum out-of-pocket expenses are a few of the inconsistent variables among insurance plans. Additionally, some insurance companies are for-profit and others are not-for-profit, indicating another point of confusion. Insurance is not the only complexity within the system. The Affordable Care Act added more agencies to this list, including state insurance exchanges and the Center for Medicare and Medicaid Innovation.
Each area of healthcare has its own complexities. As components of the larger healthcare system work together, the complex layers unfold. While change is expected in the coming years, it is likely to occur slowly. Changes in the healthcare industry usually occur at the legislative level, but once enacted these changes have a direct impact on facility operations and the use of resources.
For example, the ways patients and administrators utilize resources such as Medicare and Medicaid have changed due to legislation. Technology has had a further impact on how healthcare administrators handle resources and manage medical centers. Cultural shifts, cost of care, and policy adjustments have contributed to a more patient-empowered shift in care over the last century.
Technological advancements contribute to a shift in our patient-centered healthcare system. This trend is expected to continue as new healthcare electronic technologies , such as 3D printing, wearable biometric devices, and GPS tracking, are tested and introduced for clinical use.
Policies and procedures in individual facilities may restrict how and when new technologies are introduced, but cutting-edge technology is expected to play an increasingly larger role in our healthcare system within the coming years.
As legislative and demographic changes trickle down into care facilities, the use of hospital services is expected to grow significantly between and This growth is due to an anticipated increase in Medicare beneficiaries in the coming decade. The cost of hospital care is expected to rise from 0. Since then, Congress has made Medicare and Medicaid changes to open eligibility to more people.
For example, Medicare was expanded in to cover the disabled, people over 65, and others. Medicare includes more benefits today, including limitless home health visits and quality standards for Medicare-approved nursing homes. Medicaid has also been expanded to cover a larger group than initially intended.
This includes coverage for low-income families, pregnant women, people requiring long-term care, and people with disabilities. Wide variations in Medicaid programs across the nation occur because individual states have the ability to tailor Medicaid programs to serve the needs of their residents.
Potential consumers can now use the Marketplace website to determine their Medicaid eligibility. As the baby boomer generation approaches retirement, thus qualifying for Medicare, healthcare spending by federal, state, and local governments is projected to increase. Assuming the government continues to subsidize Marketplace premiums for lower-income populations, this increased government healthcare spending will greatly affect the entire healthcare system in the U.
Although Medicaid spending growth decelerated in due to reduced enrollment, spending is expected to accelerate at an average rate of 7. Along with policy and technological changes, the people who provide healthcare are also changing. Providers are an important part of the healthcare system and any changes to their education, satisfaction or demographics are likely to affect how patients receive care.
Future healthcare providers are also more likely to focus their education on business than ever before. This growth may result in more private practices and healthcare administrators. In recent years, the demographics of the medical profession have shifted.
Women currently make up the majority of healthcare providers in certain specialties, including pediatrics and obstetrics and gynecology. Nearly one-third of all practicing physicians are women. According to an Association of American Medical Colleges AAMC analysis, women comprise 46 percent of all physicians in training and nearly half of all medical students.
Based on these statistics, we can assume more women may enter the medical profession in the coming years. African-American women are more likely to become doctors than their male counterparts, according to AAMC data. While African-Americans comprise only four percent of the physician workforce, 55 percent of the African American physician workforce is female. This shift in demographics to include more women in healthcare supports diversity in the industry and represents overall population diversity.
The prevalence of malpractice lawsuits is one way to evaluate the competence of healthcare providers. The amount of malpractice claims in the U.
As the trend of declining malpractice lawsuits continues, it may indicate that provider competence and patient care will continue to improve. Job satisfaction is one area that must improve. Nurses report higher overall career satisfaction than doctors, based on results of the latest Survey of Registered Nurses conducted by AMN Healthcare and compared to the Physician Compensation Report. Nine out of 10 nurses who participated in the survey said they were satisfied with their career choice.
However, one out of every three nurses is unhappy with their current job. It is difficult to say whether job satisfaction will increase in the coming years, but continued technological advancements designed to streamline the healthcare process offer hope to those who may be frustrated with the complexity of their jobs. Demands on healthcare change due to various reasons, including the needs of patients. Every year, new cures and treatments help manage common diseases.
Each such development affects the entire healthcare system as much as it has a positive impact on patients.
One study notes that consumer advocates argue that narrow networks adversely affect access to care, especially for patients who have chronic illnesses. They claim that insurers structure the networks strategically to discourage the higher-cost patients from enrolling. Patients who have high needs will then have to go outside the network and possibly outside the EMR system and as a result tend to incur high expenses and receive surprise medical bills EBRI, Their medical documentation is also more likely to be missing elements.
The ACA included several provisions aimed at improving deficiencies in the nation's long-term care system to ensure that people can receive LTSS in their home or the community KFF, a. In addition, in states that accepted the Medicaid expansion, funds were made available to pay for home- and community-based attendant services in connection with matching by the federal government KFF, a.
Nonetheless, Wiener has argued that despite the growing need for HCBS, not enough progress had been made in improving the financing of long-term care. A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use KFF, c found that health insurance coverage has expanded overall, access to and use of care have increased, self-reported health status has improved, and flow of federal health-care resources into expansion states has risen.
One study by Barakat et al. It did not, however, detect a substantial change in top diagnoses or in the overall rate of ED visits and hospitalizations. The authors argued that there appeared to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization.
In contrast, Sommers et al. Wherry and Miller observed an increase in office visits to physicians but also an increase in overnight hospital stays after the Medicaid expansion. Chen et al. There is consensus among studies on the effects of the ACA on utilization of preventive services. Sommers et al. Similarly, Wherry and Miller found that Medicaid expansion under the ACA led to higher rates of preventive services, which resulted in more diagnoses of diabetes and high cholesterol.
Several studies have specifically identified ACA-related improvements in health-care utilization by people who had chronic conditions. They found improvements in multiple measures: affordability of care, regular care for the chronic conditions, medication adherence, and self-reported health. A related study by Sommers et al. They echoed the findings in the report by suggesting that regular care for chronic conditions increased substantially after Medicaid expansion.
The findings of those two studies were consistent with the findings of an earlier study by Sommers et al. Although evidence suggests that on average people who had chronic conditions experienced an increase in access to regular care for those conditions, coverage effects vary among diseases Baicker et al. Because of the many design features that are common to the ACA, the Massachusetts health-care reform of , and the Oregon Medicaid lottery of , the experiences of Massachusetts and Oregon are informative about potential effects, and in particular long-term effects, of the ACA on utilization.
A study by Cole et al. It found no effect of Medicaid coverage on diagnoses or on the use of medication for blood pressure and high cholesterol, but Cole et al. The Oregon Medicaid study Baicker et al. The evidence on cancer care is also mixed. One study of the Massachusetts health-care reform did not find any changes in breast-cancer stage at diagnosis Keating et al.
A third study of the Massachusetts reform echoed the improvement in cancer care by revealing that coverage expansion was associated with an increase in rates of treatment for colon cancer in low-income patients and a reduction in the number of patients waiting until the emergency stage for treatment Loehrer et al. In addition to health-care service utilization, the use of prescription drugs serves as an important measure of the ACA's effect, especially given their prominent role in the management of chronic conditions.
Mulcahy et al. They attributed the increase in treatment rates for chronic conditions and the reduction in out-of-pocket spending to the decrease in financial barriers to care under the ACA. The ACA has many provisions that are important for people who have disabilities. For example, denial of coverage because of pre-existing conditions is no longer allowed. Removal of a lifetime cap on benefits will enable people with disabilities to continue to receive care.
Perhaps most important, the expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify for SSDI or SSI. And the ACA authorizes federally conducted or supported studies to collect standard demographic characteristics that include disability status Krahn et al. In this section, we summarize the early literature on those effects.
The ACA's dependent coverage provision appears to have benefited young adults who have disabilities. Porterfield and Huang analyzed the periods before and after implementation of the dependent coverage provision in the ACA and compared adults who had disabilities and were 19—25 years old with adults who had disabilities and were 26—34 years old.
People in both age groups experienced coverage gains after the ACA dependent coverage provision took effect in , but for people in the older group who were unaffected by the dependent coverage provision, the coverage gains were entirely attributable to changes in public insurance. In contrast, the coverage gains for people in the younger group who were affected by the dependent coverage provision were driven by changes in private insurance.
By , low-income and moderate-income nonelderly adults—including both those who had and those who did not have chronic illnesses—also experienced coverage gains.
The Kaiser Family Foundation KFF, c notes that in some states and the District of Columbia, those gains resulted from the Medicaid expansion to adults who had incomes up to percent of the federal poverty level.
In other states and the District of Columbia, the coverage gains for people who had disabilities resulted from subsidies for qualified health plans offered on the health insurance marketplaces combined with private insurance reforms, such as the prohibition of discrimination based on health status. The ACA appears to have brought about improvements in treatment for mental disorders and substance abuse. Saloner and LeCook examined the effect of the ACA on young adults who had mental health or substance-use disorders by using data from the — National Survey of Drug Use and Health.
The authors found that after implementation of the ACA, mental health treatment of people who were 18—25 years old and had possible mental health disorders increased by 5. Uninsured visits by people who used mental health treatment decreased by Consistent with those findings, Ali et al. If those possibilities are fully realized, that would represent a 40 percent increase in behavioral services utilization, primarily for mental health services.
Golberstein et al. A recent study Hall et al. The authors noted that people who have disabilities often experience psychologic distress and comorbid health conditions and have low income and employment. New coverage options under Medicaid expansion that allow people to work more and accumulate assets could benefit people who have disabilities because they would no longer need to apply for SSI or live in poverty to qualify for Medicaid.
Results from the Hall et al. Those changes were not statistically significant, because of the small sample in the pre-ACA period. However, after the ACA, those who had disabilities and lived in expansion states were more likely to be employed The authors concluded that Medicaid expansion is an important policy for reducing disparities in access to care for people who have disabilities and for supporting their employment and financial independence.
Despite the many positive benefits of the ACA, there remain barriers to access to care among people who have disabilities. Among them is the complexity of the Medicaid application process Gettens and Adams, Cost-related difficulties present another barrier. Despite the ACA's subsidies for qualified health plans, which have reduced premium costs to some degree, deductibles and other out-of-pocket costs remain high and pose financial challenges to many people who have disabilities Gettens and Adams, Health care in the United States is financed by a combination of public and private insurance, employers, and out-of-pocket payments by individuals.
In , 37 percent of the US population received health care through a public insurance program at some point during the year. The US health-care delivery system consists of an array of clinicians, hospitals and other health-care facilities, insurance plans, and purchasers of health-care services, all of which operate in various configurations of groups, networks, and independent practices. The healthcare delivery system historically has been organized around the concept of fee-for-service medicine.
Because provider revenues increase as more services are provided—and insured and some uninsured patients do not bear the full cost of the services—the fee-for-service model creates incentives to increase utilization of health-care services and leads in many cases to overutilization of physician and hospital visits.
It brought about structural changes in the health-care system, which included sweeping efforts to improve access to health insurance through expansion of the Medicaid program and through subsidized and lower-cost health insurance plans made available through new health insurance marketplaces exchanges , elimination of pre-existing condition restrictions on coverage, elimination of lifetime caps on health-care spending, and efforts to slow growth in health-care costs through innovative payment reforms.
The plan had two major components: expansion of the Medicaid program and new structures to support the individual and small-group health insurance markets. As a result, only 32 states and the District of Columbia elected to expand Medicaid. For the individual and small-group markets, the ACA established health insurance exchanges in states to allow individuals and small groups to buy standard insurance policies with income-based subsidies from percent to percent of the federal poverty level.
The ACA eliminated medical underwriting and imposed a legal mandate to purchase health insurance, with a penalty for those who did not comply. The ACA's individual mandate was designed to compel healthier people to purchase insurance and thereby balance the risk pool and lower premiums for everyone. The ACA included payment-reform provisions to incentivize the adoption of more effective care delivery models.
The new models involve some combination of shared risk among providers to enhance collaboration and coordination of care in an effort to reduce avoidable hospitalizations, ED visits, and other forms of expensive or unnecessary care.
Beyond payment models, the ACA encouraged perhaps unintentionally the narrowing of provider networks and reshaped the delivery of LTSS, all of which have implications for how people who have disabilities receive care and the documentation of that care in the medical record.
The expansion of health insurance coverage through the Medicaid program, the health insurance exchanges, and the dependent coverage provision will allow many Americans who have disabilities to obtain health insurance coverage without having to qualify also for SSDI or SSI. A comprehensive review of the literature on the effects of the ACA Medicaid expansion on health-care use finds that health insurance coverage overall has expanded, access and use of care have increased, self-reported health status has improved, and the flow of federal health-care resources into expansion states has risen.
Coverage categories are not mutually exclusive; some people switch coverage during a year or have multiple forms of coverage. Federal law requires that state Medicaid programs make DSH payments to qualifying hospitals that serve a large number of Medicaid and uninsured people. The CLASS Act would have created a voluntary and public long-term care insurance option for employees, but in October the Obama administration announced it was unworkable and would be dropped.
Turn recording back on. Help Accessibility Careers. Search term. Narrowing Provider Networks The change in provider network size is another indicator of how the ACA has transformed the care that people get. The Affordable Care Act's payment and delivery system reforms: A progress report at five years.
New York: The Commonwealth Fund; The implications of the Affordable Care Act for behavioral health services utilization. American College of Emergency Physicians. The Oregon experiment—effects of Medicaid on clinical outcomes. New England Journal of Medicine. Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments.
The Affordable Care Act at 5 years. What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. The Quarterly Journal of Economics. Veterans' disability compensation: Trends and policy options. Medicaid managed care enrollment and program characteristics, At federally funded health centers, Medicaid expansion was associated with improved quality of care. Health Affairs Millwood.
Issue brief no. Gettens J, Adams A. Assessing health care reform: Changes to reduce the complexity of the application process for individuals with disabilities. Journal of Disability Policy Studies. Effect of the Affordable Care Act's young adult insurance expansions on hospital-based mental health care. American Journal of Psychiatry. Effect of Medicaid expansion on workforce participation for people with disabilities.
American Journal of Public Health. Colorado's patient-centered medical home pilot met numerous obstacles, yet saw results such as reduced hospital admissions.
Health Affairs. Health Affairs health policy brief: Regulation of health plan provider networks. Bethesda, MD: Health Affairs; IOM Institute of Medicine. The future of the public's health in the 21st century.
Effect of Massachusetts health insurance reform on mammography use and breast cancer stage at diagnosis. Total Medicaid managed care enrollment. Medicaid and long-term services and supports: A primer. The coverage provisions in the Affordable Care Act: An update. Total Medicaid spending FY Explaining health care reform: Risk adjustment, reinsurance, and risk corridors.
The facts on Medicare spending and financing. Status of state action on the Medicaid expansion decision. Persons with disabilities as an unrecognized health disparity population. Impact of health insurance expansion on the treatment of colorectal cancer. Journal of Clinical Oncology. Gaining coverage through Medicaid or private insurance increased prescription use and lowered out-of-pocket spending.
Porterfield SL, Huang J. Affordable Care Act provision had similar, positive impacts for young adults with and without disabilities. Early results show WellPoint's patient-centered medical home pilots have met some goals for costs, utilization, and quality. Association between the Affordable Care Act dependent coverage expansion and cervical cancer stage and treatment in young women. Saloner B, Le Cook B. An ACA provision increased treatment for young adults with possible mental illnesses relative to comparison group.
Reassessing ACOS and health care reform. Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act. Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.
Three-year impacts of the Affordable Care Act: Improved medical care and health among low-income adults. Increasing Value of Coverage for Consumers Under the rule, CMS is updating the allowable range in metal coverage levels for non-grandfathered individual and small group market plans. This change will likely require some plans to increase the generosity of their coverage, making it more comprehensive, and lower costs for many consumers.
In addition, these changes will make it easier for consumers to compare plans at the various coverage metal levels Bronze, Silver, Gold, and Platinum and distinguish between the plan offerings. Increasing Access for Consumers and Removing Barriers to Coverage The final rule aims to protect consumers from discriminatory practices related to the coverage of the essential health benefits EHB by refining the CMS nondiscrimination policy.
Specifically, a benefit design that limits coverage for an EHB on a basis protected from discrimination under this rule such as age and health condition must be clinically-based to be considered nondiscriminatory. The rule also updates Quality Improvement Strategy Standards to require issuers to address health and health care disparities. The higher ECP threshold will increase access to a variety of providers for consumers who are low-income or medically underserved.
Further Streamlining HealthCare. Maintaining FFM and SBM-FPs user fees at the level will ensure adequate funding for essential Marketplace functions such as consumer outreach and education, eligibility determinations, and enrollment process activites. CMS finalizes two of the three proposed model specification changes to the risk adjustment models, improving risk prediction for the lowest and highest risk enrollees.
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