Insurance Company Bonuses for Quality from the Care National Blog http://carenational.com/
"Just how much money are we talking about? She explained that for a health plan with just 100,000 members being evaluated by HEDIS, each quality measure would mean around $17 million in reimbursements from federal or state agencies. When you consider that there are 20-25 measures directly tied to reimbursement (depending on the health plan and the population served) the math adds up to $340 – $425 million in revenue each year! Now consider what that might look like for larger Managed Care Organizations who have a million or more members enrolled.
“You are not talking about a little bit of money. You are talking about what keeps the machine running – literally!”
In addition to standard reimbursement, CMS Stars ratings are directly related to the percentage of HEDIS measures met. That also translates to losses or gains in revenue as Stars ratings are something the public is very aware of when shopping for a health plan. Ultimately, if a health plan demonstrates poor performance for 3 or more years, CMS will assess penalties against them, up to and including shutting the organization down. Having key leaders that internalize the monetary value of each measure, and the importance of HEDIS as a whole, generally transforms the whole company’s understanding of the importance of those quality measures, such as preventative care, safety, patient satisfaction, and provider satisfaction. That is the fundamental concept behind any Pay for Performance (P4P) quality initiative."
Monday, January 19, 2015
Saturday, January 17, 2015
Here's another guest post by Dave Levingston from the patient perspective. (See the previous post from his Florida trip.)
I’d like to share a few thoughts about my recent interface with the Medical/Industrial Complex.
A brief recap of what happened to me:
I got sick with what appeared to be the flu. Actually, it was a drug reaction to an antibiotic I was taking for the aftereffects of bronchitis. I was on the next to the last day of a two-week course of the antibiotic, so I didn’t suspect it might be the problem, and I kept taking it for a day after the reaction started. That made me very sick.
I went to the ER where the doctor originally diagnosed me with a “stomach bug” and signed my discharge, saying I’d be fine in a day or two. But he took a second look when he saw that I appeared to be getting worse. At that point he noticed the head-to-toe rash that I had developed and realized it was probably a drug reaction.
Wanting to be sure of the problem, the doctor ordered several tests, leading to a lumbar puncture to look at my spinal fluid because meningitis was a possibility.
I was admitted to the hospital where I spent several days recovering.
I’m now out of the hospital recovering, not from the drug reaction, but rather from the spinal tap. They tell me I will need 3-4 weeks to fully recover. Right now just writing this at my computer is pushing me to the limits of what I’m physically able to do.
If you look that over you will see that everything, except the original lung issue from the bronchitis, was all a result not of disease, but rather a result of medical treatment.
Now, don’t get me wrong. I’m not complaining about the care I received. Far from it. I was very sick, the sickest I’ve ever been, and they cured me. I’m glad.
And I’m not a Luddite. I appreciate modern medical science and the great improvements in the health of nearly everyone as a result of the great health care we enjoy in our country.
Every single person I encountered in the health care system during this misadventure was wonderful, caring and obviously highly skilled.
But, I have to wonder if I might have been better off with care that wasn’t quite so great. If instead of being concerned about other possible problems, what would have happened if I had just been treated for the drug reaction and then watched in the hospital for a day or two in case there were other problems? I don’t know the medical protocols for my situation, but I’m sure the care and diagnostic decisions were proper and intended to make sure something much worse wasn’t going on.
So today I’m still sick…not with any disease, but with the aftereffects of that spinal tap. Let me tell you, those aftereffects are not minor. I suspect that, if I had not had the spinal tap, I would be completely fine today. The effects of the drug reaction would be long past and I’d be back to going about my normal life. Instead I can barely function and it looks like this is going to cost me several weeks of my life. And this is shortening my life not by losing a few weeks at the end with tubes running into me and struggling for every breath. These are several good weeks taken from me now, when I could be out there enjoying life and getting things accomplished.
Maybe in my case the health care was just a little too good. So it goes.
Man plans; God laughs
I’ve been gone from the internet for a week. That was not my plan. I had planned to be very busy and therefore to have a limited presence here for a while, but that’s not what happened.
Here’s the Cliff Notes version of the past week: On Wednesday I got sick. Thursday I got sicker and went to the ER. Friday I was admitted to the hospital. I was there untilbeing very sick, the sickest I’ve ever been in my life. It was very unpleasant. Now I’m out of the hospital and better and expected to fully recover…though they say that may take another four weeks or so.
If you want the TMI version, keep reading.
On Wednesday I started getting the shakes, alternated with bursts of sweating. Then I started throwing up. I thought I was getting the flu. Thursday I began getting progressively more and more ill. In the afternoon I went to the ER.
At the ER the doctor initially diagnosed it as “a stomach bug” not the flu and signed the discharge order, telling me to just go home and I’d be fine in a couple days. But then he looked back in on me and saw that I was getting worse, while he would have expected me to already have started improving. So he decided to not let me go, and to examine me more carefully.
Immediately he noticed that I had a severe rash from head to toe. It never itched, so I was too busy throwing up and being miserable to have noticed it. The rash lead to the conclusion that I was having a drug reaction. I had been taking a sulfa antibiotic for a couple weeks because of some left over lung infection from a bout of bronchitis. I’d never had a drug reaction in my life, and had taken sulfa drugs before with no problem, but this time the drug decided to wait until right at the end of the prescription to try to kill me.
Because I thought it was the flu and had been taking the sulfa for two weeks without a problem, I never suspected that was the problem and kept taking the sulfa after the reaction started, finishing the prescription just before going to the ER.
The doctor wasn’t sure the drug reaction was all that was going on, so test began. Chest X-rays, a CT scan, and then a spinal tap. For a long time Meningitis was the leading theory.
By the time I got into a hospital room in the early morning on Friday I was miserable. The most miserable I’ve ever been, and that’s saying something. At one point I remember seeing these objects in my mind. There were three identical objects, side by side. Somehow they represented the Past, Present and Future. Or Yesterday, Today and Tomorrow. Something like that. And I remember thinking that if the level of misery I was feeling was going to continue into the next 24-hour period, I was just not going to be able to do that. Any option. ANY. OPTION. Was superior to feeling like this for another day. Continuing feeling this way was just not something I was able to do. I would have agreed to anything, including not continuing to exist, just to avoid going on like that.
I was sick.
Understand that I’m not used to being sick. I’ve been very fortunate and relatively healthy all my life. My health problems are of the annoying variety, like arthritis and glaucoma, not the “kick you on your ass” variety. I get the flu shot every year and I don’t get the flu. It had been at least 20 years since the last time I threw up. The last time I was admitted to a hospital was in the first grade when I had my tonsils out. This was a very new, very scary experience for me.
Once I got to my room in the hospital and they started doing things to help me recover, my level of misery quickly dropped to barely tolerable. But then the headache started, caused by the spinal tap. Turns out most of my time in the hospital was spent trying to recover from the spinal tap. I’m still recovering from the spinal tap, and will be for weeks.
The final diagnosis was drug reaction with aseptic meningitis. That means the abnormalities in my spinal fluid were most likely caused by the drug reaction. Nothing contagious was going on. All the tests on my spinal fluid came back negative.
The rash is fading (and still not itching). The headaches are mostly gone now, just a threat in the background to keep me from trying to do anything physical. I have the good drugs if the headache returns. Typing on the computer is the most strenuous activity I’ll be engaging in for a few weeks.
But I’m alive. I’m feeling better. And I’ll be back at it soon.
I can’t say enough good about the care I received. Every single medical professional I encountered during all this was just extremely good to me, worked hard to help me, and made me feel well cared for. Especially notable was Nurse Angie who took it upon herself to research my condition on her own time. That resulted in her finding the best drug to use for my headache. Until she gave me that, what they had been giving me just reduced the intensity of the headache. An hour after taking the new drug, the headache was gone. That significant. This headache was of the mind numbing, nausea educing variety. The pain level was a 9 on a scale of 10. Having that gone greatly helped me recover.
But most of all I have to praise my wonderful wife, who was there beside me through this whole ordeal, making sure the doctors and nurses knew what was happening with me and sleeping (mostly not sleeping) on the sofa beside me the whole time I was in the hospital, taking care of me the whole time. It would have been a lot more awful if she hadn’t been there. In no way do I deserve such a fantastic, loving, dedicated wife. She is a major blessing in my life.
Now I’ve had a full night’s sleep without any tubes running into my body and nobody waking me up every couple hours to stick needles in me. I don’t think I achieved REM sleep at all during the whole hospital stay. Just a good night’s sleep was a real blessing and helped me feel much better.
So, that’s where I’ve been. I’m very glad to be back.