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  • Cameron Oglesby

How Medicare pays doctors and hospitals to give seniors better care

Before 2008, the quality of patient care and how Medicare paid for it had little to do with each other.

Doctors and hospitals provided specific services, billed with the correct procedure code, and got paid. As a result, each patient’s health records, with each different doctor, lab, and hospital, were kept in stand-alone information silos.

This was a barrier to information sharing and care coordination between different providers caring for the same patient. And when you consider how likely elders are to be seeing multiple doctors – a primary care physician plus one of more specialists – this setup could cause health problems while trying to cure them.

A recent analysis of prescription drug alerts, for example, found that the more doctors that people over 65 saw, the more different prescriptions they filled, and the higher the risk of drug-to-drug interactions, under- and overuse of drugs, and duplications of treatment.

In 2008, the Medicare Improvements for Patients and Providers Act (MIPPA) ushered in the start of a different system called value-based reimbursement. Additional laws and VBR programs followed, covering end-stage renal disease quality, reducing both hospital readmissions (2012) and hospital-acquired conditions (2014), and establishing merit-based incentive payments (2019). Some 48 states and territories, Virginia among them, have additional VBR programs.

And while VBR may sound like a matter for accountants and bookkeepers, it’s good for seniors’ health. That’s because it focuses on an integrated picture of each patient’s outcomes and overall health – not just on separate office visits, lab tests, and hospitalizations, with separate records kept by separate providers.

Each VBR program has its own standards and measurements for patient outcomes. Failing to meet them triggers reduction in reimbursement. So does failure to document and report them properly. The goal is to provide better care, faster – and without unnecessary and redundant procedures.

Failing to meet those standards can cost hospitals and medical practices millions of dollars a year.

But while VBR is a more holistic approach to senior care, it’s not wholly holistic, for two main reasons.

First, it deals only with physical health, but not with important factors that our three-part holistic needs assessment covers: mental health, functional and social abilities, cognitive health, and even a safety evaluation, to determine and address what our clients and their families personally need as individuals.

Second, meeting VBR standards (and improving patient outcomes in the process) requires coordination between providers at all levels. And coordination requires shared, current, instantly accessible information. (This is particularly important for seniors, many of whom see more than one specialist.)

That can be harder than it sounds, because most, if not all, of a patient’s electronic health information (EHI) is stored in stand-alone digital silos. Each silo is maintained by a different doctor, group practice, lab, hospital, etc., providing care to a given patient. Each contains just part of the patient’s EHI

VBR’s holistic approach calls for horizontal communication connecting all the different doctors, labs, hospitals and other providers serving the same patient.

That doesn’t exist yet.

There’s no central “cloud” for patient EHI. There isn’t even a medical equivalent of the three credit-reporting companies. And while there are localized regional health information exchanges, they’re limited in scope and aren’t always compatible with everyone else’s software.

That’s why our coordinated senior care plans can include accompanying clients to doctor appointments, making sure all their doctors know about any health changes, and ensuring that all their doctors, their caregivers and their family all know about each doctor’s latest recommendations.

So please contact us for truly holistic senior care, that picks up where Medicare’s VBR standards leave off.

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