Index – Reform

This is the index for Responding to Healthcare Reform: A strategy Guide for Healthcare Leaders

A

ACA. See Affordable Care Act of 2010 (ACA)

Accountable care organizations (ACOs), 52, 61–63, 68; joint ventures for, 98–99; local, 96, 98; Medicaid, 82; Medicare, 62, 63–64, 97, 98; physicians’ engagement in, 78; as response to healthcare inflation, 80; risk management function of, 116–117; specialty, 96

Action Plan to Prevent Healthcare-Associated Infections, 28

Acute Care Episode (ACE) Demonstration, 63–64, 69

Administration for Children and Families, 31

Administrative costs, 73, 92

Affinity groups, 99

Affordable Care Act of 2010 (ACA), 1. See also Funds flow and incentives theory; Markets theory; Health Care and Education Reconciliation Act; Patient Protection and Affordable Care Act; Systems theory: chronic disease management policy of, 10, 17–26, 49–56, 109, 115–116, 139–142; full implementation of, 93; fundamental theories of, 1–2, 3; funding sources for, 108; groundwork for, 2–3; healthcare homes policy of, 21–24, 50, 116; lack of funding for, 104; lawsuits against, 104; prevention and wellness policies of, 37–47; primary care policy of, 10–11, 23–24; productivity and quality improvement policy of, 27–35, 30–31, 33, 109, 116, 131–139; public option of, 107; public programs policy of, 72, 127–131; repeal of, 108–109; sources of policies contained in, 3; strategies for changing, 103–105; Title I, 8, 119–127; Title II, 72, 127–131; Title III, 27–35, 131–139; Title IV, 39, 139–142; Title IX, 151–152; Title V, 5, 23–24, 66, 111–112, 142–145; Title VI, 66, 145–151; Title VII, 151; Title VIII, 151–152; Title X, 153–158

Agency for Healthcare Research and Quality (AHRQ): ACA provision for, 32, 33; clinical decision support role of, 21; involvement in National Quality Improvement Strategy, 31; support for healthcare reform by, 32

Alaska, rural healthcare in, 74

Alternative care models, 52

American Academy of Family Physicians, 22, 26

American Academy of Pediatrics, 22

American College of Physicians, 22

American Osteopathic Association, 22

American Recovery and Reinvestment Act (ARRA), 19, 25, 26, 42, 49, 109

Associations, involvement in healthcare policy, 110–111

Axolotl system, 81, 84

B

Bandhold, Hans, 9

Baptist Health System, Texas, 63

Basic research, 5

Baucus, Max, 2–3

Berman, Abe, 111–112

Budgets, global, 78, 107

Bundled payments, 9, 63–64, 78, 80, 108, 116–117

C

California, Kaiser Permanente healthcare system in, 96

California Healthy Eating, Active Communities Program, 42, 43–45

“Call to Action: Health Reform 2009″ report, 2–3

Canada, 107

Capitalism, market-based, 2, 7

Capitation: global, 73; partial, 98

Cardiologists, salaries of, 50

Center for Medicare and Medicaid Innovation (CMI), 67, 73, 108, 111

Centers for Disease Control and Prevention (CDC), 31

Centers for Medicare and Medicaid Services (CMS), 29; accountable care organizations (ACOs) and, 63; involvement in National Quality Improvement Strategy, 31; Medicare Acute Care Episode (ACE) Demonstration of, 63–64; Physician Group Practice (PGP) Demonstration of, 62; role in healthcare-associated infections prevention, 34; Rural Community Hospital Demonstration of, 74

Child Nutrition and Women, Infants, and Children (WIC) Reauthorization Act, 46

Children: as Medicaid patients, 61; obesity in, 39–40

Children’s Health Insurance Program (CHIP), 72, 128

Cholesterol, elevated, in uninsured populations, 89

Chronic disease management, 10, 17–26, 49–56, 109, 115–116, 139–142; by accountable care organizations, 62; comparative effectiveness research in, 20–21; costs associated with, 17, 18; health information technology (HIT) use in, 19–20, 49–51, 52; model of, 17, 19, 26; for multiple chronic conditions, 17, 18, 115; strategy options for, 51–52; in uninsured populations, 88, 89

Claims processing, electronic, 92

Cleveland Clinic, 80

Clinical decision support, 21

Clinical prevention: coordination in, 38–39; education and outreach programs for, 39–40

Cochrane Reviews, 25

Colorado, Kaiser Permanente healthcare system in, 96

Colorectal cancer screening tests, 38, 47

Community building, 41–42

Community Care of North Carolina, 23, 26

Community clinics, 74–75

Community health, 109

Community health centers, 72

Community health teams, 23

Community transformation grants, 5, 41–42, 140

Comparative effectiveness research (CER), 20–21, 42, 107, 109

Competition: among health plans, 8, 9, 95–100, 108; among hospitals, 5

Congress, oversight hearings by, 104

Congressional Budget Office, 7, 63

Consultations, with specialists, 96

Consumer engagement, scenarios for, 53–55, 56

Consumer’s behavior, factors affecting, 4, 5

Cost drivers, of health care costs, 78

Crossing the Quality Chasm: A New Health System for the 21st Century (Institute of Medicine), 34

CVS, 54

D

Dance of Legislation, The (Redman), 111

Dartmouth Institute for Health Policy and Clinical Practice, 35, 61

Data mining, 66, 99

Decision making, shared, 24–25, 30

Denver Health, 80

Diabetes mellitus, in uninsured populations, 89

Diagnostic-related group (DRG)-based payment system, 6–7, 28–29, 74

Discrimination, based on health status, 40–41, 42, 121

Disease management. See also Chronic disease management: as health plan service, 99

Dual eligible beneficiaries, 72–73

Durable medical equipment: certification of eligibility for, 66; suppliers of, 9

Durenberger, Dave, 103, 117

E

Efficiency. See also Productivity; Quality, in healthcare: incentives for, 109

E-health initiatives, 96

Electronic claims processing, 92

Electronic health records. See also Health information technology (HIT): use in chronic disease management, 19–20, 26

Employers, wellness programs sponsored by, 40–41, 42, 55, 116

Episodes of care, 29

Evidence-based medicine, 107

Experts, in healthcare policy, 111–112

F

Federal Bureau of Prisons, 31

Federally qualified health centers (FQHC), 74–75

Federal Trade Commission (FTC), 31

Fee-for-service payment system: as dominant payment system, 78; versus quality and efficiency incentives, 6

Financial transactions, electronic, 92

Fisher, E.S., 61

Food and Drug Administration (FDA), 31

Fraud prevention: funding for, 108; in Medicaid, 66; in Medicare, 60, 66–67; Recovery Audit Contractors (RAC) program for, 66–67, 68

Funds flow and incentives theory, of the ACA, 1, 2, 5-7, 12, 59-70, 108. See also Incentives, in payment systems; Penalties, in payment systems: healthcare inflation’s effect on, 77–81; of lowest cost site of care, 6, 7; scenarios of, 77–84

G

Geisinger, 80

Generic drugs, 78

Georgia, Kaiser Permanente healthcare system in, 96

Gross Domestic Product (GDP), relationship to healthcare inflation, 79

Group practices: quality evaluation of, 29; small, 78

H

Hawaii, Kaiser Permanente healthcare system in, 96

Healthcare, rationing of, 60

Health Care and Education Reconciliation Act of 2010, 12; summary of, 158–164

Healthcare-associated infections (HAIs), 34, 65–66, 108

Healthcare associations, involvement in healthcare policy, 110–111

Healthcare costs: cost drivers of, 78; healthcare homes-based reduction in, 23; regional differences in, 27

Healthcare homes, 21–24, 50, 116

Healthcare industry, monopolistic pricing practices of, 91

Healthcare Operations Management (McLaughlin and Hays), 34

Healthcare policy, guidelines for participation in, 110–112

Healthcare reform, 117. See also Affordable Care Act of 2010 (ACA): future of, 103–113

Healthcare system: core elements of, 4; employment-based, 7, 8; second-level model of, 4

Healthcare workers. See also Physicians: Medicare wage index for, 74

Health Information Technology for Economic and Clinical Health Act (HITECH), 19–20, 25, 29

Health information technology (HIT): in accountable care organizations, 62–63; Axolotl system, 81, 84; in chronic disease management, 26, 49–51, 52; funding of, 109; in primary care, 39

Health insurance coverage: ACA-mandated, 104, 105–106, 1250126; expansion under ACA, 115, 119–126; high-deductible, 7; medical loss ratios (MLRs) of, 91, 92–93; for preventive services, 39; standard benefits of, 87, 88–91, 92–93; universal, 87, 88

Health insurance exchanges (HIEs), 8, 9, 88–93, 115; advantages to employers, 95–96; initiation date for, 105; large employers’ use of, 95–96; in Minnesota, 109; national healthcare providers’ participation in, 95–96; public option of, 107; standard benefits feature of, 106, 108; subsidies feature of, 89, 106, 108

Health insurance industry, best practices of, 87

Health Insurance Portability and Accountability Act (HIPAA), 92

Health insurance premiums, 91; effect of wellness programs on, 40–41; rate increases of, 92

Health maintenance organizations (HMOs), denial of care by, 60

Health plans: competition among, 8, 9, 95–100, 108; new relationships with, 95–100, 109

Health Resources and Services Administration, 31, 56

Health savings accounts (HSAs), 8–9

HIEs. See Health insurance exchanges (HIEs)

HIPPA (Health Insurance Portability and Accountability Act), 92

Hip replacement, variability in utilization rates of, 24

HITECH (Health Information Technology for Economic and Clinical Health Act), 19–20, 25, 29

HMOs (health maintenance organizations), denial of care by, 60

Home health services, certification of eligibility for, 66

Hospital-acquired conditions, 65–66

Hospital-associated infections (HAIs), 34, 65–66, 108

Hospital Referral Regions, 24

Hospitals: accountable care organizations of, 80; competition among, 5; public, 73, 81; quality performance evaluation of, 28–29; small rural, 73–74

Hypertension, in uninsured populations, 89

I

ICD-9 (International Classification of Diseases, Ninth Revision), 20, 25

Idaho, rural healthcare in, 74

iList, 62–63

Incentives, as payment system component, 61–64; accountable care organizations (ACOs), 52, 61–63, 68, 82, 96, 97, 98, 116–117; bundled payments, 9, 63–64, 78, 80, 108, 116–117; for prevention of readmissions, 64, 68; for quality and efficiency, 109

Independent Payment Advisory Board, 7, 61, 68, 107

Infection control, lack of, 65

Inflation, healthcare: control of, 107; effect of healthcare cost drivers on, 77–81; effect of physician engagement on, 78–81; implication for ACA repeal, 108–109

Ingenix, 81, 84

Innovations, in healthcare delivery. See Center for Medicare and Medicaid Innovations

Institute for Clinical Systems Improvement, 109, 112–113

Institute of Medicine (IOM): childhood obesity report of, 39–40; comparative effectiveness research report of, 42; Crossing the Quality Chasm: A New Health System for the 21st Century, 34

Integrated healthcare systems, 51–52, 79; advantages of, 109; in Minnesota, 109; as response to healthcare inflation, 80; “virtual,” 61

Internal Revenue Service (IRS), 104

International Classification of Diseases, Ninth Revision (ICD-9), 20, 25

Iowa, Mayo Health System in, 96

J

Joint branding, with national healthcare providers, 98, 99

Joint replacement, variability in utilization rates of, 24

Joint ventures, 98–99

K

Kaiser Foundation, 115

Kaiser Permanente, 80, 96

Klebsiella pneumoniae infections, 65

Knee replacement, variability in utilization rates of, 24

Knowledge, role in healthcare system, 4, 5

L

Lawsuits, against the ACA, 104

Laxminarayan, Ramanan, 65

Lean Six Sigma, 33, 51

Legislators, healthcare policy experts for, 111–112

Lindgren, Mats, 9

Lobbying, 110–111

M

MacColl Institute for Healthcare Innovation, 17

Magnuson, Warren, 111–112

Malpractice, 107

Managed care, backlash against, 69

Markets theory, of ACA, 2, 7-9, 12, 87-93. See also Health insurance coverage: scenarios based on, 95–100; uncertainty level of, 95

Marshfield Clinic, 62–63

Massachusetts, health insurance exchange, 108; Health Connector of, 89

Mayo Clinic, 96

Mayo Health System, 96

“Meaningful use” policy, 19–20, 25, 29

Medicaid: accountable care organizations of, 82; complex enrollment systems for, 72; expansion of eligibility for, 72, 104, 106, 127–130; federal funding for, 106; fraud in, 66; healthcare home payments from, 23; payment incentives of, 59; pediatric beneficiaries of, 61; preventive services of, 39; primary care payments from, 24; quality reporting to, 31; relationship to Medicare, 72–73; uncompensated care payments from, 71; wellness promotion by, 41, 42

Medicaid Global Payment System Demonstration Project, 73

Medical education, federal subsidies for, 75

Medical homes. See Healthcare homes

Medical loss ratios (MLRs), 91, 92–93

Medically-underserved populations, 74–75

Medicare: accountable care organizations of, 62, 63–64, 97, 98; administered pricing system of, 29–30; DRG-based prospective payment system of, 6–7, 28–29, 74; fraud and abuse in, 60, 66–67; Part D, insurance mandate for, 105–106; physician quality website of, 29; relationship to Medicaid, 72–73; wage index of, 74; wellness visit benefit of, 39

Medicare Acute Care Episode (ACE) demonstration, 63–64

Medicare beneficiaries: with multiple chronic conditions, 18; shared decision making by, 25

Medicare expenditures/reimbursement: accountable care organization-based reduction in, 62, 63; base rate reductions in, 6; for chronic conditions, 18; effect of healthcare reform on, 59, 60; for multiple chronic conditions, 18, 115; payment incentives for, 59, 60; per capita rate of growth reduction in, 68; for primary care, 24; for rural hospitals, 74; volume of services-based vs. quality-based, 27–29

Medicare Group Practice Demonstration Project, 61

Medicare Innovations Center, 61

MedPac, 64–65

Mergers, 82, 98, 99

Metropolitan Statistical Areas (MSAs), 74

Minnesota: healthcare inflation reduction in, 109; Mayo Health System in, 96

Montana, rural healthcare in, 74

N

National Association of Insurance Commissioners, 91

National healthcare providers: joint branding with, 98, 99; participation in health insurance exchange, 95–96

National Health Service Corps, 111–112

National Highway Traffic Safety Administration, 31

National Institutes of Health, 21, 31

National Prevention Health Promotion and Public Health Council, 39

National Public Radio, 66

National Quality Improvement Strategy, 30–31, 33

Nebraska, rural healthcare in, 74

Nevada, rural healthcare in, 74

New Mexico, rural healthcare in, 74

New York Times, 62–63

Nixon, Richard M., 111–112

North Dakota, rural healthcare in, 74

Nutrition: public education programs in, 39; school-based programs in, 39–40, 42, 43–45

O

Obama, Barack, 104, 105

Obesity: childhood, 43–45; in children and adolescents, 39–40

Office of Management and Budget, 31

Office of the National Coordinator for Health Information Technology, 31

Ohio, Kaiser Permanente healthcare system in, 96

Oral health, 39

Oregon, Kaiser Permanente healthcare system in, 96

Outcome research, patient-centered, 5, 20–21, 147

Outreach, in chronic disease management, 17

P

Partnerships, physician-hospital, 80–81

Patient-centered outcome research, 5, 20–21, 147

Patient engagement, in shared decision making, 24–25

Patient experience, performance evaluation of, 60

Patient Protection and Affordable Care Act, 12, 13; summary of, 119–158

Patient-provider system, 3, 4–5

Pay-for-performance systems, 116

Payment policies. See also Incentives, as payment system component; Penalties, as payment system component: backup plans for, 67–68; classification of, 60

Payment systems, global, 73

Penalties, as payment policy component, 60, 64–67; for hospital-acquired conditions, 65–66, 108; for unnecessary readmissions, 64–65, 108

Performance monitoring, in shared decision making, 25

Physician Feedback System, 28–29

Physician Group Practice (PGP) Demonstration, 62

Physician-hospital relationship, 78

Physician Quality Reporting Initiative (PQRI), 28–29

Physicians. See also Primary care physicians: accountable care organizations of, 80; financial influences on, 5–6; quality evaluation of, 29; salary caps for, 107

Pledge of Allegiance, 87

Population health, 39, 109

Praxel, Theodore A., 63

Preexisting conditions: denial of health insurance based on, 41, 88, 105, 108, 121; implication for wellness programs, 40–41, 42

Presidential election (2012), 105

Preventive care, 37–47, 116; clinical prevention component of, 37–40; community building component of, 37, 41–42; individual wellness component of, 37, 40–41; scenarios of, 53–55, 56; strategies for, 54–55, 56

Preventive Services Task Force, 39

Primary care. See also Primary care physicians: ACA provision for, 23–24, 142–145; healthcare home concept of, 21–24, 50, 116; as health plan service, 99

Primary care physicians: hospital-employed, 52; increasing the supply of, 5, 23–24, 50–52, 108, 116, 142–145; salaries of, 50; specialty consultations to, 96

Primary care practices: acquisition by large integrated providers, 97; acquisition by national health plans, 97; health information technology (HIT) use in, 39

Productivity, 27–30; improvement of, 29–30; value-based purchasing and, 27–29

Prospective payment system, DRG-based, 6–7, 28–29, 74

Pseudomonas aeruginosa infections, 65

Public education, regarding preventive services, 39–40

Public health, 39

Public health agencies, prevention and wellness programs of, 55

Public health departments, prevention and wellness programs of, 38

Public option, 107

Purchasing, value-based, 27–29, 30, 78

Q

Quality, of healthcare: ACA provisions for, 30–32, 33, 131–139; clinical, 60; versus maximized revenue and profit, 6; unevenness of, 27

Quality reporting, 30–31, 33, 109, 116; improved systems for, 60; state-based agencies for, 60

R

RAND, 88

Rationing, of healthcare, 60

Readmissions, prevention of, 64–65, 68

Recovery Audit Contractors (RAC) program, 66–67, 68

Resources, markets model of, 8

Restaurants, nutritional postings in, 39

Retail-branded healthcare, 97–98

Retail clinics, 52, 54–55

Risk-pool death spiral, 105

Rural healthcare, 73–74, 81

S

Safety, of healthcare: performance evaluation of, 60; unevenness of, 27

Safety-net healthcare providers, 71–76, 117; CHIP eligibility and, 81; community clinics, 74–75, 81; community engagement of, 81–83, 84; for dual Medicare/Medicaid beneficiaries, 72–73; Medicaid eligibility and, 81–83, 84; public hospitals, 73, 81; of rural healthcare, 73–74, 81; scenarios, 81–83, 84 for

Safeway stores, 40, 47

St. Vincent’s Hospital, New York City, 82

Salaries, of physicians, 56; caps on, 107; for specialists, 116

Scenarios and scenario planning, 9–11, 12; basic goals in, 10; for chronic disease management, 49–52; for consumer engagement, 53–55, 56; for funds flow, 77–84; for markets (health insurance coverage), 95–100; for prevention and wellness programs, 53–55, 56; for systems theory, 49–56

School-based clinics, 39–40

School-based wellness programs, 42, 43–45

Shadow pricing, 91

Shared savings concept, 61

Social Security Administration, 31

South Dakota, rural healthcare in, 74

Specialists: consultations with, 96; independent practices of, 78; salaries of, 116

Specialty accountable care organizations (ACOs), 96

Staphylococcus aureus, methicillin-resistant (MRSA), 65

State health insurance exchanges, 108

States. See also specific states: “frontier,” 74; healthcare inflation rates in, 109; lawsuits against ACA from, 104

Substance Abuse and Mental Health Services Administration, 31

Surgical Care Improvement Project (SCIP), 28, 34

Systems theory, of the ACA, 1, 2, 3–5, 12, 109; of chronic disease management, 17–26; of healthcare productivity and quality, 27–35; of prevention and wellness, 37–47; scenarios of, 49–56

T

Target stores, 51, 54

Taxes, ACA-mandated, 106

Tourism, medical, 97–98

U

Uncompensated care. See also Uninsured populations: reduction in, 6

Uninsured populations: chronic disease management in, 88, 89; pediatric, 72; safety-net healthcare for, 71–76

United Healthcare Group, 81, 84

United Health Group, 40

United States Coast Guard

United States Congress, oversight hearings by, 104

United States Constitution, commerce clause of, 104

United States Department Commerce, 31

United States Department of Defense, 31

United States Department of Health and Human Services, 40; accountable care organizations regulations of, 61, 62; Action Plan to Prevent Healthcare-Associated Infections, 28; health insurance benefits determination by, 90–91; involvement in National Quality Improvement Strategy, 31

United States Department of Labor, 31

United States Department of Veterans Affairs, 31

United States Hospital Referral Regions, 24

United States Office of Personnel Management, 31

United States Preventive Services Task Force, 46–47

Universal health insurance coverage, 87, 88

University of St. Thomas, Center for Health and Medical Affairs, 11

Urgent care, 99

Utah, rural healthcare in, 74

Utah Health Exchange, 108

V

Value-based purchasing, 27–29, 30, 78, 116

Vendors, “value solutions” of, 79

Veterans Health Administration, 31

W

Wagner, Edward, 17, 19

Wal-Mart, 51, 54

Washington, D.C., Kaiser Permanente integrated healthcare system in, 96

Washington state, Kaiser Permanente integrated healthcare system in, 96

Wellness programs, 40–41, 46, 116; scenarios of, 53–55, 56; in schools, 39–40; strategies for, 54–55, 56

WellPoint, 92

Wisconsin, Mayo Health System in, 96

Wyoming, rural healthcare in, 74

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