Saturday, September 14, 2013

Traditional Approach vs. Integrated Model of Care

Traditional  Approach
vs.
Integrated MOC
No Population Health Improvement Plan and no Individual HIP required

Reimbursement not aligned or coordinated


Comprehensive PHIP and IHIP required to be kept up-to-date

Alignment of reimbursements, incentives,  coordinated across benefit plans and across care continuum

No comprehensive population health action plan

Integrated MOC with detailed goals, critical path algorithms strictly adhered to an backed up by CME

No mechanism for health assessment within 14 days of assignment

Mandated to belong to a MCO with 100% 14 day assessment requirement culminating with an IHIP
May or may not belong to a MCO

Telephonic assessment identifies this enrollee as a priority for face-to-face health assessment

No mechanism for health assessment, prioritization

F-2-F assessment performed by licensed professional

Enrollee utilizes ER for fall and broken hip; multiple illnesses due to exposure

ER considerably more expensive then taking Model of Care preventive measures outside the allopathic model

Enrollee identified as depressed, along with typical chronic symptoms associated with this population; Home needs to be repaired and refitted in order to protect enrollee from the elements; Also bathroom needs remodeling to accommodate enrollee and prevent hip fracture or worse; 56 year, unemployed, obese, non-ambulatory son found living in garage behind house

MCO reacts to over utilization of ER over time

Son utilizes ER over 100 times because that was the only way to receive services

Son enrolled in Medicaid program; Employed  as mother’s caregiver under directed care benefits at a savings;  A line installed between house and son’s domicile as quick fix  for purposes of ambulation and hygiene

Traditional scenario:
Costs quadruple in last moments of life-not to mention multiple ER, hospital, nursing home visits scenarios; Totally unsatisfactory to all parties involved in the healthcare transaction

Triple aim achievement unlikely

Avoidance of traditional scenario:
Son employed as mom’s caregiver at lower cost, allowing her to remain at home at lower cost; More satisfaction for all concerned in this healthcare transaction

Triple aim achievement within sight


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