Performance Based Medicine: Creating the High Performance Network to Optimize Managed Care Relationships

With healthcare making the transition from volume-based reimbursement programs to value-based approaches, understanding performance measurement is vital to optimize payment and quality outcomes. Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care Relationships guides readers through the maze of definitions and discussions related to value-based purchasing, healthcare delivery, and pricing. It tackles the question of how hospitals, HMOs, physician groups, and employers can arrive at an optimized reimbursement cost and coverage access decision that is attractive to consumers yet fulfills the need for a working margin.

The book begins by looking at HMOs and the three key factors—reimbursement, coordination, and performance—that have led toward performance-based contracting. Laying the foundation for clearer communication between physician hospitals and purchasers, the author defines important concepts in the discussion, from efficiency and cost effectiveness to quality. He focuses on key issues of organizational structure, management, and measuring the outcomes of quality.

Discussing pay-for-performance, the book examines programs in the US and offers case studies of countries succeeding in the development of care management. It explores options for reengineering the healthcare delivery system, among them transitional case management programs and specialist data sharing. It also covers the use of information technology in healthcare delivery.

This timely book will be of interest to managers, vendors, employers, and insurers who have tried everything to lower cost but are discovering that all care is not equal and that matching the right doctor with the right service for the right patient can be done. Helping readers build a path between where they are and where they want to be, it offers an outline of tasks to move from a disorganized collection of care components to a seamless arrangement of high-performance care-givers.

The book is directed at the senior management level for those who are learning metrics and are trying to define performance to become more sophisticated in monitoring and leveraging this vital data in a complex marketplace of contradictory terms and ill-defined outcomes.

William J. De Marco, MA, CMC, is the President and Chief Executive Officer of De Marco & Associates, Inc., a national, independent healthcare consulting firm specializing in healthcare delivery system redesign and transformation. He expanded the company’s capabilities in 2001 by forming Pendulum HealthCare Development Corporation, a health information and management services company. Mr. De Marco is recognized as a leader in the research, design and implementation of community-based health plans. He is currently involved with assisting special needs plan startups and expansions as well as other Medicare and Medicaid program development. Mr. De Marco is a well-known author having written or contributed to over a dozen books on managed care topics. He holds a master’s degree in organizational development from DePaul University. He is a past faculty member of Loyola Law School’s graduate program and was recently awarded the Follomer Bronze award from the Healthcare Financial Management Association for his outstanding service and contributions to HFMA chapters and members. He also recently authored the Managed Care Exam Study guide for certification by HFMA executives. As an accomplished speaker on a variety of topics including reimbursement, marketing and management issues, Mr. De Marco has received high marks for offering entertaining and insightful workshops and seminars. He is a regular presenter for such audiences as Medical Group Management Association, HFMA, VHA, AHA, Quorum, NMHCC and AHIP.

Introduction
Integration and HMOs: How Did We Get This So Wrong?ReimbursementCoordinationPerformance
Performance Measurement: A Science with No FollowersFurthering Measurement and Informed PurchasingReimbursement: From Fee for Service to Risk AdjustersMore Than a TrendThe Current Status of P4PEarly Pay for PerformanceDecile ThresholdsMore Than a TrendThe Current Status of P4P
Performance Language and PracticeWhere Health Care Delivery and Information Technology IntersectThe Solution Is within Our Four WallsCan We Get Our Terminology Correct First?Short Term vs. Long TermEfficiencyEffectivenessGrades and EffectivenessRisk Adjusters and Comparative EffectivenessOrganizational Issues of Planning and ControlQuality DataOutcomes DataEvidence‑Based Outcomes DataLean EngineeringSix SigmaLearning Organizations
ReengineeringEarly GuidelinesSavings EstimatesSummary of Selected Savings OptionsGuidelines and Episodes of CareGrouping Bundles of ServicesValue‑Based Purchasing and Performance‑Based ContractingSetting Benchmarks and Attainment ThresholdsSmall Numbers on Individual Performance MeasuresWhat the Regulations Are Saying about Pay-for-Performance

ChallengesThe Pay‑for‑Performance Rumors and IssuesWhat Types of Performance Targets?Cost EffectivenessCommitmentThe VisionJust Another ProgramLean EngineeringInternational Classification of DiseasesWeb‑Based ProcessingComparative Effectiveness and Ethical LimitationsLung Volume Reduction Surgery as a QALY Example
International ReformCompetition through Improved PerformanceResults
Getting StartedIntroduction to PlanningEnvironmental ScanManaged Care’s InvolvementFeasibility and First StepsWhat Are We Trying to Prove?Legal Issues That Might Affect What You Are Trying to DoTasks to Move toward an Integrated Care SystemFeasibility Study for Nonaligned Hospitals and PhysiciansFinancial StepsPlanning StepsGeneral Issues to AvoidIssues to Decide upon Early OnNo Guarantee That Any of These Steps Will Produce a ResultThe Future of Performance‑Based MedicineOnce We Have BaselineOperating Your Performance‑Based StrategyEpisode Treatment GroupSharing Benchmarks and Eliminating Unhealthy ConflictNormal vs. Abnormal ConflictConstructive ConflictGap Analysis as an Ongoing Operational Management GoalDisease Grouping Connected to Delivery SystemsPatient Health Status ImprovementBuilding the "Front End" and the "Back End" of the Patient‑Coordinated SystemPatient Health RecordsGain Sharing and Risk ManagementCommunity‑Based Analysis versus National StandardsPayment as a Meaningful Driver of Permanent Behavioral Change for Physician and PatientManaged Care Opportunity to Share or Suppress DataDecision Tools and Artificial IntelligenceBuilding a Collaborative ModelDeinstitutionalize the Institutional ServicesMoving Toward Life Sciences Approach to Managing Care
Appendices