Learn More. The Peer-to-Peer request must be received by Maryland Amerigroup maryland prior authorization Care within two 2 business days of the initial notification of the denial. The intent of the Peer-to-Peer is to discuss the denial decision with the ordering clinician or attending physician. For specific details prioe authorization requirements, please refer to our Quick Reference Guide. Certain carefirst mental providers require prior authorization regardless of place of service.
He goes to the central market to buy fruit, taking a packed dirty bus. He thinks the city's central market was contaminated at the beginning of the pandemic, but it could not be closed as it is the main source of food in the country. He has no health insurance, and he knows that as a diabetic he is at risk, but medication for his condition is too expensive. These real stories highlight the issues that must be addressed to reduce persistent health inequalities and achieve health outcomes focusing on population health.
All three live in densely populated urban areas with poor housing, and have to travel long distances in overcrowded transport. Furthermore, all three experienced high levels of stress, which is magnified in the cases of Maria and David who were unable to be present when their loved ones died. The COVID pandemic has made it evident that to improve the health of the population and build healthy societies, there is a need to shift the focus from illness to health and wellness in order to address the social, political and commercial determinants of health; to promote healthy behaviours and lifestyles; and to foster universal health coverage.
A better future could be possible with leadership that is able to carefully consider the long-term health, economic and social policies that are needed. In order to design and implement population health-friendly policies, there are three prerequisites. First, there is a need to improve understanding of the factors that influence health inequalities and the interconnections between the economic, social and health impacts.
Second, broader policies should be considered not only within the health sector, but also in other sectors such as education, employment, transport and infrastructure, agriculture, water and sanitation. Third, the proposed policies need to be designed through involving the community, addressing the health of vulnerable groups, and fostering inter-sectoral action and partnerships.
Finally, within the UN's Agenda , Sustainable Development Goal SDG 3 sets out a forward-looking strategy for health whose main goal is to attain healthier lives and wellbeing. The 17 interdependent SDGs offer an opportunity to contribute to healthier, fairer and more equitable societies from which both communities and the environment can benefit. Available here. Permission has been granted to narrate these stories.
Buck, D. A vision for population health: Towards a healthier future. Wilton Park. Healthy societies, healthy populations WP Wiston House, Steyning. Population health as a framework for public health practice: a Canadian perspective. American journal of public health , 96 9 , Emily was 65lb 29kg above her ideal body weight, pre-diabetic and had high cholesterol.
I had no other additional resources, incentives or systems to support me or Emily to help her turn her lifestyle around. I saw Emily eight months later, not in my office, but in the hospital emergency room. Her husband accompanied her she was vomiting, very weak and confused.
She was admitted to the intensive care unit, connected to an insulin drip to lower her blood sugar, and diagnosed with type 2 diabetes.
I talked to Emily then, emphasizing that the new medications for diabetes would only control the sugars, but she still had time to reverse things if she changed her lifestyle. She received further counselling from a nutritionist.
Over the years, Emily continued to gain weight, necessitating higher doses of her diabetes medication. More emergency room visits for high blood sugars ensued, she developed infections of her skin and feet, and ultimately, she developed kidney disease because of the uncontrolled diabetes. Ten years after I met Emily, she is 78lb 35kg above her ideal body weight; she is blind and cannot feel her feet due to nerve damage from the high blood sugars; and she will soon need dialysis for her failing kidneys.
We have prevented her from dying and extended her life with our interventions, but each interaction with the medical system has come at significant cost and those costs will only rise. But we have also failed Emily by allowing her diabetes to progress.
We know how to prevent this, but neither the right investments nor incentives are in place. Emily could have been a real patient of mine.
Her sad story will be familiar to all doctors caring for chronically ill patients. Unfortunately, patients like Emily are neglected by health systems across the world today.
The burden of chronic disease is increasing at alarming rates. In the coming decades, obesity, will claim 92 million lives in the OECD while obesity-related diseases will cut life expectancy by three years by These diseases can be largely prevented by primary prevention, an approach that emphasizes vaccinations, lifestyle behaviour modification and the regulation of unhealthy substances. Preventative interventions have been efficacious. For obesity, countries have effectively employed public awareness campaigns, health professionals training, and encouragement of dietary change for example, limits on unhealthy foods, taxes and nutrition labelling.
The COVID crisis provides the ultimate incentive to double down on the prevention of chronic disease. Most people dying from COVID have one or more chronic disease, including obesity, CVD, diabetes or respiratory problems diseases that are preventable with a healthy lifestyle. COVID has highlighted structural weaknesses in our health systems such as the neglect of prevention and primary care. While the utility of primary prevention is understood and supported by a growing evidence base, its implementation has been thwarted by chronic underinvestment, indicating a lack of societal and governmental prioritization.
On average, OECD countries only invest 2. The underlying drivers include decreased allocation to prevention research, lack of awareness in populations, the belief that long-run prevention may be more costly than treatment, and a lack of commitment by and incentives for healthcare professionals. Furthermore, public health is often viewed in a silo separate from the overall health system rather than a foundational component. Health benefits aside, increasing investment in primary prevention presents a strong economic imperative.
Economic losses further extend to absenteeism and decreased productivity. Fee-for-service models that remunerate physicians based on the number of sick patients they see, regardless the quality and outcome, dominate healthcare systems worldwide. Primary prevention mandates a payment system that reimburses healthcare professionals and patients for preventive actions. Ministries of health and governmental leaders need to challenge skepticism around preventive interventions, realign incentives towards preventive actions and those that promote healthy choices by people.
Primary prevention will eventually reduce the burden of chronic diseases on the healthcare system. As I reflect back on Emily and her life, I wonder what our healthcare system could have done differently.
What if our healthcare system was a well-care system instead of a sick-care system? Imagine a different scenario: Emily, a 32 year old pre-diabetic, had access to a nutritionist, an exercise coach or health coach and nurse who followed her closely at the time of her first visit with me.
Imagine if Emily joined group exercise classes, learned where to find healthy foods and how to cook them, and had access to spaces in which to exercise and be active. Imagine Emily being better educated about her diabetes and empowered in her healthcare and staying healthy. In reality, it is much more complicated than this, but if our healthcare systems began to incentivize and invest in prevention and even rewarded Emily for weight loss and healthy behavioural changes, the outcome might have been different.
Imagine Emily losing weight and continuing to be an active and contributing member of society. Imagine if we invested in keeping people healthy rather than waiting for people to get sick, and then treating them. Imagine a well-care system. Anderson, G. Responding to the growing cost and prevalence of people with multiple chronic conditions. Retrieved from OECD. Institute for Health Metrics and Evaluation.
GBD Data Visualizations. Retrieved here. Obesity Update. Malik, V. Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology , 9 1 , Lang, J.
The centers for disease control and prevention: findings from the national healthy worksite program. Journal of occupational and environmental medicine , 59 7 , Gmeinder, M. How much do OECD countries spend on prevention? Covid risk factors for severe disease and death. Richardson, A. Investing in public health: barriers and possible solutions. Journal of Public Health , 34 3 , Yong, P.
Missed Prevention Opportunities The healthcare imperative: lowering costs and improving outcomes: workshop series summary Vol. McDaid, D. Sassi and S. Merkur Eds. Although healthcare systems around the world follow a common and simple principle and goal that is, access to affordable high-quality healthcare they vary significantly, and it is becoming increasingly costly to provide this access, due to ageing populations, the increasing burden of chronic diseases and the price of new innovations.
Governments are challenged by how best to provide care to their populations and make their systems sustainable. Neither universal health, single payer systems, hybrid systems, nor the variety of systems used throughout the US have yet provided a solution.
However, systems that are ranked higher in numerous studies, such as a report by the Commonwealth Fund , typically include strong prevention care and early-detection programmes. This alone does not guarantee a good outcome as measured by either high or healthy life expectancy. But there should be no doubt that prevention and early detection can contribute to a more sustainable system by reducing the risk of serious diseases or disorders, and that investing in and operationalizing earlier detection and diagnosis of key conditions can lead to better patient outcomes and lower long-term costs.
To discuss early detection in a constructive manner it makes sense to describe its activities and scope. Early detection includes pre-symptomatic screening and treatment immediately or shortly after first symptoms are diagnosed. Prevention, which is not the focus of this blog, can be interpreted as any activities undertaken to avoid diseases, such as information programmes, education, immunization or health monitoring. In the past few years, however, a number of countries have introduced reforms to strengthen and promote prevention and early detection.
Possibly the most prominent example in recent years was the introduction of the Affordable Care Act in the US, which placed a special focus on providing a wide range of preventive and screening services. It lists 63 distinct services that must be covered without any copayment, co-insurance or having to pay a deductible.
Whilst logic dictates that investment in early detection should be encouraged, there are a few hurdles and challenges that need to be overcome and considered. We set out a few key criteria and requirements for an efficient early detection program:.
Accessibility The healthcare system needs to provide access to a balanced distribution of physicians, both geographically such as accessibility in rural areas , and by specialty. Patients should be able to access the system promptly without excessive waiting times for diagnoses or elective treatments.
This helps mitigate conditions or diseases that are already quite advanced or have been incubating for months or even years before a clinical diagnosis. Access to physicians varies significantly across the globe from below one to more than 60 physicians per 10, people.
This should give individuals easier access to health-related services, not only in cases of sickness but also to supplement primary care. Early symptoms and initial diagnosis Inaccurate or delayed initial diagnoses present a risk to the health of patients, can lead to inappropriate or unnecessary testing and treatment, and represents a significant share of total health expenditures.
A medical second opinion service, especially for serious medical diagnoses, which can occur remotely, can help improve healthcare outcomes. Moreover, studies show that early and correct diagnosis opens up a greater range of curative treatment options and can reduce costs e. New technology New early detection technologies can improve the ability to identify symptoms and diseases early: i. Advances in medical monitoring devices and wearable health technology, such as ECG and blood pressure monitors and biosensors, enable patients to take control of their own health and physical condition.
Diagnostic tools, using new biomarkers such as liquid biopsies or volatile organic compounds, together with the implementation of machine learning, can play an increasing role in areas such as oncology or infectious diseases.
Regulation and Intervention Government regulation and intervention will be necessary to set ranges of normality, to prohibit or discourage overdiagnosis and to reduce incentives for providers to overtreat patients or to follow patients' inappropriate requests.
In some countries, such as the US, there has been some success through capitation models and value-based care. Governments might also need to intervene to de-risk the innovation paradigm, such that private providers of capital feel able to invest more in the development of new detection technologies, in addition to proven business models in novel therapeutics.
Faith, a mother of two, has just lost another customer. Some households where she is employed to clean, in a small town in South Africa, have little understanding of her medical needs. As a type 2 diabetes patient, this Zimbabwean woman visits the public clinic regularly, sometimes on short notice. At her last visit, after spending hours in a queue, she was finally told that the doctor could not see her. To avoid losing another day of work, she went to the local general practitioner to get her script, paying more than three daily wages for consultation and medication.
Sadly, this fictional person reflects a reality for many people in middle-income countries. In middle-income countries, private investors often focus on extending established businesses, including developing private hospital capacity, targeting consumers already benefiting from quality healthcare.
As a result, an insufficient amount of private capital is invested in strengthening healthcare systems for everyone. Why is this the case? Notwithstanding these barriers, healthcare, specifically in middle-income settings, could present an attractive value proposition for private investors:. Based on the context above, several areas in healthcare delivery can present compelling opportunities for private companies.
To fully realize these opportunities, government must incentivise innovation, provide clear regulatory frameworks and, most importantly, ensure that health priorities are adequately addressed.
Venture capital and private equity firms as well as large international corporations can identify the most commercially viable solutions and scale them into new markets. The ubiquity of NCDs and the requirement to reduce costs globally provides innovators with the opportunity to scale their tested solutions from LMICs to higher income environments.
Successful investment exits in LMICs and other private sector success stories will attract more private capital. Governments that enable and support private investment in their healthcare systems would, with appropriate governance and guidance, generate benefits to their populations and economies. The economic value of healthy populations has been proven repeatedly , and in the face of COVID, private sector investment can promote innovation and the development of responsible, sustainable solutions.
Faith the diabetic mother we introduced at the beginning of this article - could keep her client. As a stable patient, she could measure her glucose level at home and enter the results in an app on her phone, part of her monthly diabetes programme with the company that runs the health centre.
She visits the nurse-led facility at the local taxi stand on her way to work when her app suggests it. The nurse in charge of the centre treats Faith efficiently, and, if necessary, communicates with a primary care physician or even a specialist through the telemedicine functionality of her electronic health system. Improving LMIC health systems is not only a business opportunity, but a moral imperative for public and private leaders.
With the appropriate technology and political will, this can become a reality. John E. The emergence of the new severe acute respiratory syndrome coronavirus SARS-Cov-2 , causing the coronavirus disease COVID , has challenged both developing and developed countries. Countries have approached the management of infections differently.
Alongside limited resources for health, many developing countries may have weak health systems that can make it challenging to respond adequately to the pandemic. Even before COVID, high rates of out-of-pocket spending on health meant that every year, million people faced catastrophic healthcare costs , million families were pushed into poverty, and millions more simply avoided care for critical conditions because they could not afford to pay for it.
The pandemic and its economic fallout have caused household incomes to decline at the same time as healthcare risks are rising. In some countries with insurance schemes, and especially for private health insurance, the following questions have arisen: How large is the co-payment for a COVID test? Will my coronavirus care be paid for regardless of how I contracted the virus? These and other doubts can prevent people from seeking medical care in some countries. In the public health sector, where COVID cases are treated, health workers are paid monthly salaries while budgets are allocated to health facilities for other services.
Hospitals continue to receive budget allocations to finance all health services including the management and treatment of COVID That implies that funds allocated to address other health needs are reduced and that in turn could affect the availability and quality of health services.
Although health workers providing care for COVID patients in isolation and treatment centres in Nigeria are paid salaries that are augmented with a special incentive package, the degree of impact on the quality improvement of services remains unclear. The traditional and historical allocation of budgets does not always address the needs of the whole population and could result in poor health services and under-provision of health services for COVID patients. Ironically, despite the huge demand for medical services to diagnose and treat COVID, large healthcare institutions and individual healthcare practitioners alike are facing financial distress.
Dependence on a steady stream of fee-for-service payments for outpatient consultations and elective procedures is leading to pay cuts for doctors in India , forfeited Eid bonuses for nurses in Indonesia , and hospital bankruptcies in the United States. COVID is exposing how fee-for-service, historical budget allocation and out-of-pocket financing methods can hinder the performance of the health system.
Nevertheless, these types of innovations do not represent the dominant payment model in any country. How health service providers are paid has implications for whether service users can get needed health services in a timely fashion, and at an appropriate quality and an affordable cost.
By shifting from fee-for-service reimbursements to fixed "capitation" and performance-based payments, these models incentivize providers to improve quality and coordination while also guaranteeing a baseline income level, even during times of disruption. Health service providers could be paid either in the form of salaries, a fee for services they provide, by capitation whether adjusted or straightforward , through global budgets, or by using a case-based payment system for example, the diagnostics-related groups , among others.
Because there are different incentives to consider when adopting any of the methods, they could be combined to achieve a specific goal. For example, in some countries, health workers are paid salaries , and some specific services are paid on a fee-for-service basis. Ideally, health services could be purchased strategically , incorporating aspects of provider performance in transferring funds to providers and accounting for the health needs of the population they serve.
In this regard, strategic purchasing for health has been advocated and should be highlighted as crucial with the emergence of the COVID pandemic. There is a need to ensure value in the way health providers are paid, inter alia to increase efficiency, ensure equity, and improve access to needed health services.
Value-based payment methods, although not new in many countries, provide an avenue to encourage long-term value for money, better quality, and strategic purchasing for health, helping to build a healthier, more resilient world. In Italy, Beyond the pandemic, cardiovascular disease, cancer, respiratory disease and diabetes are the leading burden of disease, with 41 million annual deaths. People with multimorbidity - a number of different conditions - often experience difficulties in accessing timely and coordinated healthcare, made worse when health systems are busy fighting against the pandemic.
Following the care plan, Lee stopped smoking and paid special attention to her diet, sleep and physical exercises, as well as sticking to her medication and follow-up visits. She participated in a weekly community-based physical activity program to meet other COPD patients, including short walks and exchange experiences. A mobile care team supported her with weekly cleaning and grocery shopping.
Together with her family, Lee had follow-up visits to ensure her care plan reflected her recovery and to modify the plan if needed. Since the COVID outbreak, such NCD services have been disrupted by lockdowns, the cancellation of elective care and the fear of visiting care service.
These factors particularly affected people living with NCDs like Lee. As such, Lee was not able to follow her care plan anymore. The mobile care team was unable to visit her weekly as they were deployed to provide COVID relief.
That is where telehealth changes the equation. Telehealth not only makes specialists like neonatologists, neurologists, and cardiologists available to rural hospitals; it also enables patients to receive that care without being transferred to larger, more distant facilities.
They can remain in their communities, surrounded by their support systems, with the local hospital retaining most of the compensation. That strengthens not only rural hospitals but also rural communities where the hospitals are often the largest employers.
Another important confirmation from the pandemic is that integrated health care delivery systems those that offer their own health insurance plan or do so via a partnership with an external insurer are better suited to adapt and align incentives to rapidly changing circumstances. To make up that loss, non-integrated systems will, in many instances, have to cut services, raise prices, or postpone adding needed community services.
They can quickly share learnings and best practices. They are likely also to prove to be best suited to care for Covid long-haulers. In addition, when vaccines became available, Intermountain Healthcare, as an integrated system, was able to use its IT systems to rapidly identify qualifying high-risk patients and urge them to get their vaccinations. Whether a health system offers an insurance plan on its own or via a partnership with an external insurer, the integrated model allows the cost of providing care and the cost of insuring care to be aligned in ways that benefit the insurer and the provider.
We know this from our own experience. Intermountain Healthcare has an in-house nonprofit health insurance company, SelectHealth , which serves nearly one million members in Utah, Idaho, and Nevada. It also collaborates with other health care providers for instance, it has a partnership with the Idaho-based St. In each of these configurations, the goal is to provide great care and better align and integrate the cost of care and the cost of insurance.
The widespread acceptance of value-based care under which providers, including hospitals and physicians, are paid on the basis of capitation and patient health outcomes would accelerate the adoption of the above priorities. In contrast, traditional fee-for-service care does not address prevention or equity. It has resisted telehealth. It does not take full advantage of integrated health care systems. Value-based care improves quality of life and corrects misaligned incentives e.
It can reduce health care costs by making care more accessible and keeping people healthy, which reduces the treatments and procedures needed. The flawed fee-for-service system was designed to wait until individuals got sick and then treat them, and not to support the goal of staying healthy. That flaw was highlighted by the pandemic. Providers with value-based arrangements with health plans kept getting a check every month, regardless of the volume.
Value-based care enables providers and insurers to design and implement all kinds of interesting innovations that volume-based systems are not able to do. Intermountain Healthcare, for instance, is partnering with the University of Utah Medical School to jointly develop a new medical educational program the first of its kind in the United States to train the next generation of physicians in population health, which focuses on keeping people and communities healthy.
Accelerating the move to value-based care right requires significant investment, commitment, flexibility across organizations, and, for some, a leap of faith away from tradition. Align and reorganize provider panels.
There must be enough patients covered by value-based contracts i. The types of patients assigned to a provider need to be a mix of both relatively healthy people and those with chronic conditions that need more extensive and intensive attention. Restructure teams and workflows. After panels have been aligned, teams supporting physicians need to be restructured and properly resourced to succeed in this different model of care. Core workflows and processes must be adjusted and adopted.
Teams should be brought together in daily huddles to coordinate patient outreach, close care gaps, and organize care for the changing needs of the patient. Educate providers and teams. It takes a village to succeed in value. Ensure that everyone is equipped to participate in this team effort by educating them about the core tenants of value-based care, no matter how big or small of a role they will play.
Deploy novel technologies. Use tools to integrate multiple data sets and overlay advanced algorithms to harness and unlock the power of this data. This data can be used to alert clinicians to emerging patient health conditions. Use real-time insights. Predictive analytics enable providers to focus on who should be on their appointment schedule and pivot toward preventive, holistic care rather than episodic treatment.
Align financial incentives. The incentives should be focused on keeping people healthy and not just doing things that generate revenue. Without a faster shift to value-based care, the cost of health care in the United States will continue to rise.
That is not sustainable for both provider institutions and patients. For many Americans, health care is already unaffordable and difficult to access. Those problem will only worsen if costs are not brought under control. The pandemic has made the path that U. The question is whether provider organizations and private and public insurers not already on this path understand that it is the only way to realize a system that delivers better care care that does a better job of keeping patients healthy and is financially sound.
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Hospitals have become so desperate to comply with government and insurance regulations, that physicians no longer have the latitude or resources to do what they have been trained to do.
The priority is no longer the patient, but the bottom line. Just as there are schools struggling to meet national guidelines for better funding, there are plenty of hospital administrators nationwide who justify bending the rules in order to maintain revenue.
Take the bonus out of the equation and the system decompresses instantly. Few things are more personal than your health, and everyone should have the right to choose the coverage that works for them.
There does not have to be one single solution for everyone- different regions of the country have very different medical needs, and there is no one size fits all.
By allowing patients the choice of how to spend their healthcare dollar, the responsibility shifts from the government to the individual. Our laws should guarantee healthcare - not health coverage. As soon as they were free, I was checking for hypothermia and injury. Both the mother and baby are doing well today. Talk about not only being in the right place at the right time, but also feeling grateful that I had the training and experience to help! My practice is in a beautiful but remote community called Valdez, Alaska.
My partners and I are the only physicians within miles. It was winter when one of my patients was 31 weeks pregnant with twins. On Friday, I saw her and everything was fine. We discussed the plan for her to go to Anchorage on Monday and wait to deliver her babies. But in a twist of events, our community was hit by a terrible snowstorm and the babies were coming early.
We were all hands on deck that evening with 3 family physicians, a medical student and our nursing staff. The mom and kids are still doing great! Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that? I felt as if I knew everyone and their most intimate details.
My wife and I love to dance, so we would go to the bar for date night. Our clinic is high-functioning and tightly knit with our community. Also, we have a mission to serve our community with the highest sense of altruism and care. What advice would you give to other health care leaders to help their team to thrive?
Ok, thank you for that. According to this study cited by Newsweek, the United States health care system is ranked as the worst among high income nations. This seems shocking. Can you share with us 35 reasons why you think the United States is ranked so poorly? If you had the power to make a change, can you share 5 changes that need to be made to improve the overall U.
Please share a story or example for each. For example, I had a patient with an external ear infection, which is easily treated with a topical antibiotic. Because of her high deductible health plan, she avoided treatment until her infection became severe. By the time she came into my office for care, I had to hospitalize her for 4 days with IV antibiotics! The real power and cost savings comes when it is utilized by the primary care doctor in partnership with the patient to access specialists.
For example, telemedicine can be used in rural hospitals to provide access to specialty care, like oncology, enabling the primary care provider to deliver the necessary treatment in their own office with the guidance of the oncologist.
What can a individuals, b corporations, c communities and d leaders do to help? What are your thoughts about this status quo? What would you suggest to improve this? I tell medical students that there are four karmic levels of health care. But approaching medicine as a business is the root of many problems. The highest karmic level is the grocery store level.
I know I will see the patient in the grocery store after the visit and this really motivates us to do our best every day. This is how our practice has always tried to operate. If you focus on the higher level and do right by the patient, the other levels take care of themselves. Can you share how that was relevant to you in your life? The winds will blow their own freshness into you, and the storms their energy, while cares will drop away from you like the leaves of Autumn.
Nature has always played an important role in my life. I love exploring the great outdoors. I met my wife in a wilderness class. Ultimately, my passion for nature influenced the decision to move to Alaska. Are you working on any exciting new projects now?
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