Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System

Duong, Nicolette; Kim, Doran; Hernandez, Freddy A.; Heizman, Lindsey M.; Zahn, Jennifer; Ball, T.; Stathakos, Kimon

doi:10.1089/pop.2021.0024

Cited by 2 publications

(2 citation statements)

References 16 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Another large block of research centers on the healthcare system's capacity and production of healthcare services, training new and existing professionals, and the role and importance of healthcare professional entrepreneurs. This segment of the research usually deals with the organizational, procedural, and financial aspects of human resource planning in health care on the one hand and the efficiency, effectiveness, and productivity of the health care workforce on the other (Valdmanis et al, 2015;Sinisammal et al, 2016;Rees et al, 2020;Duong et al, 2021;Tudor Car et al, 2022). Typically, the healthcare needs of the entire population in the country are highlighted as a substantive basis for studying the above constructs.…”

Section: Literature Reviewmentioning

confidence: 99%

Management of health care workforce

Stanimirović

Brinovec²

2023

Management (Split, Online)

View full text Add to dashboard Cite

The healthcare system’s effectiveness depends mainly on healthcare workers’ knowledge, skills, and motivation, particularly during the COVID-19 pandemic. Systematic planning of human resources is, therefore, an essential prerequisite for ensuring the sustainability and efficiency of the health care system. This article outlines a structural human resource planning model in health care and explores the complexities involved. A detailed analytical framework is proposed, drawing on various materials and evidence to outline the factors that influence human resource planning in health care. The in-depth analytical process employs an extensive literature review to provide greater credibility to research findings. It investigates numerous sources and materials, both in national and international contexts. The purpose of human resource planning initiatives in healthcare is to calculate the needed number of healthcare workers in the future based on past and current data and assumptions about future supply and demand trends. The research findings reveal this is a very challenging task, as there are typically many unknowns when planning for the future. In addition, planners often need more reliable data and systemic deficiencies. Furthermore, the study shows that unplanned and delayed solutions concerning human resource needs in healthcare can only alleviate problems. Still, they cannot replace effective strategic measures and timely structural changes within the healthcare ecosystem.

show abstract

Section: Literature Reviewmentioning

confidence: 99%

Management of health care workforce

Stanimirović

Brinovec²

2023

Management (Split, Online)

View full text Add to dashboard Cite

show abstract

“…Better patient care and improved documentation and risk adjustment also impact other quality ratings for health care providers, such as Center for Medicaid and Medicare Services (CMS) quality ratings under the HEDIS system, and the opportunity for shared savings as through Accountable Care Organizations (21). Suboptimal patient outcomes against industry standards may lead payers to refer patients to health care providers who have better quality measures (22).…”

Section: Introductionmentioning

confidence: 99%

A Retrospective Multi-site Examination of Chronic Kidney Disease Using Longitudinal Laboratory Results and Metadata to Identify Clinical and Financial Risk

Fung,

Haghamad,

Montgomery

et al. 2024

Preprint

Self Cite

View full text Add to dashboard Cite

(350 words) Background: A retrospective, non-experimental, non-interventional study was conducted at 3 health care organizations to identify clinical gaps in care for patients with stage 3 or 4 chronic kidney disease (CKD), and financial opportunity from risk adjustment payment systems. Lack of evaluation for CKD in patients with diabetes was also assessed. Methods: Outpatient longitudinal laboratory results and patient metadata available in the electronic medical record, laboratory information system, and/or laboratory billing or facility claims data for the calendar year 2021 were evaluated. Laboratory results were compared to billing data (ICD-10 codes) and risk adjustment scores including Hierarchical Condition Categories (HCCs) to determine if laboratory-identified CKD was coded as a disease condition in the electronic medical record. Adults 18 to 75 years of age were included; inpatient laboratory results and pregnant women were excluded. Results: At the 3 institutions, 12478 of 16063 (78%), 487 of 1511 (32%) and 19433 of 29277 (66%) of patients with laboratory evidence of stage 3 or 4 CKD did not have a corresponding ICD10 or HCC code for CKD in the electronic medical record. For patients with diabetes on the basis of an HbA1c value of >6.5%, 34384 of 58278 (59%), 2274 of 2740 (83%) and 40378 of 52440 (77%) had not undergone guideline-recommended laboratory testing for CKD during the same 12 months. Using publicly available information for calendar year 2021, we estimated that of 39907 patients at the three institutions with stage 3 or stage 4 CKD documented by laboratory values only, 3937 (9.9%) would be enrolled in Medicare Advantage or Affordable Care Act Market programs. The imputed lost reimbursement under risk-adjusted payment systems for this under-documentation of CKD was $3.3M for the three institutions combined, representing lost opportunity for both identification and proactive clinical management of these patients, and financial recovery for the costs of providing that care. Conclusions: We conclude that clinical laboratories can provide value beyond routine diagnostics, for identification of gaps in care for identification and management of CKD, stratifying subgroups of patients to identify risk, and capturing missed reimbursement through risk adjustment factors not documented in the billing system.

show abstract

Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System

Cited by 2 publications

References 16 publications

Management of health care workforce

Management of health care workforce

A Retrospective Multi-site Examination of Chronic Kidney Disease Using Longitudinal Laboratory Results and Metadata to Identify Clinical and Financial Risk

Contact Info

Product

Resources

About