As part of Obama's health care reform, Medicare's management agency, CMS, launched the Medicare Shared Savings Program (MSSP) in 2012, which requires participating ACOs to reduce healthcare costs through more intensive patient management, multi-level collaboration with healthcare facilities, and more. . The MSSP incentives are: direct rewards for ACOs that reduce medical costs, and fines for ACOs that fail to meet the requirements. According to the information released by the MSSP project, as of April 2016, a total of 433 ACOs participated in the MSSP project, covering 7.7 million users. 61% of participating ACOs are located in urban areas (more than 85% of the users covered are located in cities).
The MSSP assessment criteria are divided into three steps: first, the baseline value is determined from historical data. Then, according to the assessment criteria, the current situation of the control fee is judged, and the specific realization amount of the control fee is obtained. The final step is to confirm the reward/and the amount.
In terms of actual operation, the public information in 2014 showed that about one-quarter of the participating ACOs met the criteria for obtaining rewards, and the CMS also extended the period of imprisonment for ACOs that failed to meet the standards – from three years to Six years. Judging from the implementation of MSSP, it is still difficult to save the cost savings on a clear amount in the short term. The goal is to change the service behavior of medical institutions and promote the initiative of medical institutions to manage patients and diseases. Prevention, so as to achieve the goal of service improvement in the long run.
There are three tips for this project. First of all, in the standard of assessment criteria, the standard design features are meticulous, multiple and professional. The MSSP assessment criteria include four aspects: 1) doctor-patient experience (such as doctor-patient communication efficiency, patient-to-doctor rating, etc.); 2) medical service coordination/security (such as unexpected diabetes admission, 30-day repeat admission, etc.) 3) preventive care (BMI measurement and follow-up intervention, breast cancer screening, etc.); 4) clinical management of high-risk groups (such as hypertension management, diabetes ophthalmology risk management, etc.). Judging from the 34 assessment items actually set, the diseases and medical services according to different categories are more detailed, and from patient participation to clinical practice, it is very specific and suitable for implementation.
Second, the actual assessment and acquisition of incentives is still difficult. Although the control of medical expenses can be calculated by the actual amount, it seems that the method of benchmarking with last year is also straightforward and not complicated. In fact, the implementation methods involved in cost control, such as closer communication between doctors and patients, high-risk patient case management, prevention screening, etc., cannot simply quantify the cost, and if it is not directly converted into cost reduction, it cannot Explain that these measures are useless. The effectiveness of these measures is related to multiple factors such as the patient's own situation, participation, and hospital implementation, so the direct cost reduction is not as intuitive as imagined.
Third, in view of the above two points of revelation, and the MSSP will be exempt from the extension of the penalty period, in fact, the purpose of the medical incentives has been multiple, and the cost savings is a direct standard, but through this project, it will help to encourage the hospital to expand. More closely managed services, the four aspects of the MSSP assessment clearly indicate this direction: through more close communication between doctors and patients, better prevention screening, more effective management of high-risk patients, and repeated admissions The fine management of projects with high medical expenditures, to establish a medical education, prevention and management system, with conventional treatment, to improve the efficiency of medical treatment for a long time. The establishment of this system may not be able to convert to the amount of savings on all ACOs in the short term, but it has a subtle influence on medical services in the long run.
These three revelations also apply to China. At present, Shenzhen has launched a similar incentive plan to reward the hospital for the cost control of medical insurance. However, the characteristics of the Chinese market are lower medical service costs, higher self-pay rates for medical expenses, and the meticulous management system for medical insurance is not yet mature. These characteristics have led to the lack of medical insurance funds in some areas where the health care fund is under pressure, and the situation of patients being pushed at the end of the year. If the fee is used as the criterion for evaluation, it is likely that there will be an increase in the amount of the self-funded project, and finally the burden on the patient cannot be alleviated.
Therefore, in the purpose of establishing incentive mechanism, it is more to guide medical institutions to establish a system similar to MSSP, such as closer cooperation, better prevention screening and management of high-risk patients. These services are currently lacking in China, and such systems are lacking. The establishment of the short-term may have limited impact on costs, but in the long run it is beneficial to change the medical service model.
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