The 50-Plus Room - for

[Lilianna23]

And today, as if we need a day, is Love Your Pet Day.
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That's every day at my house!

 

[Lilianna23]

Today is also National cherry pie day.

So eat your cherry pies…

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Oooh! I wish I had known! I have tons of cherries in my freezer and could have made one. Maybe tomorrow I will.

 

[Lilianna23]

Here are the rules
The Rules of Cricket

You have two sides, one out in the field and one in.

Each man that's in the side that's in goes out, and when he's out he comes in and the next man goes in until he's out.

When they are all out, the side that's out comes in and the side thats been in goes out and tries to get those coming in, out.

Sometimes you get men still in and not out.

When a man goes out to go in, the men who are out try to get him out, and when he is out he goes in and the next man in goes out and goes in.

There are two men called umpires who stay out all the time and they decide when the men who are in are out.

When both sides have been in and all the men have got out, and both sides have been out twice after all the men have been in, including those who are not out, that is the end of the game!

Thank you SO much for this explanation, Polranny! Now I understand it perfectly!

 

[B2fromA2looking4U]

Good morning! What a wonderful day ahead - up into the 50s!!!!

About Cricket - give me baseball.

Have a great day and may your fantasy come true.

 

[Polranny]

Good morning! What a wonderful day ahead - up into the 50s!!!!

About Cricket - give me baseball.

Have a great day and may your fantasy come true.

Baseball ... no thanks

 

[Gamine67]

Baseball ... no thanks

EZPZ compromise - LACROSSE world’s greatest game with a ball and stick.

You’re welcome

 

[Polranny]

EZPZ compromise - LACROSSE world’s greatest game with a ball and stick.

You’re welcome

I beg to differ ... Field Hockey

 

[Missk_2022]

I beg to differ ... Field Hockey

Add a horse and you have polo.....and who doesn't love horses!!!!

 

[oxbowguy]

I'll go with Hurling for the best ball and stick game.

 

[RosevilleCAguy]

In my youth I found my interest in sports where the primary focus involved hitting people. At least that was my primary focus. Moving an air filled bladder across a chalk line on the ground was secondary.

 

[Missk_2022]

In my youth I found my interest in sports where the primary focus involved hitting people. At least that was my primary focus. Moving an air filled bladder across a chalk line on the ground was secondary.

Hahaha... get all that aggression out and maybe talk a little smack too?

 

[ramoredrake]

has anyone here worked at a medical practice/group that was purchased by private equity? What was the effect? New investment and growth, or was the practice starved of capital and labor?

 

[RosevilleCAguy]

Hahaha... get all that aggression out and maybe talk a little smack too?

I would never dream of talking smack.

 

[curl4ever]

has anyone here worked at a medical practice/group that was purchased by private equity? What was the effect? New investment and growth, or was the practice starved of capital and labor?

I know it wasn’t your question, but… As a *patient* through three practice buyouts, service has gotten worse all three times.

 

[RosevilleCAguy]

Something about being called old at the age of 50, I don't know, I sure don't feel it, Lol.

I remember being younger; I couldn't wait to be older, now that I am, I don't want to be old anymore.

As long as I can go from horizontal to vertical and am still sucking wind I'm in the game.

 

[Missk_2022]

I would never dream of talking smack.

Hahahaha.... mmmhmm....

 

[Missk_2022]

I know it wasn’t your question, but… As a *patient* through three practice buyouts, service has gotten worse all three times.

so I am employed by an ACO or Accountable Care Organization also known as a big hospital system. We have a clinically Integrated Network. We want more practices to join us, and it's sort of the way of the world right now. It's very difficult for practices to be able to manage the amount of patients that are out there without care. It can be a big financial and administrative burden. So what we do is manage and help them maintain quality and risk adjustment goals. So it just depends on who is buying who, and I suppose who you ask. There are some providers that will never ever ever go in with a hospital system. And there are some that have said they would never go but came and were glad. There is a financial benefit to joining a clinically Integrated Network. And the patients have a bigger team to help them. For instance my job is to make sure that the providers are documenting and recapturing chronic illnesses that were captured the year before because it tells the center for Medicare and Medicaid was that more resources are needed for their care. Otherwise there would be no money provided for terribly sick people. It is very intertwined and a lot of cogs running the big wheel and I'm just a teeny tiny COG. There's also medical expense and quality and making sure people go for their annual Wellness visits and managing their medications and and and and.. so why are provider wouldn't go along with it is beyond me but it's their practice and their life so

 

[Missk_2022]

has anyone here worked at a medical practice/group that was purchased by private equity? What was the effect? New investment and growth, or was the practice starved of capital and labor?

I am employed by an ACO or Accountable Care Organization also known as a big hospital system. We have a clinically Integrated Network. We want more practices to join us, and it's sort of the way of the world right now. It's very difficult for practices to be able to manage the amount of patients that are out there without care. It can be a big financial and administrative burden. So what we do is manage and help them maintain quality and risk adjustment goals. So it just depends on who is buying who, and I suppose who you ask. There are some providers that will never ever ever go in with a hospital system. And there are some that have said they would never go but came and were glad. There is a financial benefit to joining a clinically Integrated Network. And the patients have a bigger team to help them. For instance my job is to make sure that the providers are documenting and recapturing chronic illnesses that were captured the year before because it tells the center for Medicare and Medicaid was that more resources are needed for their care. Otherwise there would be no money provided for terribly sick people. It is very intertwined and a lot of cogs running the big wheel and I'm just a teeny tiny COG. There's also medical expense and quality and making sure people go for their annual Wellness visits and managing their medications and and and and.. so why are provider wouldn't go along with it is beyond me but it's their practice and their life so

 

[Noor]

I am employed by an ACO or Accountable Care Organization also known as a big hospital system. We have a clinically Integrated Network. We want more practices to join us, and it's sort of the way of the world right now. It's very difficult for practices to be able to manage the amount of patients that are out there without care. It can be a big financial and administrative burden. So what we do is manage and help them maintain quality and risk adjustment goals. So it just depends on who is buying who, and I suppose who you ask. There are some providers that will never ever ever go in with a hospital system. And there are some that have said they would never go but came and were glad. There is a financial benefit to joining a clinically Integrated Network. And the patients have a bigger team to help them. For instance my job is to make sure that the providers are documenting and recapturing chronic illnesses that were captured the year before because it tells the center for Medicare and Medicaid was that more resources are needed for their care. Otherwise there would be no money provided for terribly sick people. It is very intertwined and a lot of cogs running the big wheel and I'm just a teeny tiny COG. There's also medical expense and quality and making sure people go for their annual Wellness visits and managing their medications and and and and.. so why are provider wouldn't go along with it is beyond me but it's their practice and their life so

I’m curious how making sure patients are managing medications is evaluated?
Also how about rare disease patients?

 

[Missk_2022]

I’m curious how making sure patients are managing medications is evaluated?
Also how about rare disease patients?

I am not sure about rare disease as I personally only deal with primary care or family docs and these patients are usually managed at a specialist or even places like osu or Cleveland clinic where they have better resources. So medical management for instance statin drugs for diabetic patients or hypertension management, are Hedis measures that are kept track of by us and other entities (payers like humans Aetna etc) that are part of quality star measures and if you reach a better star level the more money you can make to care for patients....(I want to say it is shared savings but may be wrong) Lilliana may be better able to explain. It is very detailed and I dont work in quality.....it is truly a giant cog machine. What I manage is the risk adjustment part of it so there is a rule that says that you have to spend a specific percentage of what you receive for patient outcomes and so we try really hard to make sure that we control expenses and accurately and appropriately document the patients diagnoses that we're treating them for.

 

[Noor]

I am not sure about rare disease as I personally only deal with primary care or family docs and these patients are usually managed at a specialist or even places like osu or Cleveland clinic where they have better resources. So medical management for instance statin drugs for diabetic patients or hypertension management, are Hedis measures that are kept track of by us and other entities (payers like humans Aetna etc) that are part of quality star measures and if you reach a better star level the more money you can make to care for patients....(I want to say it is shared savings but may be wrong) Lilliana may be better able to explain. It is very detailed and I dont work in quality.....it is truly a giant cog machine. What I manage is the risk adjustment part of it so there is a rule that says that you have to spend a specific percentage of what you receive for patient outcomes and so we try really hard to make sure that we control expenses and accurately and appropriately document the patients diagnoses that we're treating them for.

Thank you!
In my state, commercial health insurance has to spend 80% on patients and excess money getd refunded.

 

[Missk_2022]

Thank you!
In my state, commercial health insurance has to spend 80% on patients and excess money getd refunded.

And the rules differ slightly if dealing with commercial vs Medicare advantage trading Medicare and medicaid ....... the medical loss ratio is medical expense divided by pt acuity captured withhcc diagnosis with an hcc designation and corresponding monetary value called raf (risk adjusted factor) the goal is 85 %... and not everything is risk adjusted..... way out of my pay grade.

 

[RosevilleCAguy]

Hahahaha.... mmmhmm....

 

[Lilianna23]

I am not sure about rare disease as I personally only deal with primary care or family docs and these patients are usually managed at a specialist or even places like osu or Cleveland clinic where they have better resources. So medical management for instance statin drugs for diabetic patients or hypertension management, are Hedis measures that are kept track of by us and other entities (payers like humans Aetna etc) that are part of quality star measures and if you reach a better star level the more money you can make to care for patients....(I want to say it is shared savings but may be wrong) Lilliana may be better able to explain. It is very detailed and I dont work in quality.....it is truly a giant cog machine. What I manage is the risk adjustment part of it so there is a rule that says that you have to spend a specific percentage of what you receive for patient outcomes and so we try really hard to make sure that we control expenses and accurately and appropriately document the patients diagnoses that we're treating them for.

You said it very well, MissK! In the 1980s, Congress started looking at practice patterns, overuse and misuse of procedures, and spending by CMS (Centers for Medicare and Medicaid Services). It found wide ranges of effectiveness and patient outcomes, many not substantiated by clinical evidence. Congress created what is now known as the AHRQ (Agency for Healthcare Research and Quality) to focus on clinical effectiveness, practice outcomes, and treatment guidelines.

A tsunami of quality improvement initiatives, task forces, and sentinel reports ensued along with organizations that sprang up to help healthcare delivery organizations meet these initiatives. This ultimately led CMS to develop a Pay For Performance model, in which a certain percentage of a hospital or provider's payment was held back and only paid out on meeting certain initiatives. These initiative goals can change year after year. CMS first started these initiatives for hospital-based organizations; they have been expanded to outpatient clinics, surgery centers, and provider offices.

Meeting these quality markers results in better remuneration as well as improved rankings. Insurances are more willing to do business with organizations and offices with better rankings.

Most of my work in Quality was done in a hospital-based setting with some outpatient setting work. IDK if this answered the question. I'd be happy to address others.

 

[B2fromA2looking4U]

Thanks to MissK and Lillian for explaining the performance-based health system under Medicare and other insurances. The quality management and emphasis on better outcomes is commendable. My concern is with the patient that does not respond to the typical treatment approved by the insurance company. It is a battle for a patient that is an outlier. I had a recent experience with my type 2 diabetes medication. I had to battle with both doctor and insurance to get back on the medication that had dropped my A1C to 6.1. Neither wanted to renew it because of the cost.


BTW - Good morning!