The 50-Plus Room - for

[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!

 

[Wonderer67]

Has anyone ever had a job that was just plain fun and you might have done it for free?

I won’t go first because I had the best one

I really like my job now. It’s interesting, work with good people and the company is good I’m 56, but I’d love to work up into 62 to 65 range if possible.

Can’t say I’d do it for free… a little too much bullshit for that. If I hear the word governance, one more time, my head will explode.

One job I do for free, because it loses money, is our farm. Our expenses way outstrip any profits we make. It’s sort of a tax thing for us.

We sell primarily firewood, but we’re not a giant operation. We sell seedlings in the spring, and grow pumpkins and gourds and sell them in the fall..

It’s a hobby for me.

 

[Missk_2022]

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!

Yeah....it is annoying what the pts go through getting meds esp the glp1 meds that are for diabetics esp if morbidly obes (dont get me started because I will rant). Soooo expensive and soooo needed by patients but not covered by insurance.

 

[Missk_2022]

Yeah....it is annoying what the pts go through getting meds esp the glp1 meds that are for diabetics esp if morbidly obes (dont get me started because I will rant). Soooo expensive and soooo needed by patients but not covered by insurance.

And by that i don't think non diabetic who need to lose 15 lbs to look nice in their clothes need to be on glp1 meds. There are people out there that need them...... rant beginning

 

[Biggalute]

Yeah....it is annoying what the pts go through getting meds esp the glp1 meds that are for diabetics esp if morbidly obes (dont get me started because I will rant). Soooo expensive and soooo needed by patients but not covered by insurance.

I've been following this thread, it seems the system really doesn't serve the needs of many patients. The NHS and the HSE here in Ireland have many problems but are free at source and need, rather than money, driven. It makes a big difference.