Models of Care and Reimbursements in Geriatrics with Dr. Nick Schneeman

Ridgeview Podcast: CME Series

In this podcast, Dr. Nick Schneeman, a geriatrican and the Chief Medical Officer for LifeSpark, brings his passion and expertise to discuss the state of care in geriatrics, along with how current delivery in care and payment models effect the geriatric population.

Disclosure note: Dr. Nick Schneeman , speaker for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Enjoy the podcast.

Objectives:Upon completion of this podcast, participants should be able to:

• Describe what is meant by "value-based care".
• Describe current barriers to delivering high value care to a senior population.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at [e-mail].

Click the link below, to complete the activity's evaluation.

CME Evaluation

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None of Ridgeview's CME planning committee members have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All of the relevant financial relationships for the individuals listed above have been mitigated.

Thank-you for listening to the podcast.

SHOW NOTES: *See the attachment for additional information.

PODCAST OVERVIEW- Geriatric care delivery and quality has not evolved significiantly. - Pockets of excellence exist in academic centers. - Social support systems is integral, but lacking in many parts of the country. - Fee for service (FFS) system is not a sustainable model per Dr. Schneeman for complex senior patients. - Training and exposure to the 'business platforms' in medicine is lacking with providers - FFS = paying for a specific service, procedure, treatment, etc.

Value Based Care (VBC)- Value based care = outcomes/cost - Clinical outcomes - Experience outcomes of patient/family and caregiving team - How is VBC measured? - Medical loss ratio (cost containment) - How does VBC work? - Organization contracts with payor - VBC organization takes on risk - Money savings opportunity - Half of seniors in USA are already in a VBC model - Medicare (CMS) - ACO (group of doctors, health care organization, etc.) - Medicare advantage (CMS product that insurance companies contract with federal government) - Cost Product (Medicare advantage product) - Introduced in MN with assumption that this state will do such a good job with cost containment, but this wasn't how it worked out. - For-profits don't participate in Medicare advantage products which keep the non-profits more accountable, although there are also disadvantages with for-profit programs. - How does the care delivery work in VBC organizations (Nick's viewpoint)? - Step 1: Journey from simple problems into complexity - Step 2: What is the current reality and quality of life? (When people hear you restating their story, trust goes up immensily.) - Step 3: What are you hoping for? (patient, family, etc.) - Step 4: Acute care planning - Step 5: Chronic care planning - Outcomes: POLST (physician orders for life-sustaining treatment) form that is comprehensive; Chronic care plans that are clear and purposeful and match goals of care - Well done POLST forms require intential discussion with patient and advocates who have decision making capacity and understanding of the patient's reality and values

Palliative Care- How it's integrated and its controversy - All practitioners should be able to make palliative decisions with and for their patients who they know intimately - Palliative care as a specialty exists largely due to a FFS model - Often this is a clinican the patient has never met before and is a one time consult - Private equity had created palliative care 'cold call' business models in recent years

Value Based Care (VBC) - continued- How does a practitioner go about doing this? - Make sure the organization you join actually values the primacy of primary care - Clinicians need TIME with their complex patients and to be paid for this time - FFS can work well for simple problems - Who does this well? Small pockets, mostly senior care (i.e. clinic-based, homebased healthcare etc.) - Nurse, APP, physician - are assigned to each patient and continue to follow their care, avoid overprescribing, inappropriate abx - Private equity and Big insurance is getting into the game, but their approaches tend to be siloed and perhaps less humanistic - Recruiting quality providers to this care delivery model is imperative - Improved patient outcomes and costs exisst (i.e. geriatric assessment before cancer care) - Value Based Care really has to be an "all in" experience for a clinic or organization for it to work

Training- Training typically happens in house, as opposed to a training program or course - Subspecialists will still be very much part of the care team, although decision making about proceeding with advanced therapies will be oriented around the VBC medical home team - Pharmacy is a valuable team member as well, especially if part of the "goals of care" as opposed to merely looking up medications - Challenge: SNFs and long term care facilities often have significant staff turnover, care quality issues, and these can lead to unnecessary care, ED visits and hospitalizations

Evidence Based Moment (EBM) ResourcesMagill MK. Time to Do the Right Thing: End Fee-for-Service for Primary Care. Ann Fam Med. 2016 Sep;14(5):400-1. doi: 10.1370/afm.1977. PMID: 27621155; PMCID: PMC5394371. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394371/pdf/0140400.pdf

Basu S, Phillips RS, Song Z, Landon BE, Bitton A. Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model. Ann Fam Med. 2016 Sep;14(5):404-14. doi: 10.1370/afm.1960. PMID: 27621156; PMCID: PMC5394379. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.annfammed.org/content/annalsfm/14/5/404.full.pdf

Thanks to Dr. Nick Schneeman for his expert knowledge and contribution to this podcast.