Posted: March 12th, 2023

healthcare

2-3 lines short answers.

1. Describe the objectives of tort law.

Discuss the distinctions among negligent torts, intentional torts, and strict liability.

3. What forms of negligence are described in this chapter?

4. How does one distinguish between negligence and malpractice?

5. What elements must be proven in order to be successful in a negligence suit? Illustrate your answer with a case (the facts of the case can be hypothetical).

6. Can a “duty to care” be established by statute or contract? Discuss your

answer.

1. Explain the importance of a “written” contract.

2. Explain the elements of a contract.

3. Describe the differences between an express and an implied contract.

4. Describe various defenses and remedies available for nonperformance of a contract.

5. Explain why and under what circumstances an employee handbook can be considered a contract.

6. Explain why employers should place disclaimers in employee handbooks.

Chapter 13: Asymmetric Information and Incentives

Case 13.1 – Incentives in Accountable Care Organizations

An accountable care organization (ACO) represents a consortium of doctors, hospitals, and other providers who contract to take financial responsibility for the quality of care.  As such, it faces a complex incentive problem, needing to identify contracts that allow it to meet its quality and cost targets.  An ACO also needs to establish contracts with providers that incentivize them to provide efficient, high-quality care.  In addition, the ACO must do this as the providers are simultaneously being paid using traditional volume-based methods, bundled payments, and a variety of alternate payment models.  Whitman (2017) quotes Mickey Tripathi, founder and CEO of the Massachusetts eHealth Collaborative, as saying, “What makes a successful ACO?  An end as an industry, we do not know.”

A consortium that decides to form an ACO contracts with Medicare for three years.  Medicare sets a benchmark that is a weighted average of spending by beneficiaries that are attributed to the ACO.  One implication is that consortia with high levels of spending in the past find it easier to meet cost goals.  In contrast, commercial ACO contracts are based on a negotiated rate and a negotiated degree of risk.

For example, UnityPoint Health, a $4 billion system with 43 hospitals across Iowa, Illinois, Wisconsin, and Missouri, has a physician led ACO that in 2016 covered 70,672 Medicare beneficiaries in the Medicare Next-Generation ACO model.  Through its self-insured health plan and its ACO contracts with private payers, including UnitedHealthcare, Wellmark, and Blue Cross and Blue Shield of Illinois, it covered another 255,379 individuals, with 102,125 of those in full risk contracts (UnityPoint Accountable Care 2017).  UnityPoint did not reduce its cost in its first attempt at a Medicare ACO but ultimately developed a system for reducing cost.  The system tracks high-risk patients, standardizes care pathways, using analytics to understand the population it serves (and the care being provided), and emphasizes incorporating behavioral health into primary care.

UnityPoint Clinic, which has 500 physicians across Iowa and Illinois, now bases 86 percent of compensation on productivity.  By 2020 it plans to have 33 percent of physician compensation based on productivity, 33 percent based on salary, and 33 percent based on cost, quality, and satisfaction measures (Barkholz 2017).  The logic is that provider payments need to be aligned with payments for care.

Discussion Questions

1. Why is creating a successful ACO difficult?

2. How many Medicare ACO’s are there?  How are they structured?

3. How many commercial ACO’s are there?  How are they structured?

4. How many Medicare ACO’s are there?  How are they structured?

5. Is the number of ACO’s increasing or decreasing?

6. What outcomes represent success for an ACO?  What predicts success?

7. Do ACO’s that except more risk get more shared savings?  Why?

8. Do some ACO’s improve clinical quality?  How do they do it?

9. Do some ACO’s improve patient satisfaction’s?  How do they do it?

10. How does being paid in varied ways complicate ACO design?

11. How does being paid in various ways affect provider incentives?

12. What sort of incentives does pure volume-based payments create for providers?

13. What sort of incentives does a mixed payment model create for providers?

14. What sort of incentives does pure salary create for providers?

15. How does MACRA affect incentives to create a Medicare HMO?

16. What incentive does the Medicare benchmark create?

Chapter 14: Economic Analysis of Clinical and Managerial Interventions

Case 14.1 – Teledermatology

Most dermatologists reside in metropolitan areas, so teledermatology should be considered as an access option for individuals living outside these areas. However, two

questions must be answered. How much does it cost? How valuable is it? A team of Veterans Administration researchers attempted to answer these questions (Datta et at. 2015).

The team used two cost perspectives. One examined costs from the perspective of the Veterans Administration, estimating how much it costs to produce teledermatology care and how much it costs to produce a face-to-face visit. Two challenges emerged from this effort. First, costs varied considerably. From the Veterans Administration perspective the average cost of a teledermatology consult was $308, but the standard deviation was $298. The average cost of a face-to face consult was $338, but the standard deviation was $291. Second, the authors chose not to include the cost of equipment used to take images of the patient’s skin, arguing that the incremental cost of an image was negligible.

In looking at costs from a societal perspective, the team added spending for dermatologic care from providers who did not work for the Veterans Administration, travel costs, and patient time costs. From a societal perspective the average cost of a teledermatology consult was $460, but the standard deviation was $428. The average cost of a face-to-face consult was $542, but the standard deviation was $403.

This study was a CUA, so the team measured utility before and after treatment. They used a time trade-off technique to measure patients’ quality of life. This technique presents respondents with directions such as “Imagine that you have ten years left to live. You can choose to live these ten years in your current health state, or you can choose to give up some life years to live for a shorter period in full health. Mark the timeline with the number of years in full health

that you think is of equal value to ten years in your current health state.”

          1         2         3         4         5         6         7         8         9         10

At baseline, average quality of life was o.90 for both samples. Over nine months the teledermatology groups’ average increased by 0.03 and the face-to-face visit groups’ average increased by 0.02.

Discussion Questions

1. Would you be willing to use teledermatology? Why or why not?

2. Which perspective on costs seems more valid to you?

3. Do you think that the costs of the imaging equipment should have been included?

4. Did the team use the right approach to evaluation? Would a CMA have been acceptable?

5. What is your reaction to the time trade-off technique?

6. What is your recommendation for assessing the value of teledermatology?

7. Would you be willing to adopt teledermatology for your health system?

8. Should Medicare use economic evaluation in making coverage decisions?

9. Congress has largely banned considering costs in making coverage decisions. Do you agree?

10. Can you find published examples of CMA? CEA? CBA? CUA?