Definition of Serious and Complex Medical Conditions (1999) / Chapter Skim
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Appendix A Workshop to Define Serious or Complex Medical Conditions
Appendix A Workshop to Define Serious or Complex Medical Conditions
Pages 65-106
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From page 65... ...
The workshop presentations also provided a detailed analysis of the potential impact of He proposed regulations for Medicare+Choice on health care plans and opportunities to discuss issues of reimbursement and ensuring quality of care for patients with serious or complex conditions. The workshop was successful in stimulating questions and ideas among committee members, panel members, and workshop participants.
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From page 66... ...
First, the purpose of the definition of serious or complex medical condition must be clearly articulated. Second, any definition of serious or complex medical condition must be inherently flexible and must encompass a diversity of individuals and types of services and health care needs.
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From page 67... ...
Ideally, the committee would develop a definition of serious or complex medical conditions that identifies persons for whom the absence of highquality care has the potential to lead to a significant deterioration of their health status or quality of life or to prevent them from improving their health status. The committee was urged to establish a definition of serious or complex medical conditions that would guarantee access to the highest level of care that can be reasonably provided, including access to qualified, trained, and experienced providers.
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From page 68... ...
A number of problems would be created if a definition of serious and complex medical conditions was crafted such that a person would be covered only if he or she was experiencing an acute episode of illness. In addition, measures such as activities of daily living or instrumental activities of daily living can help determine if someone does have a serious or complex condition.
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From page 69... ...
Establishing a definition of serious or complex medical conditions can allow the bar to be set higher for what is expected of health plans for people with these conditions. This means that a great deal of work will have to go into the development of performance and outcomes measures relating to individual categories of persons with these conditions, as well as measures that can monitor health plan performance in the aggregate for people with serious or complex conditions.
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From page 70... ...
He cited a recent report to the Institute of Medicine by Hillner and Smith (Institute of Medicine, 1999) that demonstrated a clear dose-response curve between the experience of the health care provider and patient outcomes with a wide variety of cancers, stage for stage.
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From page 71... ...
However, if one considers all women diagnosed with breast cancer and three positive nodes, it is very difficult to be sure which of these women will be cured and which will not. All of this means that experience and intuitions are sometimes helpful, but patients require some kind of follow-up until they are "out of the woods." The management of cancer patients in the initial episode is well illustrated by pediatric oncology.
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From page 72... ...
Durant encouraged the committee to be flexible in developing definitions for serious or complex medical conditions. He also emphasized that there are important behaviors that influence the outcome for a fraction of patients who would benefit most from having care provided by experienced specialists at the time of the initial diagnosis.
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From page 73... ...
Joanne Lynn, director of the Center to Improve Care of the Dying and Americans for Better Care of the Dying. Her presentation focused on the relevance of the category of serious or complex medical conditions to the delivery of health care.
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From page 74... ...
Unfortunately, the structure of traditional Medicare fee-for-service payments encourages fragmentation rather than integration of care. Medicare managed care plans have the potential to offer integrated specialty care for patients with long-term health needs.
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From page 75... ...
In summary, serious and complex medical conditions can include those illnesses that cause progressive deterioration in health status over time and frequently require care from multiple specialties including health, emotional, social, and mental interventions.
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From page 76... ...
Serious medical conditions would include those that are substantially disabling, progressive, and eventually fatal. Complex conditions would require services in a variety of domains or disciplines for the person to live well in the time preceding death.
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From page 77... ...
Patients with serious or complex conditions can be identified with meaningful administrative and clinical criteria. For example, congestive heart failure might qualify with one hospitalization for failure and an echocardiogram to document an ejection fraction less than 30 percent or severe diastolic dysfunction.
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From page 78... ...
For example, the threshold for congestive heart failure might be one exacerbation, hospitalization for failure, and ejection fractions of less than 30 percent or diastolic dysfunction. The threshold for dementia might be immobility and incontinence.
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From page 79... ...
This rate could support the development of some terrific service arrays for a disease that accounts for 25 percent of all deaths. An urban setting could support a comprehensive health care delivery team that really knew how to take good care of congestive heart failure, for example, if the providers of care could malce a living at it.
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From page 80... ...
Brody provided some background information on Kaiser's Social Health Maintenance Organization project, which is a national Medicare demonstration project designed to maintain frail elderly in their homes by providing comprehensive benefits that include home-based, long-term-care services. During the past 15 years, this project has relied on a self-report health status form in compliance with the mandate by HCFA that social health maintenance organizations collect self-report data from members about their health on an annual basis.
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From page 81... ...
The Health Status Form Questionnaire was examined to build an empiric model instrument, to predict elderly members at risk of frailty in the coming year. A total of 5,810 members returned completed questionnaires for a 92 percent response rate.
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From page 82... ...
Ms. Brody then addressed the action items undertaken by Kaiser Permanente to put the Health Status Form Questionnaire in place at Kaiser sites across
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From page 83... ...
Kaiser divisions participating in the Medicare Screening Project send their Medicare enrollment information, including address, age, and name information, to the Center for Health Research via e-mail. Mailing of the Health Status Form Questionnaires to new members is done on a monthly basis.
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From page 84... ...
One question of interest was whether the Health Status Form Questionnaire could be used to screen nonelderly enrollees in Medicare. It was pointed out that these patients might benefit from a similar type of screening and from development of the same type of care plan.
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From page 85... ...
Ms. Brody was also asked if the interventions and care plans developed in response to results from the Health Status Form Questionnaire were mandated within the Kaiser system and subject to audit.
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From page 86... ...
Smits concerning issues related to the range of managed care plans, the response of plans' medical directors to the issue of serious or complex conditions, and potential risks and concerns associated with plans of care. Managed Care and Approaches to Regulation Dr.
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From page 87... ...
Most medical directors of plans would begin to identify categories of patients with serious or complex medical conditions by collecting information from their case managers about the types of patients they are managing. Case management would be very tightly related to the process of patient care within a Kaiser-type model of managed care, a staff model health maintenance organization, or a physician group accepting risk.
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From page 88... ...
In many instances, they will self-refer to a clinical trial while not informing the members of their original care team. This pattern of self-referral will be important to consider in any definition or treatment plan for serious and complex medical conditions.
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From page 89... ...
Smits on a number of issues. Specifically, she was asked about members of the HealthRight, Inc., managed care plan with serious or complex medical conditions and whether their classification as serious or complex had any relationship to the amount of money being spent on them?
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From page 90... ...
Dr. Smits advocated for managed care plans using good computer systems for case management that will allow the case manager to close a case but also generate a reminder in 4 or 6 months to follow-up with the patient or provider to determine current health status and needs.
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From page 91... ...
Lynn and Ms. Brody advocated strongly for case management for patients with serious or complex conditions, in which one individual assumes responsibility for coordinating all aspects of the requisite care.
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From page 92... ...
In response to questions from plans about giving beneficiaries the right to approve these care plans, HCFA encouraged managed care organizations to allow the beneficiary to participate in the development of the treatment plan but did not mandate it.
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From page 93... ...
Efforts are ongoing to answer questions about the type and extent of management that should be provided by managed care plans, especially for patients with serious or complex medical conditions. If not case management for serious or complex conditions, what is managed care doing in addition to limiting costs?
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From page 94... ...
Dr. Etheredge urged the committee to consider the recommendations of the National Cancer Policy Board report and identify those areas that would be representative of the issues relevant to serious or complex medical conditions.
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From page 95... ...
Examples of other areas with experience relevant to the efforts of the committee to define serious or complex medical conditions might include the following: 1. coverage of kidney disease patients and other serious or complex conditions, combined with efforts to build payment systems and quality assurance around these categories of patients 2.
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From page 96... ...
To accomplish this, it would be necessary to have criteria to define clinically relevant populations at need, as well as actuarial data about these populations that would support the calculation of some costs for care, to ensure that there really is effective choice and incentive for competition. This type of information would also be useful to health plan managers, especially network managed care plans, in which contracts must be established with health care providers to ensure access and delivery of services to patient populations.
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From page 97... ...
In closing, Dr. Etheredge encouraged the committee to consider its efforts as part of an overall, ongoing strategy to build a better system to provide care to all patients, especially those with serious or complex medical conditions.
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From page 98... ...
From this perspective, a second question was raised by the committee about whether managed care plans are being asked to develop a "miracle" health care delivery system to deal with the needs of persons with serious or complex medical conditions.
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From page 99... ...
In the absence of good disease management, patients ultimately seek care in emergency room visits that are quite costly. Systems such as those implemented by Kaiser for patients with congestive heart failure, which involve a daily telephone call to check on health status and weight, can be effective in preventing predictable crises and keeping patients out of emergency rooms.
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From page 100... ...
This is a nice resource to support efforts to reform the health system. If however this purchasing power is not applied, new programs for certain patient populations such as those with serious or complex medical conditions will not develop.
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From page 101... ...
He argued that simply developing a definition of serious or complex medical conditions, including recommendations about when access to specialists should be provided for Medicare+Choice enrollees, fails to address the fundamental problems and challenges of the current health care delivery system. Committing the resources necessary to develop sound definitions for serious or complex medical conditions could begin to resolve some of these basic problems.
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From page 102... ...
The group of individuals involved with identification of serious or complex medical conditions could contact the National Committee for Quality Assurance to request a hearing to support the development of a new set of standards to select serious or complex conditions. The group should elicit external input and advice in determining if an area ought to be defined as serious or complex.
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From page 103... ...
Clear clinical definitions for serious or complex conditions, combined with the ability to accurately estimate costs of care for these conditions, will allow providers such as specialists to develop proposals for insurance companies to care for such patients. This can allow specialists the opportunity to get involved with health insurance and compete with other health care plans to provide an array of services for specific groups of patients.
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From page 104... ...
Jones suggested that the most realistic way to determine the appropriate amount of payment for patients with serious or complex medical conditions would be to solicit proposals for specific conditions. From HCFA's perspective, it would work best to identify a group of patients for whom services are required and realistic costs of care can be estimated.
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From page 105... ...
These options might include the plan in which the patient is already enrolled, as well as some other choices of health care plans and providers. Information about these choices might be made available to a patient by the provider or by specific plans that are marketing specialized services to the patient.
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