Month: November 2017

Distribution of Health Insurance coverage in NY State vs. USA

Distribution of Health Insurance coverage in NY State vs. USA

Distribution of Health Insurance coverage in NY State vs. USA

Health Insurance                            NY state                        USA

 Private                                             33%                               34%

Medicare                                          20%                               23%

Medicaid                                         27%                                17%

Other                                                20%                               26%

USA Medicaid spending is $575 Billion/year

Not counting admin cost, NY State Medicaid spending is $65 Billion/year only to be exceeded by CA $80 Billion. Per Medicaid person spending in NY State is $10500/year only to be exceeded by MA $11100/year, Nevada the lowest $4100/yr. while USA average is $5600/year. NY state Medicaid spending almost 2 times of the national average, hence VBP, P4P and Medicaid Redesign programs coming up.


AHRQ: Cracking the Code in Healthcare:

AHRQ: Cracking the Code in Healthcare:

AHRQ: Cracking the Code in Healthcare:

What is the triple aim of the Affordable Care Act?

The three components are: (1) improve the patient experience, (2) improve population health and (3) reduce per capita cost. … In 2010, the Patient Protection and Affordable Care Act (ACA) promised quality, affordable health care for all Americans.

Population health has been defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”. It is an approach to health that aims to improve the health of an entire human population.

Population Health Management is the aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.

What is a value based care?

With fee-for-service, doctors and hospitals are paid based on the number of healthcare services they deliver, such as tests and procedures. Payment generally has little to do with whether their patients’ health improves. But what does that mean for you? A valuebased approach is designed around patients.

ValueBased Payment (VBP) is a strategy used by purchasers to promote quality and value of health care services. The goal of any VBP program is to shift from pure volume-based payment, as exemplified by fee-for-service payments to payments that are more closely related to outcomes.

The Hospital ValueBased Purchasing (VBP) Program is a Centers for Medicare & Medicaid Services (CMS) initiative that rewards acute-care hospitals with incentive payments for the quality of care they provide to Medicare beneficiaries.

Healthy People 2020 aims to reach four overarching goals: Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all.

The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.

Radical Redesign in Health Care:

 Change the balance of power: Co-produce health and wellbeing in partnership with patients, families, and communities.

  1. Standardize what makes sense: Standardize what is possible to reduce unnecessary variation and increase the time available for individualized care.
  2. Customize to the individual: Contextualize care to an individual’s needs, values, and preferences, guided by an understanding of what matters to the person in addition to “What’s the matter?”
  3. Promote wellbeing: Focus on outcomes that matter the most to people, appreciating that their health and happiness may not require health care.
  4. Create joy in work: Cultivate and mobilize the pride and joy of the health care workforce.
  5. Make it easy: Continually reduce waste and all non-value-added requirements and activities for patients, families, and clinicians.
  6. Move knowledge, not people: Exploit all helpful capacities of modern digital care and continually substitute better alternatives for visits and institutional stays. Meet people where they are, literally.
  7. Collaborate and cooperate: Recognize that the health care system is embedded in a network that extends beyond traditional walls. Eliminate siloes and tear down self-protective institutional or professional boundaries that impede flow and responsiveness.
  8. Assume abundance: Use all the assets that can help to optimize the social, economic, and physical environment, especially those brought by patients, families, and communities.
  9. Return the money: Return the money from health care savings to other public and private purposes.

Change Balance of Power:  How?


  1. Sift power from Doctor to Patient.
  2. Use what patient and family brings. Talk less and ask more and listen.
  3. Do not ask “What’s the matter” but ask “What matters to you”
  4. Make transparency limitless.
  5. Protect privacy but “Repeal and Replace HIPPA”!
  6. Equip homes and communities to replace institutions.
  7. Share decision making.
  8. Do not design care systems around one hard case or cases.


  1. Dr Kavita Bhavan at Utah school of medicine: Long term IV antibiotics given in the hospital then at home by visiting nurse converted to self-administered IV antibiotics by the patients. Project saved 26000 hospital days in that population of patients saving the system $40 Million. Now being adopted at many communities.
  2. 10 year old kid made a U-Tube video how to daily self-introduce nasogastric tube. He was self-feeding x 12 hours a day to maintain nutrition in the setting of Crohn’s disease and mal absorption so that others can follow his examples.
  3. Children’s hospital in Ireland initiated a program where by each pediatric patient had his own chef where they can order what they would want to eat saving money in waste of food and improving nutrition.
  4. Rural small community hospital serving population of 3000 or so people in Wisconsin empowered the patients. Bellin Health in Green Bay, Wis., has employed a technique gained from user experience research to change the balance of power and more deeply understand how the diagnosis and treatment of gynecological cancer integrates into the everyday ebb and flow of a patient’s life over time.
  5. In Sweden a patient named Christian Farman who was an engineer with Chronic kidney failure and chronic dialysis use started self-dialysis program where by patients were in charge to hook themselves up and start dialysis, improving their experience, satisfaction and joy. Now 50% of the dialysis in Sweden is done by patients reducing cost of care by 50% and reduction in infection rate by 30%. This experiment was reproduced in Waco Texas where hospitalization rate fell by 50% and mortality by 30%
  6. In Scotland one of the elementary school of 480 students had 45% obesity rate among the students. Student and teachers started a program “Daily Mile”. Fit to play and Fit to learn. Students and teachers will run a mile daily at the start of the school. After 18 months obesity rate in student population was 0%. Program is now spreading worldwide. In Netherlands 580 schools are now have daily mile program.
  7. North Shore–LIJ Health System in New York recently partnered with Project ECHO at the University of New Mexico School of Medicine to explore how to move knowledge, not people while delivering much needed care for those with behavioral health conditions
  8. NY times 10/6/2016 issue printed letter to editor from husband of a young 23 years old Asthma patient who died after 7 days of hospitalization in one of the hospital in New York where by husband described the genuine compassionate care provided to his wife and how nursing and physician staff took upon themselves to accommodate every need of the family by sifting control to the patient and family. Along the way many rigid rules of the hospital policy and procedures were broken. Letter worth reading.

Summary adopted from the lecture of Dr. Don Berwick
Former Administrator,
Centers for Medicare and Medicaid Services

Tarun Kothari MD 10/25/17