将人群健康纳入健康管理

Incorporating Population Health into Healthcare Management US Models 将人群健康纳入健康管理-美国模式,Jack Needleman, PhD Professor and Chair, Department of Health Policy & Management UCLA Fielding School of Public Health Jack Needleman, 博士 UCLA 菲尔丁公共卫生学院，卫生政策与管理系， 教授兼系主任 Wuhan, China March 25, 2017,Making population health a focus of health care management,President Xis call last August Called for full protection of peoples health Health in all policies Health care system providing prevention, treatment, rehabilitation Parallel focus in US Institute for Healthcare Improvement call for Triple Aim (2007) Simultaneous pursuit of: Improved patient experience of care Improve the health of populations Reduce the per capita cost of health care Improved patient experience is not just patient satisfaction but improvement in all 6 Institute of Medicine dimensions of quality Safe, effective, patient-centered, timely, efficient, equitable Robert Wood Johnson Foundation (largest US health philanthropy) Health and health care Culture of health Health in all policies 翻译见下页,人群健康将成为健康管理的核心部分,去年八月的重要讲话 呼吁充分保护人民的健康 健康融入所有政策 卫生保健系统能够提供预防、治疗、康复服务 同样，在美国 医疗促进协会呼吁三重目标 (2007) 同时追求: 改善患者医疗体验 改善人群健康 减少人均医疗保健成本 改善患者医疗体验不仅仅是提高患者满意度，而是医学研究所提出的6个质量维度的全面改善 安全、有效、以患者为中心、及时、高效、公平 罗伯特·伍德·约翰逊基金会(美国最大的医疗慈善机构) 健康与卫生保健 健康文化 健康融入所有政策,Incentives for population health in changing payment systems 改变支付体系来刺激人群健康,Capitation 按人头付费 Accountable care organizations 责任医疗组织 Value-based modifications of fee for service payment 基于价值修订的服务费用支付,Capitation 按人计费,Total payment for all care needs 所有医疗需求的总支付金额 Provides incentive to control total costs of care 通过刺激来控制总的医疗成本 Incentive to improve population health is lower 改善人群健康的刺激是较弱的 Patient satisfaction to sign up 患者根据其对服务提供者所提供服务的满意度来决定其去留 But under capitation, health system may not want the sick 但在在按人计费的情况下，医疗系统可能不希望有病人 Separate measures of population health that need to be achieved to receive full capitation 单独的人群健康措施需要去实现收到全部的人头税,CMS: Accountable Care Organization (ACO) Shared savings program 美国医保与医助服务中心：责任医疗组织节余分享计划,Accountable Care Organization 责任医疗组织 No patient enrollment but patients attributed to ACO based on preponderance of primary care use 无须再进行患者招募，患者会基于基本医疗服务利用的优势来选择ACO Estimated risk adjusted target or budget compared to actual costs 评估风险调整基准或相对于实际成本的预算 Savings shared 节余 Losses also shared and limited 亏损会被分摊和限制 Typical sharing is 50/50 but can vary and 典型的分享模式是50/50，但是可能也会变化 Higher quality increases savings share, reduces loss share 高质量的医疗照料会增加节余，并减少亏损 33 measures in 4 areas, weighted score 在四个方面的33个评定项目，加权分数 Include: getting timely care and appointments, access to specialists, physician communication metrics, vaccinations and immunizations, unplanned admissions or avoidable admissions or readmissions, poor diabetes control, mammography screening, colorectal cancer diagnostics, shared decision making, and patient education.（包括：及时获得医疗与体检，对专家的可及性 糖尿病控制差，乳房摄影筛检，结直肠癌诊断，共同决策和患者教育）,ACO scoring determines the amount of savings it shares or the amount of losses it owes ACO分数决定共享节余总数和亏损总数,Additionally, CMS will reward ACOs that demonstrate significant improvement in their quality measure performance by adding up to 4.00 points to each domain score. 此外，CMS将会奖励那些的质量绩效显著提高责任医疗组织，表现为在4个模块的评分中各增加4分。,绩效评分度量方法,ACO绩效水平,质量得分,医患体验,医疗服务协调/安全,预防医疗,高危人群,各模块总计,模块,评定项目数,参与评分的评定项目数,模块权重,总的可能分数,2016年报告：每个模块的质量绩效标准总分,New physician payment methods with emphasis on value Example: MACRA: Medicare Access and CHIP Reauthorization Act of 2015 强调价值的新医疗付费方式 例如：MACRA：2015年美国的医疗服务可及性与儿童健康保险项目再授权法案,Streamlines multiple quality reporting programs into the new Merit-based Incentive Payment System (MIPS) （简化多质量报告程序的过程并纳入到新的基于绩效的激励支付系统） Provides incentive payments for participation in Advanced Alternative Payment Models (APMs) （为参与高级替代付费模式的医生提供奖励） Most physicians expected to participate in MIPS （预计大多数医生会加入绩效奖励支付系统（MIPS） Can participate as individual or as part of group practice （能够以个人或部分联合医疗的方式加入）,The Merit-based Incentive Payment System (MIPS),or,Advanced Alternative Payment Models (APMs),基于绩效的激励支付系统 （MIPS）,高级替代付费模式（APMS）,PROPOSED RULE MIPS: Performance Category Scoring,35,翻译见下页,拟议的规则 MIPS:绩效分类记分,35,质量：临床医生选择六项最能反映他们的医疗实践的指标报告给美国联邦医保与联邦医助服务中心（CMS）。这些指标中，必须有一个是结果指标或高价值指标，或是一个横切指标。临床医生还可以选择报告专业指标集。,推广护理信息：临床医生将报告那些协调操作和信息交换的关键指标。临床医生在对他们最重要的指标的表现上获得绩效奖励。,Need a framework for thinking about population health in a health system context（需要一个在卫生系统背景下考虑人群健康的框架）,What is the health of the population and need for services （人口的健康状况和服务需求是什么？） What influences health and what is the role of the health system （是什么影响了健康？卫生系统的作用是什么？) What can systems implement （系统能实现什么?）,Health is influenced by circumstances outside of the health care system, and requires engagement outside of health sector （健康受到医疗保健系统以外的环境的影响，需要卫生部门以外的其他主体参与）,Source: Robert Wood Johnson Foundation, 2014,（资料来源：Robert Wood Johnson基金会，2014）,Kaiser Pyramid: Risk Segmentation,Very High （极高） 0 0.5% High （高） 0.5 5%,Moderate （中） 5 20%,Low （低） 20 100%,Ka