Description
Book SynopsisWith healthcare making the transition from volume-based reimbursement programs to value-based approaches, understanding performance measurement is vital to optimize payment and quality outcomes. Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care Relationships guides readers through the maze of definitions and discussions related to value-based purchasing, healthcare delivery, and pricing. It tackles the question of how hospitals, HMOs, physician groups, and employers can arrive at an optimized reimbursement cost and coverage access decision that is attractive to consumers yet fulfills the need for a working margin.
The book begins by looking at HMOs and the three key factorsreimbursement, coordination, and performancethat have led toward performance-based contracting. Laying the foundation for clearer communication between physician hospitals and purchasers, the author defines important concepts in the discussion,
Trade Review
Bill De Marco draws upon his extensive experience to provide a comprehensive and detailed discussion of performance-driven improvement in healthcare. There is much here of value to policy makers, healthcare system leaders and anyone who wishes to have an in-depth and practical understanding of how to improve healthcare performance and how to align payment to drive better performance. Healthcare continues to be in crisis and in need of further reform, and Bill helps leaders understand the steps they need to take to get that done.
—George J. Isham, MD, Chief Health Officer, HealthPartners
Real health reform must solve deep systemic problems in the delivery of medical services, not just the way we pay for care. This latest book by Bill De Marco presents a realistic and practical blueprint for fixing the system at its base. Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care, not the Affordable Care Act, should be required reading for all who really want to build a new and better health system.
—Jeff Bauer, PhD, author of Paradox and Imperatives in Health Care and Statistical Analysis for Decision-Makers in Health Care
I feel fortunate to have been given the opportunity to review and endorse Mr. De Marco’s amazing new book, Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care. This book is particularly remarkable in that it focuses not just on pay-for-performance and performance-based medicine, but truly on the provider side of innovating managed care and embracing pay-for-performance. This provider focus emphasizes physician organizations, and transitioning the delivery of actual healthcare to one that rewards clinical excellence, benchmarked performance attainment, and improving purchaser value. This focus of the managed care enterprise from the physician’s perspective, especially in the contexts of performance benchmarking and Lean engineering, is truly unique just by itself. But Bill De Marco, goes a few steps further. As we’re now seeing with the rise of state healthcare exchanges, accountable care organizations, and attempts by purchasers to narrow their provider markets according to their own metrics, Mr. De Marco has hit a "home run" with his book: He has shown how to re-engineer clinical pathways and disease processes – even with free, public-domain tools – to add value in ways that most emerging ACOs and healthcare exchanges have not yet realized how limited their value will be without moving toward value-based care and performance-based contracting. I was particularly impressed with the findings shared by Bill De Marco in describing Episode Treatment Groups® (ETGs®) and their syntheses of complex and statistically-valid disease management datasets in ways that the healthcare market is just beginning to realize. For example, I can easily see Bill’s descriptions of ETGs as transforming pharmacy benefit managers (PBMs) and Third-Party Administrators (TPAs) away from micro-managing consumption to setting clinical pathways, specific to disease states and their co-morbidities, and therein rewarding benchmark attainments and disease adaptations of specific people. This model is truly the ultimate goal of Paying-for-Performance and transitioning to Performance-Based Metrics, designed to improve clinical care, adherence to healthier lifestyles, optimal disease adaptation, morbidity and mortality prevention, as well as assurance of improved clinical outcomes – all of which purchasers (including CMS) have always wanted to buy from health plans and managed care organizations but have never been able to do so. With Mr. De Marco’s new book, Performance-Based Medicine, these market transformations can finally occur and at the broadest levels within a newly re-emerging U.S. healthcare delivery system. Great job, Bill!
—David I. Samuels, author of Managed Health Care in the New Millennium
Bill De Marco draws upon his extensive experience to provide a comprehensive and detailed discussion of performance-driven improvement in healthcare. There is much here of value to policy makers, healthcare system leaders and anyone who wishes to have an in-depth and practical understanding of how to improve healthcare performance and how to align payment to drive better performance. Healthcare continues to be in crisis and in need of further reform, and Bill helps leaders understand the steps they need to take to get that done.
—George J. Isham, MD, Chief Health Officer, HealthPartners
Real health reform must solve deep systemic problems in the delivery of medical services, not just the way we pay for care. This latest book by Bill De Marco presents a realistic and practical blueprint for fixing the system at its base. Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care, not the Affordable Care Act, should be required reading for all who really want to build a new and better health system.
—Jeff Bauer, PhD, author of Paradox and Imperatives in Health Care and Statistical Analysis for Decision-Makers in Health Care
I feel fortunate to have been given the opportunity to review and endorse Mr. De Marco’s amazing new book, Performance-Based Medicine: Creating the High Performance Network to Optimize Managed Care. This book is particularly remarkable in that it focuses not just on pay-for-performance and performance-based medicine, but truly on the provider side of innovating managed care and embracing pay-for-performance. This provider focus emphasizes physician organizations, and transitioning the delivery of actual healthcare to one that rewards clinical excellence, benchmarked performance attainment, and improving purchaser value. This focus of the managed care enterprise from the physician’s perspective, especially in the contexts of performance benchmarking and Lean engineering, is truly unique just by itself. But Bill De Marco, goes a few steps further. As we’re now seeing with the rise of state healthcare exchanges, accountable care organizations, and attempts by purchasers to narrow their provider markets according to their own metrics, Mr. De Marco has hit a "home run" with his book: He has shown how to re-engineer clinical pathways and disease processes – even with free, public-domain tools – to add value in ways that most emerging ACOs and healthcare exchanges have not yet realized how limited their value will be without moving toward value-based care and performance-based contracting. I was particularly impressed with the findings shared by Bill De Marco in describing Episode Treatment Groups® (ETGs®) and their syntheses of complex and statistically-valid disease management datasets in ways that the healthcare market is just beginning to realize. For example, I can easily see Bill’s descriptions of ETGs as transforming pharmacy benefit managers (PBMs) and Third-Party Administrators (TPAs) away from micro-managing consumption to setting clinical pathways, specific to disease states and their co-morbidities, and therein rewarding benchmark attainments and disease adaptations of specific people. This model is truly the ultimate goal of Paying-for-Performance and transitioning to Performance-Based Metrics, designed to improve clinical care, adherence to healthier lifestyles, optimal disease adaptation, morbidity and mortality prevention, as well as assurance of improved clinical outcomes – all of which purchasers (including CMS) have always wanted to buy from health plans and managed care organizations but have never been able to do so. With Mr. De Marco’s new book, Performance-Based Medicine, these market transformations can finally occur and at the broadest levels within a newly re-emerging U.S. healthcare delivery system. Great job, Bill!
—David I. Samuels, author of Managed Health Care in the New Millennium
Table of ContentsIntroduction. Integration and HMOs: How Did We Get This So Wrong? Performance Measurement: A Science with No Followers. Reimbursement: From Fee for Service to Risk Adjusters. Early Pay-for-Performance. Performance Language and Practice. Reengineering. Challenges. International Reform. Getting Started. The Future of Performance-Based Medicine. Appendices.
