Value of STEMI education We live in a society exquisitely dependent on science and technologyin which hardly anyone knows anything about science and technology. Carl Sagan, Astronomer Contributing to Organizational Success in a Value Based World Using the CLIS to Impact Clinical Decision Making and Laboratory Utilization in a Value Based Environment
R Bruce Wellman, MD Sue Ann Hedrick, MT 2 So, am I only one who sees a conflict of interest here? 3 Objectives Health care costs are the problem. Data can change behavior. Our experience in developing data to create information that can lead to change using SCC basic functionality.
Carle Health System Clinic founded 1931-Hospital founded 1948- Health Plan started 1980 Integration of Clinic, Health plan and Hospital- April1, 2010 Average daily census Inpatient admissions w/ newborns Births Neonatal Intensive Care Unit patients Emergency Department patients Trauma patients Outpatient visits Outpatient/inpatient/ASC surgical
7 Pathologists 2 Path Assistants Services-1.6 million billable events Surgical, Autopsy, Gyn and NON Gyn Cytology Blood Bank, Chemistry, Immunology, Hematology Molecular, Referral, Point of Care 32% Inpatient/68% Outpatient Operating Budget-$ 25 million Accreditation CAP, AABB, CLIA Carle Lab-Center of the Universe Carle Lab
Hospital and Clinic Target rich Environment For improvement-2014 High blood use compared to peers Repeat inpatient lab tests Use of recommended thyroid profile algorithm Vitamin D testing by provider and site Test use variability between Providers PSA Screening of men over age 70 Use/Misuse of thrombophilia testing in inpatients Incidence of Anemia in hospital population Ambulatory anemia management-Iron testing and Hgb levels Impact of Hepatitis C recommendation to test baby boomer cohort(1945-1965 birth dates)
Appropriate use of referred/non-in house testing Appropriate use of molecular testing Want some free software? Our Electronic Setup: Carle Electronic infrastructure: Epic House with most modules, excluding Beaker LIS: SCC: Lab, MIC, Bank-Live since 1994 SoftLabMIC: 4.0.7 Bank: 188.8.131.52.1 SCC: Pathology-Live Since 2003 Path: 184.108.40.206.13
Dedicated LIS staff-3.5 FTE Our Starting Point What we did not have: Data mining experience in relational databases Report modules/products of any kind Anything other than basic knowledge in Excel Dedicated Report Writer Money to purchase products or services
What we had: A provider willing to drive information to affect change Willingness to learn and explore what we could do with what we had available Partnership with our analytics group to help us assess tools and provide some answers to our questions Your software contract is too confusing .... Health Care- Its Complicated
Health care costs are the problem What is covered? Who is covered? Who is going to pay? Who is going to provide the services? US personal health care expenditures rising 2014 $3 Trillion SOURCE: CDC/NCHS, Health, United States, 2014, Figure 19 and Table 104. Data from the Centers for Medicare & Medicaid Services, National Health Expenditure Accounts (NHEA).
US Healthcare Costs are high.. Not new information.. 15 Difference driven by hospital costs.. And.. 16 The major difference driver between US and other countries of the national spending per capita is 50 + years of Medicare FFS benefit
THANK YOU! 17 Not just USA has issues. National Health Service Reports that Most UK Hospitals Operating in Deficit Situations The National Health Service of England (NHS) ended 2014 with a budget overrun of 800 million, placing financial stress on the entire UK health system The major cause of the financial crisis stems from overspending on wages for outsourced staff and management consultants, according to the report.
Dark Report-April 4, 2016 The Problem- Health Care Cost TOO High Cost= # of events X cost per event Health care cost (depends who is paying) Individual Insurance premium, deductible, copays, time, inconvenience Insurers/payers Benefit Cost versus premium/copays/deductibles Claims paid- per event /per bundle/per life Operations-people, contracting, marketing, compliance, etc. Providers-what we spend to deliver services
People, facilities, supplies, compliance, insurance, recruiting, training, technology, turnover, etc. Different payment rates for the same service Moving from event based payment to value based payment Everyones goal is increased or same QUALITY for LOWER COST PLEASE DEFINE QUALITY! COST! This is an equation! We have not proven increased quality reduces long term cost. If you change one variable it will theoretically effect the Value. Definitions are important! Only Cost can be directly measured.
Everyones goal: INCREASED QUALITY (at lower cost) No worries- The Government will solve it! They are redefining what an event is. MACRA=MIPS, APMs, CEG, PRC, PCG Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Merit-Based Incentive Payment System (MIPS) Metrics: Average cost per patient, patient satisfaction, patient use of EMR, mortality, infection rates, readmissions, access, etc Alternative Payment Models (APMs) -New Section of MACRA: "Collaborating with the Physician, Practitioner, and Other
Stakeholder Communities to Improve Resource Use Measurement In one year (2016) this requires creation of new metrics: Care Episode Groups Patient Relationship Categories Patient Condition Groups For masochists I have attached a definition of these new events in slide deck 22 Hanlons Razor: Never attribute to malice that which is adequately explained by stupidity.
Lab costs in 2012 accounted for only 1.7% total Medicare costs (but Lab events and intensity increasing rapidly) Medicare Lab Spend 2003-2012 Bottom line. Avg. increase of 5.6% Increase in 2012 was 9.1% As price schedule is fixed increases reflect increased volume or
increased use of high cost tests Managed Care - October 2014 24 How can the Lab positively effect this equation? 15 year meta-analysis of published lab utilization studies (1997-2012) Overall rate of inappropriate (overutilization) testing 20.6% Overall rate of underutilization 44.8% (based on fewer studies) Rate of inappropriate initial testing 43.9% Rate of inappropriate repeat testing 7.4%
Inappropriate use by restrictive criteria 44.2% Inappropriate use by permissive criteria 12.0% 10-40% lab tests are unnecessary (using objective criteria) Underutilization is bigger problem than overutilization Reducing test volume is not the only answer! Focus should be on how lab use adds/reduces the cost of the outcome, not just the cost of testing. Findings from Zhi et al. PLoS ONE 8(11):e78962, 2013 26 DATA matters.more than $ incentives Quality = reduction in variation You can do this with SCC LIS
From 2003 through last year, tests per 100 well visits dropped from 2.5 to 0.43 for the 14 chemistry tests; 2.5 to 0.91 for CBCs; and 1.7 to 0.3 for TSH, she reported. To manage utilization, Riddell developed a report card for each family physician showing who orders medical laboratory tests inappropriately. The effort focused on the most-ordered tests, such as chemistry panels, the thyroid stimulating hormone test, and the complete blood count. Then we did a deeper dive to see how many of these were ordered and by whom, Riddell said. Just by creating awareness about the overuse of testing, we saw a drop in utilization. Then when the report cards came out, we saw another drop in utilization because a lot of physicians quit ordering inappropriate tests entirely.
Kim Riddell, M.D., Service Line Chief-Clinical Laboratory at Group Health Cooperative in Seattle, Washington As Medical Laboratory Test Utilization Grows, Health Insurers Develop Programs to Manage Rising Costs | Dark Daily http://www.darkdaily.com/as-medical-laboratory-test-utilization-grows-health-insurers-develop-programs-to-manage-risingcosts-306#ixzz41b5VU9Pi 27 Why CHANGE????? Faced with the choice between changing one's mind and proving that there is no need to do so, almost everyone gets busy on the proof. John Kenneth Galbraith,
Canadian-American Economist Identifying Resources: SCC Canned reports in the LIS Transfusion Report, Verified Results Report, Tests per Month and anything else canned in the system. Preconfigured SQL reports available in Soft with some minor changes Online and Community College courses http:// www.wiseowl.co.uk/blog/s217/sql_server_tuto rial.htm
Online searches (thank you, Google!) Roadblocks: There was never one SCC canned report that had everything we needed. Sometimes you need data from the EMR integrated into your reports. The complexity of the data requests quickly outstripped our abilities. Not only our expertise, but sometimes the data structure did not allow us to easily pull the information needed. Massive amounts of time trying to manipulate and display data.
Evolution of our progress: SCC canned reports were reformatted and additional fields were added via tasks. Originally started with the canned reports and adding additional information manuallythis can never be maintained. Became more Excel savvy. Became familiar with relational databases and how to pull data via the Oracle/SQL Tools. Still learning! Data can change behavior
Clinical Challenge High Blood utilization compared to Premier peer group- no single reason Created SCC based report exported to Excel, tracking use of every transfused component, with pre-order labs. Data can change behavior This data can then be pivoted or charted for further analysis and distribution: Data can change behavior Clinical Challenge Routine Vitamin D testing is of no clinical value
Data can change behavior Clinical challenge PSA not routinely recommended for men over 70 BIG Data 20% decrease in RBC use across the country in 6 years Data can change behavior Clinical Challenge High Blood utilization compared to Premier peer group- no single reason
2012-over 10% of adult admissions received RBC National trend showed decreasing use Created SCC based Excel report tracking use of every transfused component, with pre order labs. Profile by specialty, site, ordering provider, where components used, pre Hgb, platelet count, INR, use of special products, single unit events, dosing of FFP. Review by quarter IP OR blood use report By case number, record number, provider, specialty, procedure, order, date and time of component use, pre and post lab values, Provided customized reports to main users Oncology, Surgery, Hospitalists
Resulted in discussion of criteria, coagulation reversal order set, new best practice guidelines and new Epic indication driven order set . Hospitalist Transfusion Summary 2014-2015 % Avg. Post Discharge HGB <10.0 g/dL by Surgeon, 2015 Q1=39% Q2= 55% General Q1:Q2 2015
Q3= 43% Q4=54% System activity up RBC use down 1300 units Premier Peer Group Comparison 2013-2015 IP days 16 % Admits 20% Decreased RBC units transfused, fewer transfusions events per admission, fewer units per patient, lower pre Hgb levels,
more 1 unit transfusions Data can change behavior Clinical Challenge Routine Vitamin D testing is of no clinical value. Carle performed over 16,000 tests in 2014. Mostly ordered in primary care, significant variation in volumes and adjusted for patient panel size. Initiated best practices recommendation Primary care leadership rolling out as part of medical home process.
Practice ordering variation Concern over thyroid testing led to thyroid cascade. We tested this and provided feed back to best practices. Found conflicting order sets in primary care and fee schedule issues. NOTE to Best Practices Committee: We have folks ordering both TSH and T4, or ordering TSH and then a second draw for the T4. Most are ordering way more TSH, than Thyroid Cascade Panels which starts with a TSH and then reflexes to a T4 if TSH is
abnormal. We do 13,100 TSH separately orders annually from the 4000+ Thyroid Cascade Panel TSH tests followed by 2800 T4 ordered. I doubt we have 25% incidence of low TSH but am looking at that now. Or we have a lot of folks on therapy for hypothyroidism. We cant replace your old computer. That would be age discrimination Lessons Learned: You may be able to produce meaningful data working with
what you have. Presenting data in a relevant way does not necessarily require more than basic skills. Consider all reports a work in progress. Surprisingly, you may find what you originally thought you wanted can be reshaped by what your data shows. Dont worry about perfection (except for the validity of the data!). As reports change practice, the needed information may evolve. Results may show inconsistencies. Reports have shown us opportunities to identify variances and tighten processes. Where do we go from here?
As we become more data driven from the provider side and the business side we need to consider how to manage the required resources for obtaining the necessary data. We need dedicated products for lab specific analytics such as Soft Reports, or additional personnel with the expertise to pull this data via other methods. Timely reports are the most effective so we will need to emphasize how we can best meet the needs quickly. Development of SCC Canned Reports for those one time ASAP or low complexity extracts needed. We are always resource challenged..
Do not let what you cannot do interfere with what you can do. John Wooden, Basketball Coach Data can change behavior Volume is there a problem or opportunity? Unexplained variation between providers Variation from guidelines Care deficiencies, overuse? Advantages of organizational LIS over Payer Data
Can quantify direct cost savings for organization Not segmented by payer, shows whole picture Distinguishes ordered tests and performed tests Can easily identify abnormal subsets Can help set priorities Can customize to your organization needs Helps define value of data that drives change and
guide software and staffing decisions Using the LIS to Impact Clinical Decision Making and Laboratory Utilization in a Value Based world Physicians focus on an individual care episode or patient Without outcome data presented in a meaningful way they do not know if they are doing more or less than others. They attribute differences to their unique population. Organizations rarely aggregate population data. They get reports from different payers but not a picture of a whole practice pattern. LIS data allows customize answers to organizational
specific problems without having to invest in new software. The LIS data is all payer..this is a big deal! 50 Value Based Care Goal is to align incentives to lower cost and maintain/improve Quality Payments/penalties for events modified by metrics Payment by patient per year modified by metrics Both Federal and Commercial payment models evolving
SCC LIS can support and drive the Value based organizational strategies It is all about outcomes 52 Questions? Wheres the Coffee? Extra credit Harvard Conference on Lab utilization and Laboratory Developed Tests https://theforum.sph.harvard.edu/events/ medical-tests/
Discusses importance of audit and feedback in the success of any clinical intervention Characteristics of most effective interventions Format: Verbal and written feed back Source: Trusted colleague or supervisor Frequency: More frequent better than less frequent Instructions for improvement: Explicit and measurable target and action plan Nature of behavior change: Decreased activity > increased activity Profession of recipient: Non physicians change greater than Physician
J Gen Intern Med 29(11):153441, 2014 In 2014, U.S. health care spending increased 5.3 percent following growth of 2.9 percent in 2013 to reach $3.0 trillion, or $9,523 per person. The faster growth experienced in 2014 was primarily due to the major coverage expansions under the Affordable Care Act, particularly for Medicaid and private health insurance. The share of the economy devoted to health care spending was 17.5 percent, up from 17.3 percent in 2013. https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/ nationalhealthexpenddata/downloads/highlights.pdf Hospital Care: Spending for hospital care increased 4.1 percent to $971.8 billion in 2014 compared to 3.5% growth in 2013. The fastest growth in 2014 was influenced by a resurgence of growth in non-price factors such as use and intensity of services. In addition, hospital services experienced faster growth in Medicaid,
private health insurance, and Medicare spending compared to 2013. Lastly, ACA-related coverage expansion contributed to increased hospital spending for both Medicaid and private health insurance. Physician and Clinical Services: Spending on physician and clinical services increased 4.6% in 2014 to $603.7 billion from 2.5 % growth in 2013 when spending was at a historical low. Faster growth in both price and non-price factors contributed to the acceleration in overall spending for physician and clinical services. Medicaid, private health insurance, and Medicare spending for physician and clinical services all accelerated in 2014. Other Professional Services: Spending for other professional services reached $84.4 billion in 2014, an increase of 5.2%, which is an acceleration from 3.5%in 2013. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or
chiropractic medicine. In 2014, U.S. health care spending increased 5.3 percent following growth of 2.9 percent in 2013 to reach $3.0 trillion, or $9,523 per person. The faster growth experienced in 2014 was primarily due to the major coverage expansions under the Affordable Care Act, particularly for Medicaid and private health insurance. The share of the economy devoted to health care spending was 17.5 percent, up from 17.3 percent in 2013. Dental Services: Spending for dental services increased 2.8% in 2014 to $113.5 billion, faster than in 2013 when growth was 1.5%. Private health insurance (which accounted for almost half of dental spending in 2014) increased 3.4% after growing 1.3% in 2013. Out-of-pocket spending for dental services (which accounted for 40% of spending in
2014) increased slightly at 0.2%in 2014, following growth of 1.0% in 2013. Other Health, Residential, and Personal Care Services: Spending for other health, residential, and personal care services grew 4.1% in 2014 to $150.4 billion, which was a slowdown compared to 4.7% growth in 2013. This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities. Home Health Care: Spending growth for freestanding home health care agencies accelerated in 2014, increasing 4.8% to $83.2 billion following growth of 3.3% in 2013. The faster growth in 2014 was attributable to increased spending by the two largest payers of home health, Medicare, with growth of 3.3%, and Medicaid, with growth of 3.5%. Combined, both payers of home health care represented 77% of total home health spending. Nursing Care Facilities and Continuing Care Retirement Communities: Spending for freestanding nursing care facilities and continuing care retirement communities increased
3.6% in 2014 to $155.6 billion, an acceleration from growth of 1.3% in 2013. The faster growth in 2014 was due to the increased spending in Medicare, with 4.1% growth, and Medicaid, with 3.1% growth. Health Spending by Major Sources of Funds: Medicare: Medicare spending grew 5.5% to $618.7 billion in 2014, an acceleration from 3.0% growth in 2013. This increase was primarily attributable to faster growth in spending for prescription drugs, physician and clinical services, and government administration and the net cost of insurance. Medicare accounted for 20% of total health care spending. Medicaid: Total Medicaid spending, which accounted for 16% of total national health expenditures, increased 11.0% in 2014 after growing 5.9% in 2013. State and local Medicaid expenditures only grew 0.9%, while federal Medicaid expenditures increased 18.4% in 2014. The increased spending by
the federal government was largely driven by the newly eligible enrollees under the ACA, which were fully financed by the federal government. Private Health Insurance: Total private health insurance expenditures increased 4.4% (33% of total health care spending) to $991.0 billion in 2014, faster than the 1.6% growth in 2013 which was the slowest rate since 1967. The faster rate of growth reflected the impacts of the ACA, including the introduction of Marketplace plans, health insurance premium tax credits, health insurance industry fees, and mandated benefit design changes. Average monthly marketplace enrollment was 5.4 million in 2014. Out-of-Pocket: Out-of-pocket spending grew 1.3% in 2014 to $329.8 billion which was slightly slower than annual growth of 2.1% in 2013. The slowdown in 2014 was influenced by the expansion of insurance coverage and the corresponding drop in the number of individuals without health insurance. MACRA, MIPS, APMs
Extracredit For years, the limitations of healthcare claims data have been a major barrier to identifying opportunities to control healthcare spending and to developing alternative payment models. Current resource use measurement and payment systems use complex episode groupers, statistical attribution methodologies, and risk adjustment systems in order to try and extract information from claims data that it was not designed to provide. As a result, these methodologies have many serious weaknesses that have the potential to harm patients and healthcare providers, particularly small physician practices and hospitals. For example: Physicians cannot control all of the services and spending assigned to them under typical resource
use measures. Physicians are not attributed the spending for many services they do provide. Many patients are not assigned to the physicians who are helping them manage their health problems. Risk adjustment systems do not adequately adjust for differences in patient needs. Fortunately, Congress recognized these problems and created mechanisms to solve them as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Although MACRA is best known for creating the Merit-Based Incentive Payment System (MIPS) and encouraging Alternative Payment Models (APMs), a little-known section of MACRA, entitled "Collaborating with the Physician, Practitioner, and Other Stakeholder Communities to Improve Resource Use Measurement," requires the creation of three new ways of classifying services and patients:
Care Episode Groups. MACRA requires the creation of "care episode groups" that define the types of procedures or services furnished for particular clinical conditions or diagnoses. If properly designed, Care Episode Groups will enable far better measures of the kinds of services and costs physicians can control or influence than the total cost of care and episode spending measures used in payment programs today. Patie nt Re lationship Cate gories. MACRA requires the creation of "patient relationship categories" that define and distinguish the relationship and responsibility of a physician or applicable practitioner with a patient at the time of furnishing a service. If properly designed, Patient Relationship Categories will enable payments and accountability for spending and quality to be far more accurate than the retrospective statistical attribution methodologies used in payment programs today. Patie nt Condition Groups. MACRA requires the creation of "patient condition groups" based
on a patient's chronic conditions, current health status, and recent significant history, such as hospitalization or surgery. If properly designed, Patient Condition Groups will enable far better risk adjustment and acuity stratification than the methods used in payment programs today. Each of these new groups and categories will have an associated code that physicians will record on the claims they submit for payment beginning on January 1, 2018. This will enable payment models and spending analyses to be based on far more complete and accurate information than is possible today. A new report from the Center for Healthcare Quality and Payment Reform Improving Resource Use Measurement Under MACRA - explains these requirements of MACRA and describes how the Centers for Medicare and Medicaid Services (CMS) should implement them in order to enable more effective resource measurement and to facilitate the successful development and implementation of Alternative Payment Models. Improving Resource Use Measurement Under MACRA also describes the problems with current episode groupers, attribution methodologies, and risk adjustment systems and explains why the new codes required under MACRA are so important. The report can be downloaded free of charge
59 Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results John Hickner, MD, MSc, Pamela J. Thompson, MS, Tom Wilkinson, MPH, Paul Epner, MBA, MEd, Megan Shaheen, MPH, Anne M. Pollock, BA, Jim Lee, MS, Christopher C. Duke, PhD, Brian R. Jackson, MD, MS and Julie R. Taylor, PhD, MS + Author Affiliations JABFM MarchApril 2014 Vol. 27 No. 2 1768 physicians (5.6%) responded to the survey They reported uncertainty about ordering tests in 14.7% and uncertainty in interpreting results in 8.3% of these diagnostic encounters. The most common problematic challenges in interpreting and
using test results were not receiving the results and confusing report formats. Physicians infrequently sought assistance or consultation from laboratory professionals but valued these consultations when they occurred. With more than 500 million primary care patient visits per year, the level of uncertainty reported in this study potentially affects 23 million patients per year and raises significant concerns about the safe and efficient use of laboratory testing resources. From the Department of Family Medicine, University of Illinois College of Medicine, Chicago (JH); the Centers for Disease Control and Prevention, Atlanta, GA (PJT, AMP, JRT); the Altarum Institute, Ann Arbor, MI (TW, MS, JL, CCD); Paul Epner LLC, Evanston, IL (PE); and the Department of Pathology, University of Utah, Salt Lake City (BRJ); and ARUP Laboratories, Salt Lake City, UT (BRJ). Corresponding author: John Hickner, MD, MSc, Department of Family Medicine, University of Illinois Chicago, 1919 W. Taylor, MC 663, Chicago, IL 60612 (E-mail: [email protected]).
60 Primary Care Physicians' Challenges in Ordering Clinical Laboratory Tests and Interpreting Results John Hickner, MD, MSc, Pamela J. Thompson, MS, Tom Wilkinson, MPH, Paul Epner, MBA, MEd, Megan Shaheen, MPH, Anne M. Pollock, BA, Jim Lee, MS, Christopher C. Duke, PhD, Brian R. Jackson, MD, MS and Julie R. Taylor, PhD, MS + Author Affiliations JABFM MarchApril 2014 Vol. 27 No. 2 Conclusions: Improvement in information technology and clinical decision support systems and quick access to laboratory consultations may reduce
physicians' uncertainty and mitigate these challenges. 61 Where do we spend the commercial health care dollar(2012)? Source: IMS LIFELINK Health Plan Claims 74 Million unique patients in >80 US Health Plans Spending per year (N=over 15 million patients) $ mean Total (100%) 709
Lab Costs=4.2% of spending What Contributes Most to High Health Care Costs? Prichard, D et al J of Managed Care and Specialty Pharmacy vol. 22, no.2 62 Commercial Payer Costs to Lab and Pathology Services Increasing Around $190 avg./person/year in 2012 5% of total cost For High Risk Patients(5% of total) 4% of total costs can be attributed to lab and pathology
costs $2000 avg. 5% are High Resource Patients.. (used to just be called sick) 63 Using the LIS to Impact Clinical Decision Making and Laboratory Utilization in a Value based world How can the cost of a clinical event be influenced by lab use? Direct cost - make or buy How does the test effect the outcome? Cost of managing the Clinical Cost of patientlab interaction
Decision to order, Patient education on need and value of test, Effect of Turnaround time Managing access, specimen acquisition, managing result, dealing with abnormal results, integrating result into data base, providing access to result, follow-up of abnormal or normal. Liability to perform or not perform? 64 All of these interventions require data Four Types of Algorithms: Pathologist-driven: Review of pathology findings determine next steps in testing algorithms; cancel or add appropriate next steps
Genetic Counselor-driven: Review of genetic test requests require genetic experts with laboratory knowledge; make phone calls to add or cancel testing Laboratory-driven: Laboratory results drive subsequent test selection. Testing is performed by laboratories using available specimens; specimens are shared between labs IT-driven: Clinical input and information drive what testing gets ordered or not. From Mayo Clinic Lab utilization presentation available on line at Mayo Lab web site Midwest Provider Owned Health Plan: Clinical lab 2012-2015 spending trends show
Lab costs 5+% and rising Commercial % change in premium % change in Hosp lab claims % change in Clinic lab claims +17% +30% +18% % Total Change in Lab claims +26% Medicare Advantage %change in premium +12% % change in Hosp lab claims
-28% % change in Clinic lab claims +12% % Total Change in Lab claims -5% Rapid increase over the past 4 years compared to historical trends. 66
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