Session 7

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(10’) Welcome Back
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Students share any updates for the class; any comments lingering from the last session
(45’) Discussion on Module 9 - recommend that discussions begin with mini-presentations on Capitation vs. Bundled Payments -- debates are encouraged! Below are some questions to foster more discussion 
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Module 9 reviews different payment models, which Dr. Gwynne should be expounding upon in his lecture. 
Mini Presentations on Capitation vs. Bundled Payments
Review of Bundled Payments (to be done via Mini-Prez): 
Five conditions that must be met:
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What’s a potential way that bundled payments might not be effective? 
Providers could try to offset price decreases with volume increases.
Review of Capitation
Providers receive a fixed per person payment that covers all health services over a defined time-period
Review of global payments
Global payments are extremes of capitated payments where a fixed payment is made for all services for a specified period of time, usually a year.
Review of ACOs
A combo of capitation and FFS where a group of doctors and other providers voluntarily come together to provide care for Medicare patients. Care is coordinated. 
It's key to keep in mind that capitation and global payments are more population-focused; that is, they are comparing patient outcomes to that of a population at-large which isn’t necessarily something that patients weigh heavily.
Precision Benefit Design (Value-based insurance design) is a way to change payment at the level of the payor, where there’s cost-sharing on high-value practices and low-value services would cost more to the individual patient.
The following question might be challenging for clinical students to answer; however, this is also an opportunity for attendings and/or others to chime in. In what ways have you ever felt incentivized to provide lower- value care (e.g., repeating tests; ordering unnecessary tests, images, or screens, etc.)? In what ways have you ever felt de- incentivized to provide low-value care?
In Module 9’s Story from the Frontlines, the resident and medical student from the Module 8 discuss the migraine patient’s negative CT-scan results. The med student admits that, though unnecessary, he probably would have ordered the test as well just to be safe. The resident is upset because this woman has now been unnecessarily exposed to radiation and charged for the CT when it wasn’t beneficial for her health or presented concern.
Think about the different payment models discussed in this module: Pay-for-performance, bundled payments, capitation, and global payments. If your organization were looking into changing its model, which would you advocate for? Why? What do you see as the potential barriers and pitfalls in this adoption? 
Does anyone in the group already work or have experience in an institution with a payment model other than fee-for-service? Ask them to expand upon this.
What speciality are you thinking about going into? If your organization were to adopt value-based models, what specific effects might it have on your processes within this specialty? Do you think that overall, it would change the way that you practiced? 
**(10') Break
(45’) Discussion on Module 8
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Ultimately, making systemic change hinges upon the responsiveness of those around us. As medical students, we get thrown into different micro-cultures all the time, whether through our volunteer experiences, or on the wards rotating on different specialties. For this first part of the discussion, we will reflect on the cultural practices we’ve experienced or noticed, we’ll learn from faculty, and we’ll review the mechanisms of initiating change (i.e., Nudge unit). 
Clinical students: discuss the differences in cultural practices you saw between the different specialties -- are you optimistic that the overall system can see broad change? 
Non-clinical students: share an experience outside of medicine where the “culture” was particularly toxic, or not. These experiences could be in the context of school, of sports teams, of other work experiences or volunteer positions. 
Module 8 discusses the power of the story to bring about change. Since this is the last week of the class, we can do a throwback/recall exercise - what story was most impactful to you? As you look back on the past few weeks, was there one story that stood out? 
The number one contributor to health care waste is unnecessary services. As the Module 8 video explained, wasteful practices are often culturally perpetuated. What low-value practices have you seen in the environments you’ve worked in that could be attributed to culture? How did you find yourself responding to these practices? (For example, at UNC, we talked about the 2 units of blood being transfused nonsensically - what do you think this says about the culture? What does it say about the people who realized this cultural practice was futile?)
The Module 8 Story from the Frontlines explores the tensions between best practice and established culture. It depicts a woman presenting to the ER with symptoms both a resident and attending diagnose as a migraine. The attending tells the resident to order a CT, though this isn’t best practice for a migraine and probably won’t serve the patient’s interests.
Do you think all cultural practices that contribute to low-value care can be overcome? What are some barriers to changing aspects of culture? 
Barriers discussed include hierarchies, institutional inertia, and siloes.
How do you think you can apply some of the frameworks or lessons from this module to help lead cultural change in your primary clinical environment? 
Frameworks and tools that were presented include the High-Value Care Culture Survey (HVCCS) which defines four domains of a high-value culture (Leadership and health system messaging; data access and transparency; comfort with cost conversations; blame-free environment), Kotter’s 8-Step Model for Change, and the MacColl Center for Health Care Innovation’s framework on creating the conditions for change. 
Dr. Moriates talked about a time in his residency where he saw a change unfold at his institution, thanks to the work of one attending physician. What are your thoughts on the power of One to change the institutional culture? If you’ve been on clinical rotations, have you seen exemplary leadership from your attendings or residents? 
Module 8 discussed “nudge” theory and the potential effects of increased transparency with peers regarding patient care decisions. If your goal was to decrease unnecessary testing in your clinic by 10%, how would you go about this? Do you think that adding a justification step to EHR notes might aid in this? Would this impact your own test orders? How should you plan for and test this theory? What are some other ways this decrease might be achieved? 
Nudge theory posits that the framing of information will lead to different results, and that one can achieve desired results through appropriate framing. Research has shown that individuals are more likely to do something if their peers are doing it or if they know that their peers will be impacted by or judgmental of the individual’s actions or lack thereof. 
Examples are: handwashing adherence rises if people are told not doing so will lead to others getting sick, but not when told that they themselves may get sick. In a non- medical sense, taxes are paid more often when people are told everyone else pays their taxes, but not when people are told the benefits or consequences associated with paying/not paying taxes.
(10’) Wrap Up

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