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201 exam 1

Trends in Healthcare

how were health services reimbursed in the early 1900's? Out of pocket Prepaid health insurance for employees Health care Reform attempted
how were health services reimbursed in the 1920's-30's Large employers and insurers contracting for care including hospitals. Blue Cross is established. Average lifespan 62.5 yrs. Labor unions began to contract with prepaid group practices (insurance?)
how were health services reimbursed in the 1940's-60's Fee for service predominates! Federal Government imposes wage and price controls. Health insurance made tax exempt.
who opposed prepaid group practices in 1940-60 AMA
when was shift from solo to group practice? 1940-60
when did specialties increase (vs general practitioners) after WW2
when was Medicare and Medicaid enacted in to legislation? 1965
what did Medicare and Medicaid stimulate? university medical centers and investor owned hospitalsthe cost based health care reimbursement Gap insurance
gap insurance medicare pay 85%, gap insurance is used to cover the remaining balance
secondary insurance full coverage for the individual, if primary won't pay, then secondary can cover
supplemental insurance will only pay 20% of primary pays 80%
when was HMO (health maintenence organization) act? 1973
when did health care costs increase and managed care began to take hold? 1980's
managed care restricted services and individual could use and how many visits etc.
prospective payment estimated/restricted payment based on how long the average person with that diagnosis stayed in the hospital/ how much care they needed
when did prospective payment start to affect hospital occupance? 1980's
what was managed care influenced by in the 1990's regional differences
focus of healthcare in the 1990's Hospital costs contained Focus on other cost containment measures: risk sharing Failure at attempts for universal health insurance coverage
average lifespan in the 2000's 77.8 years
focus of healthcare in the 2000's? Increased focus on out-patient for cost containment Consolidation of the industry (payors and providers)
focus of healthcare in 2010's and beyond Increased focus on home health care Management of chronic diseases ie: Alzheimer's, diabetes etc. Pay for Performance
when did affordable care act come into effect? 2010's
when did ACHO's begin? 2010
pay for performance payment is determined base on if you can show that you are making progress with a patient
Government programs (Medicare and Medicaid) trying to ____ costs, transfer____ decrease, risk
Medicare contribution in 1964 vs 2023 5:1 in 1964, 2:1 in 2023
Employers looking to ____costs of health care benefits ___ remains primary determinant for employer (not quality) decrease, Cost
insurance company cherry picking insurance company wants to know ages and gender of employees, then they will decide what the rate should be based on that info
Acute Average stay in 2017= ___days; 2019 =___ days. this increased to use of lesser levels of care 7.2, 4.5
strategies to reduce costs by insurance company Higher copays or deductibles Payment models (PTA/OTA cut 2022) PDPM – patient driven payment model vs PDGM – patient driven groupings model
age at home you have to take care of yourself at home, no SNF
why does insurance deny claims? Mistakes on forms Documentation does not support No pre-authorization Over-utilization Compliance (Fraud, waste, and abuse)
CARE Medicare Driven (Continuity Assessment Record and Evaluation).
FOTO Focus on Therapeutic Outcomes, Inc. determine patients' functional status, report severity modifiers, and track outcomes
Optimal APTA Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) is an instrument that measures difficulty and self-confidence in performing 22 movements
outcome registry APTA database for tracking outcomes based on Diagnosis
functional assessment tools for outpatient therapy FOTO, optimal, outcome registry
who signed ACA into law president Obama in 2010, upheld by supreme court in 2012
what % of Americans have insurance through ACA 94%
ACA says insurance cannot discriminate based on.. pre-existing condition
purpose of ACA Expanded eligibility for Medicaid; extends Children's Health Insurance Program for 2 years Intent to move away from “Fee for Service” model Promoted preventative health care by decreasing deductibles and copays for those procedures
ACHO accountable health care organizations organization of health providers accountable for quality and overall cost $ of CMS beneficiaries.
ACHO is ____ driven Medicare
purpose of ACHO Provider with strong primary care, responsible for total cost $ across continuum of care. Payments linked to quality improvement, outcomes and decrease cost $. Reliable performance measurement to support costs $.
how did ACHO affect Medicare shift $117 billion out of a projected $380 billion away from fee-for-service payments. $411 million savings in 2014 attributed to ACOs participating in the Medicare Shared Savings
10 mandatory essential health benefit categories ambulatory pt services emergency service hospitalization maternity and newborn care mental health and substance abuse services prescriptions rehab and devices labs preventative care pediatric services
purpose of bundling Establishes a national Medicare pilot program to develop and evaluate making bundled payments for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care.
what may bundling cover? services furnished by a single entity or items and services furnished by several providers in multiple care delivery settings.
how does payment work with bundling? Single negotiated episode payment of a predetermined amount for all services. Paid prospectively or retrospectively
comprehensive care for joint replacement (CJR) program A system that requires hospitals in metropolitan areas to participate in a bundled payment program for total knee and total hip replacements started 2016.
Physical Therapy Classification and Payment System (PTCPS A system that uses a severity-intensity framework as a basis for payment, rather than a procedural-based, fee-for-service system. The evaluation codes associated with the new system implemented January 1, 2017.
medical home Approach to primary care where one practice takes the lead on coordinating all aspects of patient care
integrative medicine Combining Western Medicine with Alternative treatments
individualized medicine Gene profiling changing the way medical decisions are made. Tailored to specific needs and diseases
telehealth Telecommunications technology is used to provide and support in-home healthcare
electronic health records Storing all patient information (hx,meds,tests) in computer for record sharing to improve safety and costs $
MIPS Merit-based Incentive Payment System a major part of (QPP) Quality Payment Program.
when did MIPS begin? The changes took effect on January 1, 2019 in outpatient clinics.
according to MIPS, practices with more than ___ clinicians need to use a vendor to report data 15
The right vendor or registry with MIPS can pay off, both in terms of ____ and as a way to streamline ___ by way of integration with your EHR system. ongoing performance feedback, data entry
2023 threshold amount for using the KX modifier, which confirms services are medically necessary and justified by appropriate documentation is: (for PT, SLP, OT) $2,230 for PT and SLP combined $2,230 for OT Above $3,000 exceptions process and targeted medical review
when did PTA/OTA payment differential begin? Required by Bipartisan Budget Act of 2018 Effective January 2022 **Was supposed to start claims in 2020 for adjustment period, APTA/AOTA avoided
how much is the PTA/OTA payment differential 15% cut in reimbursement for services provided that treatment Utilize 10% rule for CQ Modifier – OP services furnished in whole or part by PTA
where is PTA/OTA payment differential applicable? private practice, OP hospitals, rehab, SNF, Home Health
PPDM system a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay.
PPDM grouping Definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.
PDGM Patient Driven Groupings Model (PDGM).
PDGM system moved care from 60-day to 30-day episodes and eliminated therapy service-use thresholds from case-mix parameters. The rule also allowed PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist
Created by: bdavis53102
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