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201 exam 1
Trends in Healthcare
| Question | Answer |
|---|---|
| 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 |
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