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Health Care, Week 9 Notes

by: Loretta Hellmann

Health Care, Week 9 Notes HCA 340 -002

Loretta Hellmann
GPA 3.75

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week 9 notes, only from Thursday, notes are from the first week after the midterm
Steven W. Maddox
Class Notes
25 ?





Popular in Nursing and Health Sciences

This 9 page Class Notes was uploaded by Loretta Hellmann on Tuesday April 5, 2016. The Class Notes belongs to HCA 340 -002 at Western Kentucky University taught by Steven W. Maddox in Spring 2016. Since its upload, it has received 28 views. For similar materials see HEALTH CARE ORG/MGT in Nursing and Health Sciences at Western Kentucky University.


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Date Created: 04/05/16
Week 9 Notes Thursday, March 31, 2016 9:37 AM Chapter 8  Self0funded insurance programs  Large employers collect premiums and pool funds into account to pay medical claims instead of using a commercial carrier  Use actuarial firms to set premium rates and third party firms to administer benefits, pay claims, collect utilization data; third parties may provide case management services  Employer advantages: avoid commercial carrier administrative charges, premium taxes; accrue interest on cash reserves, exemption from ERISA (employee retirement and income security act)  ERISA controversies , e.g.: states' interpretation of their responsibilities off or consumers' protections through regulation of employer-sponsored plans; states' loses of premium revenue taxes; prohibition of employees' suits against employer sponsored health plans about insurance coverage decisions  Currently, organizations administering employer based health insurance plans have legal immunity for withholding insurance coverage or for failing to provide necessary care  Government as a source of payment: a system in name only  Early focus: military, government employees, special populations, e.g. native Americans  Now: Medicare, Medicaid, U.S. Public Health Service hospitals, state, local, long-term psychiatric facilities, workers' compensation, public health protection, service grants  Mosaic of reimbursement, vendors/purchaser relationships, matching funds, direct services e.g.  Contrasts with providers, not direct service provision (Medicare, Medicaid, grants)  Federal with state matching funds (Medicaid)  Direct services (veterans affairs)  ACA: federal support programs for uninsured; not a comprehensive, universal "system"  Medicare: Historical Significance  1965: Title XVIII of Social Security Act  All Americans 65+ years. Entitled to health insurance benefits; 20 million entered system in 1965; today 50 million covered  Financed by payroll taxes  Conceded accreditation, administration to private sector- JCAHO…Now "JC"  Hospital payments by local Blue Cross intermediaries  Initial Medicare Components  Part A: mandatory hospital coverage, outpatient diagnostics extended care facilities, home care post-hospitalization; funded by Social Security payroll taxes  Part B: voluntary MD coverage, tests, medical equipment, home health; funded by beneficiary premiums payments matched with federal revenues  Cost sharing: BBA created private health plans, deductibles, co-insurance; medi-gap policies  Part C: managed Care Options of Private Health Plan Enrollment (97)  Part D: Prescription Drug Coverage ('03)  Medicare Cost Containment and Quality Initiatives  Costs rose much more rapidly than expected  By 1976: most cost growth due to added hospital personnel, non-personnel costs and profits  Early amendments added covered services, increased costs; quality concerns escalated through 70s and 80s  Later amendment addressed cost growth reductions and quality improvement  Comprehensive Health Planning Act (1966): organize local health planning  Professional Standards Review Organizations (1972: review Medicare hospital care  Health Systems Agencies (1974): plan for health resources based on population needs (replaced CHP); plans based on local population needs  OBRA 1980, 1981 amendment to reduce hospital lengths of stay, advocating come care  Tax equity and fiscal responsibility Act (TEFRA) 1982: peer review organizations (pro) replaced professional standards review organizations (PSROs), providing clearer costs/quality criteria  2001: renamed PROs  DRGs 1983  Shifter Medicare from retrospective pay  Pre-set hospital care reimbursement based on diagnoses of the International Classification of Disease (ICDA) codes (10,000+, grouped into 500+ categories)  Rewarded efficient care; financially penalized inefficiency  Other insurers followed lead  HIPAA (Kennedy-Kassenbaum Bill)  Reaction to concerns raised in debates about Clinton National Health Security Act e.g.  Ensured continued coverage between employers; prohibited exclusions for pre- existing conditions  Established "portable" Medical Savings Accounts  Balanced Budget Act of 1997  Reduce Medicare spending growth rate over 5 years through direct and indirect cost reductions  Fund state child health insurance program (SCHIP) to enroll 10+ million Medicaid-eligible children  Introduce Medicare Part C- managed care  Combat fraud and abuse  Strong Resistance to the Balance Budge Act(BBA)  Balanced Budget Refinement Act (1999) to restore $17.5 billion in cuts, delay implantation of BBA provisions  Benefits Protection and Improvement Act (2000) increased health plans' and providers; payments  Medicare Cost Containment and Quality Improvement  2001: CMA "quality initiative" to monitor conformance with standards of care  Hospitals, nursing homes, home health care agencies, physicians, other facilities  Medicare Quality Monitoring System:  Monitors quality of care delivered to Medicare fee for-service beneficiaries  2005: "Hospital Compare" website: criteria assessing hospital conformity with evidence-based practice and consumer assessments of hospital care  2008: No reimbursement for treatment of hospital acquired infection of "never happen events" and resulting treatment costs  "never happen events" e.g. catheter- acquired infections, foreign object, other traumas  Medicaid and the SCHIP  1965: Title XIX of Social Security Act  Mandatory joint federal-state program  Shared state support based on state's per capita income  Basic insurance coverage for 62 m low income individuals  19% of personal health service spending; 31% of nursing home care  Federally Mandated Medicaid Services  Inpatient, outpatient hospital services  Physician services  Diagnostic services  Nursing home care for adults  Home health care  Preventive health screening  Pregnancy related and child health services  Family planning services  Medicaid Funding  Personal income tax, corporate and excise taxes  Unlike Medicare  No entitlement  A transfer payment from more affluent to needy individuals  Direct reimbursement to providers, no intermediaries  Medicaid Quality Initiatives  CMA and State Operations develops and implement Medicaid and CHIP quality initiative with state programs  Division of Quality, Evaluation and Health Outcomes provides technical assistance to state for quality improvement initiatives  Quality Assessment Criteria  Prevention and health promotion  Management of acute conditions  Family experience of care  Availability of services  Division of Quality Evaluation and Health Outcomes provides technical assistance to states on quality improvements efforts  Prelude to Passage of the ACA  2008 presidential election: voter concerns on health care second only to Iraq War  Obama promised swift action of health reform  2009-2010 bitter debates, public outcries  Death of Sen. Edward Kennedy lost Senate majority by replacement with Republican  March 2010 ACA passes in Obama's 14th month in office;; unparalleled reforms since Medicare and Medicaid in 45 years earlier  Healthcare Financing Provisions of the ACA  "individual mandate" and insurance expansion: beginning 2014, most Americans must carry health insurance or pay a penalty (tax), except those:  For whom the cost would exceed 8% of income  With income is below federal filing requirement  Religiously exempt  Undocumented immigrants  Incarcerated  Members of Indian tribes  Medicaid expansion: states may expand eligibility levels for non-elderly parents and childless adults with incomes  Health Insurance Exchanges (HIEs)  State must stablish health benefit exchanges (American Health Benefit Exchanges) and create separate exchanges for small employers of up to 100 employees (Small Business Health Options Program) or federal government will establish within states  Web-based, consumer friendly, comparative information in standard formats to facilitate consumer choice on benefits, pricing  For exchange participation, health plans must meet federal requirement for minimum coverage ten essential benefits" 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devises 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care  Penalties, taxes and fees help pay for ACA  Employer health insurance: no requirement to provide but..  Employers of 50+ assessed $2,000/ FT employee if do not offer coverage and at least 1 employee receives a premium credit through ab HIE; if do offer coverage and at least one employee receives a premium credit through HIE assessed lesser of $3,000  Large employers offering coverage must automatically enroll employees into lowest cost plan if employee or does not opt out of coverage  Reimbursement Experimentation  ACA pilot programs conducted over several years experiment with payment reforms with dual goals of slowing spending growth and improving quality  Pilot results will provide information valuable for planning and refine future initiatives with the same goals  Accountable Care Organizations (ACOs)  Groups of providers, suppliers of health care, health-related services, other voluntarily join to coordinate services for Medicare patients  Avoid fragmentation across multiple providers; timely, appropriate care to reduce service duplication, unnecessary hospitalizations and costs based on Medicare per-capita benchmarks  Combine fee-for service with shared savings and bonus payments  Hospital value-based purchasing program (VBP)  CMS began pilot projects in 2003; replicated by private insurers  ACA requires VBP for 3,000+ Medicare participating hospitals; VPB gives incentive payments based on clinical outcomes and patient satisfaction; discourages inappropriate


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