Payment for Outcomes Flashcards
What is payment for outcomes?
pay for end results instead of procedures
What is functional status?
pain levels, return to physical activities, return to work, etc…
Who is more valuable in a FFS world?
those who can produce the most billable units
Who is more valuable in an outcomes based world?
those who can produce better outcomes (process, clinical, functional)
Value Equation
Outcomes (variable)/Total Cost
What are the components of cost/resources?
clinical staff, administrative staff, equipment and supplies, facility
What are the characteristics of a FFS (volume) based market?
centered on provider, incentive to do more, longer patient stay, create reason for patient to return, no incentive for quality of care or outcomes
What are the characteristics of an outcomes (value) based market?
patient centered; incentivizes outcomes and quality of care; don’t want to add procedures or increase LOS
What type of payment form is Medicare trying to shift toward?
one that is primarily alternative pay methods and FFS that is linked to quality of care
What is Pay for Reporting vs. Pay for Performance?
P4R: the provider is paid or penalized for reporting DATA, but not for the outcome
P4P: provider is paid or penalized based on the outcomes achieved
What is the IMPACT Act of 2014?
Improving Medicare Post-Acute Care Transformation Act;
What does the IMPACT Act require?
SNF, IRF, LTCH to report on quality measures
What is the goal of the IMPACT Act?
to advance Post-Acute Care (payment based on needs; payment aligned with care)
As of October 2016 what must PAC’s report on?
Medicare Spending Par Beneficiary
Discharge to Community
Hospitalization rates of potentially preventable readmissions
What is the purpose of the continuity assessment and record evaluation?
is designed to be a uniform assessment tool for all setting vs current state of affairs; to ensure that all assessment tools have common elements
Condition (body region) vs performance based functional status
Condition: measures that quantify functional status for a specific condition or body region (Oswestry, DASH)
Performance: measures that quantify function specific to a task or tasks (TUG, 6MW)
Quality Assessment vs Assurance
Assessment: refers to measurement of quality compared to some goal or standard
Assurance: continuous quality improvement
How can we achieve quality assurance?
measure performance, set future goals, implement process changes, measure results
What is effectiveness research?
looks are care from both efficaciousness and cost standpoint; compares one form of treatment to another
5 components of customer satisfaction?
- communication of treatment plan
- consistency of clinicians
- respect for patient autonomy and patient
- time clinician spends with patient
- clinician understands patients history and condition
What is HCAHPS?
Hospital Consumer Assessment of Healthcare Providers and Systems
What happens if G-codes are not on a claim for Part B services?
the entire claim is NOT PAID
What are the functional limitation categories?
- mobility: walking and moving around
- changing and maintaining body position
- carrying, moving and handling objects
- self care
When are G-codes to be reported?
initial evaluation; once every 10 treatment days; formal re-evaluation; discharge
How are PT’s to measure functional limitation?
with valid and reliable assessment tools or objective measures
How is a PT to determine severity?
with valid and reliable assessment tools or objective measures
What is the CH modifier used for?
to reflect a zero percent impairment when the therapy services being furnished are not intended to treat
What are the various severity modifiers?
CH: 0% CI: up to 20% CJ: 20-40% CK: 40-60% CL: 60-80% CM: 80-99% CN: 100%
