Payment Legislation

Question 1

TEFRA

Answer 1

• Tax Equity & Fiscal Responsibility Act of 1982

- established first prospective payment system (PPS) for acute hospital care

Question 2

What law created DRGs?

Answer 2

-TEFRA

Question 3

What law created first UR bodies for Medicare

Answer 3

• TEFRA

- called Peer Review Organizations (PROs)

Question 4

BBA

Answer 4

• Balanced Budged Act of 1997

- Established PPS in all post-acute settings

Question 5

BBA most Targeted _____ & _____

Answer 5

• SNF—>per diem

- Home Health—->case rate

Question 6

BBA on other care facilities

Answer 6

• Outpatient Hospitals (APCs)—>case rate
• OP Rehab & Physicians (MPFS)—->fee schedule
• IRF—->case rate
• LTACH—->case rate

Question 7

BBA created______

Answer 7

• Medicare Part C

- medicare replacement plans

Question 8

APC

Answer 8

-ambulatory patient classifications

Question 9

MPFS

Answer 9

-medicare physician fee schedule

Question 10

Goal of BBA

Answer 10

• to save $115 billion over 5 years

- saved 2-3x that amount

Question 11

MMA

Answer 11

• Medicare modernization act of 2003

- established medicare part D (prescription drugs)

Question 12

Larges overhaul of medicare

Answer 12

-MMA

Question 13

PPACA

Answer 13

• patient protection and affordable care act of 2010
• (Obamacare, ACA, Health Reform Law)
• changes from 2010-2020

Question 14

2010 Opportunities

Answer 14

• dependent children on parent’s insurance til 26
• prevention coverage for new insurers
• independent payment advisory board
• website for people to find affordable health insurance
• no lifetime coverage limits

Question 15

2010 Threats

Answer 15

• charity pt charges same as for insured (uninsured people must pay for total billed care)
• independent payment advisory board

Question 16

IPAB

Answer 16

• independent payment advisory board
• composed of 15 members (6 yr terms)
• developing detailed proposals for methods of slowing increase of medicare costs
• outcome depends on who’s on the board

Question 17

2011 Opportunities

Answer 17

• medical loss ratio requirements (insurance must spend 80-85% of their premium $ on pt care or pay it back to beneficiaries)
• hospital value based purchasing (HVBP)
• center for medicare/medicaid innovation

Question 18

2011 Threats

Answer 18

• medical loss ratio requirements
• HVBP
• center for M/M innovation

Question 19

HVBP

Answer 19

• Hospital value based purchasing
• “Pay for performance/outcomes”
• portion of payment is tied to process and outcome measures
• reward good care, decrease payment for poor care

Question 20

M/M

Answer 20

-medicare/medicaid

Question 21

Goal of HVBP

Answer 21

-change provider behavior to increase outcomes and customer satisfaction scores

Question 22

2012 Opportunities

Answer 22

-medicare shared savings accountable care organization program begins

Question 23

ACO

Answer 23

• accountable care organization

- health system model provides and manage with pt, the continuum of care across institutional settings

Question 24

2012 Threats

Answer 24

• requirements for care coordination and readmissions

- medicaid bundled payment demonstration begins

Question 25

2013 Opportunities

Answer 25

• deadline for establishing voluntary medicare bundled payment system for hospitals
• increase in medicare hospital payrool tax to 235% from 1.45% for high earners

Question 26

2013 Threats

Answer 26

-

Question 27

Bundled Payments

Answer 27

• medicare pilot launch july 2013

- try to reduce medicare spending

Question 28

4 Methods of Bundled Payment

Answer 28

• retrospective acute care hospital stay only
• retrospective acute care hospital stay plus post-acute care for 30, 60, 90 days
• retrospective post-acute care only
• acute care hospital stay only