Payment Legislation Flashcards
TEFRA
- Tax Equity & Fiscal Responsibility Act of 1982
- established first prospective payment system (PPS) for acute hospital care
What law created DRGs?
-TEFRA
What law created first UR bodies for Medicare
- TEFRA
- called Peer Review Organizations (PROs)
BBA
- Balanced Budged Act of 1997
- Established PPS in all post-acute settings
BBA most Targeted _____ & _____
- SNF—>per diem
- Home Health—->case rate
BBA on other care facilities
- Outpatient Hospitals (APCs)—>case rate
- OP Rehab & Physicians (MPFS)—->fee schedule
- IRF—->case rate
- LTACH—->case rate
BBA created______
- Medicare Part C
- medicare replacement plans
APC
-ambulatory patient classifications
MPFS
-medicare physician fee schedule
Goal of BBA
- to save $115 billion over 5 years
- saved 2-3x that amount
MMA
- Medicare modernization act of 2003
- established medicare part D (prescription drugs)
Larges overhaul of medicare
-MMA
PPACA
- patient protection and affordable care act of 2010
- (Obamacare, ACA, Health Reform Law)
- changes from 2010-2020
2010 Opportunities
- 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
2010 Threats
- charity pt charges same as for insured (uninsured people must pay for total billed care)
- independent payment advisory board
IPAB
- 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
2011 Opportunities
- 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
2011 Threats
- medical loss ratio requirements
- HVBP
- center for M/M innovation
HVBP
- 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
M/M
-medicare/medicaid
Goal of HVBP
-change provider behavior to increase outcomes and customer satisfaction scores
2012 Opportunities
-medicare shared savings accountable care organization program begins
ACO
- accountable care organization
- health system model provides and manage with pt, the continuum of care across institutional settings
2012 Threats
- requirements for care coordination and readmissions
- medicaid bundled payment demonstration begins
2013 Opportunities
- deadline for establishing voluntary medicare bundled payment system for hospitals
- increase in medicare hospital payrool tax to 235% from 1.45% for high earners
2013 Threats
-
Bundled Payments
- medicare pilot launch july 2013
- try to reduce medicare spending
4 Methods of Bundled Payment
- 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
