Week 7 Flashcards
T/F a form of reimbursement method is fee for services (FFS)
True
Define the prospective payment system (ex. With Medicare)
Given a specific diagnosis requiring in-patient care, ins will only cover a set amount of days. Once you exceed those days Medicare no longer pays and the hospital has to cover the extra days
What is the reimbursement criterium for fee for service?
Per diagnosis
Per patient
Per year
What are three examples of programs that help measure quality of healthcare plans?
-Healthcare Effectiveness Data and Information Set (HEDIS)
-Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Health Outcomes Survey (HOS)
What is the NCQA HEDIS Measure?
Report as part of the five star quality rating system for Medicare advantage plans
Measures the amount of women over age 67 getting bone mineral density tests performed or begin anti-osteoporosis therapy within 6 months of a fracture
What did CPOMS program do to help women over 65 who sustained a fracture?
Increased ability to receive treatment, (tests, medication) and improved patient use of post-fracture medication
When did Medicare advantage plan ratings become implemented?
What was its purpose?
2012
If scaled bonuses will lead to better quality improvements in Medicare advantage plans
What percentage of rebate do 5 star plans receive? Is the benchmark higher based on star rating? The rebate percentage is the difference between the _______ and _________
73%
Yes
Benchmark, plan bid
Which program implemented the star rating program?
CMS
The new benchmark percentage for a 5 star plan is the original benchmark plus what %?
5%
What is the rebate percentage for a 3 star plan?
67%
The new benchmark percentage for a 3 star plan is the original benchmark plus what %?
3%
What is the Accountable Care Organization (ACO)?
Is it rewarded for positive outcomes and penalized for negative outcomes?
Delivers care to patients and of receiving payments from insurers focused on primary care
Yes
What is the purpose of Oregon CCO Measures?
Determine if CCOs are effective at improving care, access to quality care, removing health disparities, and controlling costs
What does the Pharmacy Quality Alliance (PQA) do?
Use data to implement quality measures
T/F CMS has used PQA measures in star rating for Part B programs
False, part D programs
What is the purpose of the CMS Readmissions Reduction Program?
How much can they reduce reimbursements?
Penalize hospitals for readmissions to incentivize adequate care to prevent readmissions within 30 days
Up to 3%
Define transitions of care
Movement of a patient from one setting of care to another
Define stick
Excessive readmission penalties
Define carrot
Codes used identifying reimbursement for care management and care coordination
What are ICD-10 codes used for?
Codes used to describe conditions
What are CPT codes used for?
Describe procedures medical professionals do
What provider service was implemented to prevent readmissions related to drugs?
Pharmacist spends 30 minutes with pt
How did transitional care billing impact patients and hospitals?
Hospitals are able to bill properly to receive higher reimbursement from insurance thus reducing cost billed to patient
What is the quadruple aim?
- Improve population health
- Reduce cost of care
- Enhance patient experience
- Improve care team well-being
Define scope of practice
Everything a healthcare practitioner is permitted to do under their license
Define provider status
Classification allowing a healthcare professional to be reimbursed for services allowed by scope of practice
Define credentialing (provider)
Verification of experience and ability to provide care that allows a healthcare professional to be reimbursed
T/F a pharmacist’s scope of practice is defined by the state they’re practicing in
True
What was the House Bill 2397?
What was it composed of?
What is its purpose?
Formed the Public Health and Formulary Advisory Committee consisting of two physicians, two nurse practitioners, and three pharmacists
Makes recommendations to board of pharmacy to determine what pharmacists can prescribe and dispense
What did the pharmacy and medically underserved areas enhancement act do?
Allow pharmacist services under Medicare part B be reimbursable in underserved populations
T/F pharmacists are considered providers on a federal level
False
