411. midterm

CDC

Centers for Disease Control and Prevention

The earliest health care regulations were primarily created at the ____________ level.

State

Medicaid is funded

jointly by the federal and state governments.

Moral Hazard

lack of incentive to guard against risk where one is protected from its consequences. ; Examples of moral hazard in healthcare: 1) Providers set very expensive prices because insurance will pay. 2) Patients covered by Medicaid overuse certain services because they do not have to pay for them (there is no Medicaid copayment, premium, or deductible). 3) Drug companies set very expensive prices because insurance will pay.

HEAT

(Brings together hhs, federal, and local law enforcement); Health Care Fraud Prevention and Enforcement Action Team ; uses actual people; Florida is important b/c there are alot HEAT offices since many old people live and retire there

Categories that is required to prove charitable status

(failure to comply can bring fines, sanctions, and eventually revocation of tax exempt status) 1.Provide a community benefit, this could be financially driven or not. Activities like uncompensated care, free clinics, educational activities would be included. IRS defines 3% of billing as uncompensated, to qualify as charitable. a. 3% can be through charitable services office that is already set up or through ER with EMTALA (uncompensated billing 2. Not seek to influence legislation, this means no campaign donations (ex: why preachers should not take sides in the church) 3. May not "inure to the benefit" of individuals, meaning that the hospital itself can not financially incentivize private doctors to perform. Hospitals can simply provide a space for doctors to practice.

Data Analytics

(goal is to understand programs and create flagging mechanisms) -reveal high-risk activities, in particular medical services, and provider types. Example: Durable medical equipment (like scooters) -identify specific outlier health care providers that bill differently than other similar health care providers in a statistically significant way -ACA directs an increase in funds for systems that detect and prevent fraudulent billing -Example: CMS Integrated Data Repository (IDR).

The Liaison Committee on Medical Education (LCME)

, a non profit organization, accredits medical schools in the United States and Canada.

Federalism

-An overarching national government is responsible for issues that affect the entire country (based on the Constitution), and smaller subdivisions govern issues of local concern.

Hospital Consumer Assessment of Healthcare Providers and Systems

-HCAHPS or H-Caps, -Survey instrument used to measure patients' perspective of hospitals., -Patients are surveyed between 48 hours and six weeks after discharge., -27 categories including communication with doctors and nurses, cleanliness and quietness, - Reimbursements tied to HCAHPS and results reported on Hospital Compare.

Moral Hazard

-Making decisions when you don't feel the true pain/burden of those decisions -Change in perspective of risk associated with decisions -when people do something b/c they don't necessarily understand what they're giving up ex. Litter

National Practitioner Data Bank (NPDB);Reporting

-Reporting certain adverse information is required by law, fosters quality in health care, and assists the health care community in making sound employment, credentialing, and licensing decisions. -collects information and maintains reports on the following: A. Medical malpractice payments, federal and state licensure and certification actions, adverse clinical privileges actions, adverse professional society membership actions, health care-related criminal convictions and civil judgment, etc..

Fraud Safe Harbor

-The "safe harbor" regulations describe various payment and business practices that, although they potentially implicate the Federal anti-kickback statute, are not treated as offenses under the statute; There must be a demonstrated benefit to the patient, and no financial benefit to the providers.

National Practitioner Data Bank (NPDB); Privacy

-The general public does not have access -Drugs and alcohol reporting are confidential in order to encourage treatment. -All proceeding involve due process, and require time and recourses -Final decisions reported on State website

Medicare reimbursement as regulation

-Through Medicare, the federal government administers the largest single healthcare reimbursement program in the country. -19% of national health spending comes from Medicare payments -More than 30 percent of all physician services rendered in the United States are reimbursed through Medicare. -Through Clinical oversight, Medicare has a strong impact on physician quality in the United States. -To qualify to receive payment, physicians must enroll in the Program by demonstrating basic qualifications.(Including absence of legal proceedings and Medicare fraud).

Continuous Quality Improvement (CQI)

-aim to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness -Involve systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups -Look for problems ND solutions over long term

Regulatory Agency; Health Resources and Services Administration (HRSA)

1. Component of DHHS. 2. Charged with increasing access to health care services for the nation's most vulnerable populations in rural and urban regions. 3. Training of health professionals. 4. Compensates individuals harmed by vaccination. 5. Maintains databases that protect against health care malpractice, waste, fraud and abuse (National Practitioner Data Bank)

Hospital Compare (overseen by CMS Hospital Quality Initiative)

1. Data is gathered from the Hospital Consumer Assessment of Healthcare Providers and Systems (H-caps) survey consisting of 27 questions https://alwaysculture.com/hcahps-questions 1. a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. 2. allows consumers to select multiple hospitals and directly compare performance measure information related to heart attack, heart failure, pneumonia, surgery and other conditions. 3. Patients are surveyed between 48 hours and six weeks after discharge. 4. Reimbursements are tied to HCAHPS - so not all hospitals receive the same reimbursement. Many hospitals may not encourage patient feedback for the sake of improvement - because they could risk receiving a poor patient evaluation and therefore a reduction in reimbursements.

Regulation through private insurance

1. Practitioners must work with insurance companies to receive reimbursement. 2. Control can intend to reduce costs or improve quality. 3. HMOs, especially, can exert significant control over practice through reimbursement. a. Specific rate for doctors= stability in finances but hmo dictate how the doctors run their practice. b. Will shoulder weight of disciplinary action to hide the doctors name= lessen negative media attention. c. Standardizes quality and maybe just the amount of money

Private roles in regulating practitioners and providers

1. Private organizations provide integral oversight, often through self-regulation. 2. Private organizations provide credentials for professionals and entities beyond the state requirements. 3. Private organizations also have the ability to penalize and discipline physicians for misconduct. a. Have to know abt conduct and can actually shield their physicians from governmental boards that might penalize the conduct 4. Private organizations also accredit post graduate medical training and develop licensing exams. 5. The regulatory structure of healthcare in America represents a form of public-private partnership. 6. Private accrediting and certifying organizations, composed of professionals who work in the field, inject technical expertise and set standards. 7. State and federal agencies attempt to maintain safety, quality, and equity in the field and provide coordination.

State roles in regulating practitioners and providers; Medical Licensing

1. States issue new licenses. a . applicants document their education, post-graduate training and pass required licensing examination. 2. States renew licenses b. based on absence of disciplinary proceedings and completion of continuing medical education. 3. Each state sets its own requirements for initial medical licensure and renewal. State licensure is a legal requirement for the practice of medicine

We spent

700 billion dollars in medicare last year and lost 70 billion to fraud and abuse in health care

National Practitioner Data Bank (NPDB);

A database that protects against health care malpractice, waste, fraud and abuse, by logging all known cases of practitioners who are found guilty of malpractice. B. is an electronic information repository created by Congress in 1986 as part of the Health Care Quality Improvement Act. B. It contains information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers. c. Federal law specifies the types of actions reported to the NPDB, who submits the reports, and who queries to obtain copies of the reports. d. maintained/managed by an office within the Department of Health and Human Services called the Health Resources and Services Administration. (HRSA)

Adverse Selection

A high-risk person benefits more from insurance, so is more likely to purchase it (a young person will want the cheapest insurance if they are healthy)

Global Budget

A revenue budget for the hospital covering all of its services, set at the beginning of the year. It is not based on volume; as a result, it supports needed delivery improvements

AHRQ

Agency for Healthcare Research and Quality

Health care as a business is somewhat unique because

All of the above are ways health care as a business is unique.; Users often times do not pay the actual prices of good and services, Third parties (such as insurance companies and government programs) artificially limit the market., Government programs can determine which services are available,

Sherman Act of 1890

Antitrust Regulations; (identifies the behavior; not really enforcement) earliest, first attempt to federally limit trusts and monopolies but with limited success

Federal Trade Commission Act 1914,

Antitrust Regulations; established a federal agency (FTC) to regulate interstate trade to ensure a competitive environment, as well as other issues like false advertising; Commandment to Sherman act

Clayton Act 1914,

Antitrust Regulations; strengthened the Sherman Act, especially with regard to business mergers that created anti-competitive environments

Medical education as a regulating force

Bureau of Health Workforce ( part of Health Resources and Services Administration office within the DHHS) addresses the nationwide shortage of primary health care providers through scholarship, loan and loan repayment programs.

Department of Health and Human Services HHS agencies

CMS - Centers for Medicare & Medicaid Services -Administers Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the ACA -Writes and administers legislations pertaining to Medicare, Medicaid, CHIP and the ACA -Designs and manages Prospective Payment Systems (PPSs) for various providers

CMMI

Center for Medicare and Medicaid Innovation -A center within CMS; -Created by the ACA in 2010; -Tasked with testing innovative payment and health care delivery models that aim to achieve better care for patients while reducing costs; Examples Accountable Care Organizations (ACOs) (Success) Advanced Primary Care Practices or Medical Homes (Failed)

is not legally required for a physician to practice, but has become an informal expectation over the years.

Certification

Certification in private roles

Certification in not a LEGAL requirement of practice, buthas become an EXPECTED one for most health care professionals.; Board certification is an essential credential for physicians holding themselves out as having expertise in a specialty. It is also necessary for membership as a specialist on most hospital staffs and for inclusion in insurance provider networks.; There are twenty-four medical boards, ranging from American Board of Internal Medicine to the American Board of Emergency Medicine. Their activities are coordinated by the American Board of medical Specialties (ABMS).; each individual state has their own licensing that's required; certifications isn't but its expected

FTC is not coming down on business mergers

Change in politics change the way things become enforced

Recovery Audit Program

Conduct post payment review of claims to detect improper underpayments and overpayments.; Between 2005 and 2008 recovery auditors recovered over $900 million in overpayments and nearly $38 million in underpayments. (use billing codes), 2016 $3.8 bil recovered from all Medicare fraud detection; in legitimate providers interest to cooperate because they can get money back as well

The Rulemaking Process

Congress passes a law to address an economic or public need. Congress does not think through the details of execution.; Currently, the appropriate agency creates regulations to implement the law. The agency is responsible for "filling in the details."; Regulations can enable legislation if the regulations created tell the public how the agency will administer and enforce the regulation.; After the regulation is written, the agency must post the regulation in the Federal Register for public comment.; Proposed new regulations must be posted a minimum of 30 days before the regulation can take effect; usually longer; There is a review and comment period that the agencies use to address concerns expressed by the public; After the final comment period, the regulation becomes a final rule; Congress and the President can review the regulation before it is

Externalities

Consequence that occurs as the result of a transaction, which impacts a third party who did not intend to be involved in the process. ; may be positive or negative; ex. higher tax rates from ACA implementation. It may be unwanted, but it's not unintended!

In the 1970s, this system of coding was developed to help contain costs related to hospital reimbursement.

DRGs

Detecting fraud and abuse

Data Analytics , Recovery Audit Program, HEAT,

Quality in Healthcare

Despite having the most expensive health care system, the United States ranks last overall among 11 industrialized countries on measures of health system quality, efficiency, and equity.

How is quality in healthcare achieved

Develop, track, measure, analyze quality measures, Look for areas of improvement, Plan and implement improvement projects, Monitor progress

The third largest program in terms of federal costs for healthcare is

Employer tax subsidie

False Claims Act (FCA)

Enacted in 1863 as a consequence of suppliers defrauding the Union Army during the Civil War. ; Imposes civil liability on any person or organization who knowingly submits a false or fraudulent claim to the federal government. ; Example: In 2013, Beth Israel Deaconess Medical Center payed $5.3 Million to the government. ; Beth Israel improperly admitted Medicare patients and then billed for inpatient stays for services that should have been provided in an outpatient setting.

Fraud and Abuse laws

False Claims Act (FCA), Anti-Kickback Statute, Physician Self-Referral Law (Stark Law), Exclusion Statute

FDA

Food and Drug Administration

Unintended consequences of EMTALA:

Free Riders (allows for an increase in users in the system that are not paying into the system), Moral Hazard (since the cost is not felt, the emergency service is more likely to be overused), Emergency Room closures (because of the first two, some hospitals have felt financial strain and closed their emergency rooms. This contradicts the goal of EMTALA- providing more access to emergency departments)

Goals for HEAT

Gather resources across the government., Prevent waste, fraud, and abuse in the Medicare and Medicaid programs., Highlight best practices by providers and organizations dedicated to ending waste, fraud, and abuse in Medicare.

Policy

Guidelines to help an organization meet its objectives; Created by many types of organizations; Such as: smoke free campus policy ; Policy can include regulations, but not all policies are backed with legal action

Office of Inspector General (OIG)

HHS and other agencies involved in fighting fraud; Agency within HHS; Responsible for identifying and combating waste, fraud, and abuse in various HHS programs, including Medicare and Medicaid.

Department of Justice (DOJ)

HHS and other agencies involved in fighting fraud; Executive level department; Partners with the OIG and other federal, state, and local law enforcement offices.

Federal Trade Commission (FTC)

HHS and other agencies involved in fighting fraud; agency (not part of the executive department); Prevents business practices that are anticompetitive or deceptive or unfair to consumers.

Federal Bureau of Investigations (FBI)

HHS and other agencies involved in fighting fraud; part of DOJ; Partners with the OIG and other federal, state, and local law enforcement offices.

The National Committee for Quality Assurance initiated the accrediation of

HMOs

National Practitioner Data Bank (NPDB);Problems

HMOs regularly fail to report sanctions and malpractice cases are often settled with the physician removed as a named defendant to avoid reporting obligation. 2. Reporting entities may see reports for their own physicians, and physicians may review their own data and add short comments. 3. According to a recent report, NPDB has approximately 50,000 incomplete files.

Charitable Status Hospital

Hospitals have historically been not for profit. For profit hospitals are a relatively new phenomenon, gaining ground only as recently as the 1990s (clinton was president). Most are still not for profit, and enjoy tax-exempt status

this organization provides the foundation for the regulation of tax exempt status in health care.

IRS

Federal Tax Subsidy

IRS ruling in 1954 Health insurance benefits are not considered wages, and are tax exempt -Medicare costs were $750 billion in 2018 (17% fed budget), Medicaid was $597 billion (9% fed budget). Only Social Security (24%) and Defense (31%) were greater. -Health Insurance tax subsidy was $280 billion in 2018 -ACA subsidy for health insurance projected $57 billion in 2020 (total of approximately $337 billion in lost tax revenue)

Does U.S. federalism enhance or impede the development of social programs, particularly for health care?

Impedes it because there are different standards and eligibility requirements across states, which is hard to navigate as a policymaker and a consumer of healthcare.

Free riders

Individuals or entities in a transaction that do not pay for goods or services that the majority of users do pay for. -Ex:downloading music illegally, using somebody else Netflix

What is health care fraud

Knowingly submitting false statements or misrepresenting material facts to obtain a government health care payment.; Knowingly soliciting, paying, or accepting remuneration to induce or reward referrals for items or services reimbursed by government health care programs.; Making prohibited referrals for certain designated health services

US Values

Liberty (freedom of choice), Fairness (equity), Quality, Responsibility, Progress/ Innovation, Privacy, Integrity, State rights over federal government

C

Medicare Advantage (optional - not part of standard Medicare);Managed care, voluntary

Long Term Care, Medicaid spend down

Medicare covers 100 days of LTC after hospital admission. Anything else is only covered by Medicaid.; Duly- eligible, eligible for Medicare due to age and Medicaid due to income; Restrictions on the Medicaid spend down

Examples of health care fraud

Medicare fraud extends beyond professionals in the medical field. -Corporations can also commit Medicare Fraud. a. Pharmaceutical companies misbranding drugs. -Knowingly billing for services not furnished or supplies not provided. -Knowingly altering claim forms, medical records, or receipts to receive a higher payment -Billing for unnecessary medical services -Misusing codes on a claim

Why is Medicare Fraud such a problem?

Medicare fraud is the most common type of fraud in government health care billings. ; Fraud drains billions of dollars from the Medicare Program each year, putting beneficiaries' health and welfare at risk by: 1. Exposing them to unnecessary services 2. Taking money away from care 3. Increasing costs; Fraud jeopardizes quality and threatens the integrity of the program.

Whatever Medicare decides to do sets the standard for the healthcare industry.

Medicare uses schemes like diagnosis-related groups (DRGs) and resource-based relative value scale (RBRVS) to determine reimbursement rates. As a result, the insurance industry as a whole has also turned to these methods.

Medicaid:

Minimum standards and eligibility set at the Federal level, Funding shared between Federal and State, Program administered in the State, often through Private organizations

State/Private/Federal partnerships

NPDB and Medicad

NCQA;Regulation through private insurance:

National Committee for Quality Assurance not for profit accrediting and certifying body for private insurance providers, including those participating in the health care exchanges. a. Regulates insurances and their standards

NIH

National Institute of Health

Which agency maintains primary enforcement authority of HIPAA?

OCR

OIG

Office of Inspector General

Accountable Care Organizations (ACOs)

One of the innovative programs introduced by CMMI; ACOs are groups of providers and suppliers of services (e.g., hospitals, physicians) that agree to work together to coordinate care for the Fee-For-Service patients.; ACOs are financially rewarded if they show cost savings and penalized if they incur costs above a set benchmark.

B

Outpatient coverage;Medical, physician coverage, Automatic with social security benefits, voluntary otherwise

Anti-Kickback Statute

Part of the ACA amendment to the False Claims Act; Makes it a criminal offense to offer, pay, solicit, or receive money (kickback) to induce or reward referrals of items or services reimbursable by the government. ; Kickbacks include: Cash for referrals, Excessive compensation, Free rent or below fair-market value rent

The main function of the National Practitioner Data Bank (NPDB) is to record

Physician disciplinary action reports

Organizations for Quality

Private: The Joint Commission and National Committee for Quality Assurance and public: Agency for Healthcare Research and Quality

NPDB:

Provider education and certification at Private level, with licensure at State., Action taken in the State, Action recorded at the Federal level, Action reported to the public in the State

The first goal of health care regulation, historically, was to ensure

Quality

Oregon was unique in it's use of _________________ to contain costs in the state Medicaid program

Rationing

Which of the following is a way that CMS works to reduce fraud in health care?

Scrutinize billing to eliminate "kickbacks" through referals

Physician Self-Referral Law (Stark Law)

Self-referral is the practice of referring a patient to a medical facility in which the physician has a financial interest. ; Stark Law Prohibits a physician from making such referrals. ; Stark Law discourages overutilization of services and encourages competition. ; can't refer patients to yourself or family members = because it limits competitive between other providers in the area and it is a monopoly

The licensing of medical professionals is a duty of the

State Government

Federalism in Healthcare

State and federal government collectively coordinate public programs. (ex. Medicaid) This relationship can become a source of tension. (Medicaid example: The federal government has tried a number of change strategies for Medicaid. Democrats and Republicans alike have protested these changes. )

SAMHSA

Substance Abuse and Mental Health Services Administration

The federal government regulates education and training needed to enter the workforce.

The Bureau of Health Workforce ( part of HRSA) addresses the nationwide shortage of primary health care providers through scholarship, loan and loan repayment programs.

COBRA

The Consolidated Omnibus Budget Reconciliation Act (COBRA) gave individuals the ability to extend insurance coverage for 18 months post employment termination, but with full responsibility of the cost of the premium. The Centers for Medicare and Medicaid Services (CMS) is the authorizing agency of COBRA. ` a. Continued coverage of employer health plan for 18 months post separation b. individual pays both the employee and employer contributions for premiums. This can end up being quite costly c. Continued coverage for spouse for 36 months post divorce or death (again with full cost of premium)

EMTALA

The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay. The goal is to provide more access to emergency departments. This includes women in labor. Once a patient is stabilized the hospital is not under obligation to continue to provide in patient treatment, and may transfer the patient to another hospital. Since its enactment in 1986 has remained an unfunded mandate (there is no Congressional (or other) funding put in place to cover costs incurred through the regulation).

HIPAA coverage

The Health Insurance Portability and Accountability Act 1996 1)Guarantees coverage for preexisting conditions if continuous coverage has previously been kept (HIPAA Title 1) and 2) Provides for privacy and security of personal health information (HIPAA Title 2); 2013 Amendment HITECH Act, strengthens privacy and incentives for the adoption of electronic health records (EHRs); helps you keep your insurance if you lose your job before you get another one; title 1

CMS Integrated Data Repository (IDR).

The IDR creates an integrated data environment that contains data from Medicare and Medicaid claims, beneficiaries, providers, and other data.; The IDR does the following: Provides greater information sharing, Provides broader and easier access, Provides increased security and privacy, Provides a unified data repository for reporting and analytics

The Joint Commission

The Joint Commission on Accreditation of Healthcare Organizations , Sends auditors to survey facilities for compliance with quality standards and grants then "accredited" status if they pass., JCAHO approval is needed for reimbursement under Medicare and Medicaid and under most insurance plans., JCAHO surveys focus on such factors as construction, equipment, appropriate protocols, procedures, and clinical outcomes., no legal enforcement, has to have funding to have enforcement , Accredit hospital facilities such as safe and practicing good health care, pros- no outsider making important decisions

Opportunity Cost

The cost incurred by making a choice from several mutually exclusive options. Opportunity cost is what is given up by not choosing the next most desirable alternative

Medicaid basics;

The federal government set minimum standards and eligibility but the states can expand coverage from there. Some states are generous and others are not in their coverage.

Licensing

USMLE, ACGME, LCME

Exclusion Statute

Under the Exclusion Statue, OIG is legally required to exclude from participation in all government health care programs individuals and entities convicted of: -Medicare or Medicaid fraud; Patient abuse or neglect. -Felony convictions for other health-care-related fraud. -Felony convictions for unlawful manufacture, distribution, prescription, or dispensing of controlled substances -For certain offenses, the OIG must impose mandatory exclusion. -Mandatory exclusions stay in effect for a minimum of 5 years. -Excluded physicians may not bill for treating Medicare and Medicaid patients, nor may their services be billed indirectly through an employer or a group practice.

Example of quality in healthcare Plan-Do-Check-Act (PDCA)

Used for:Implementing change, Problem Solving, Continuous Improvement, Developing a design. -PLAN the change' then evaluate the outcome. -DO: Conduct a pilot test of the change -CHECK: Gather data about the pilot change to ensure success. -ACT: Implement the change on a broader scale and continue to monitor

Part DDonut Hole

When purchasing prescription drugs Medicare pays a portion and the patient pays a portion until they meet their deductible. After the deductible has been met, Medicare will pay additional costs. The portion that the patient is responsible for is know as the donut hole. ; The ACA has provisions to limit this donut hole and make prescriptions drugs more affordable for those on Medicare.

Free Market

When the prices of goods and services are set freely by buyers and sellers, without government (or other) intervention.

McCarran-Ferguson (Antitrust in Healthcare);

a United States federal law that exempts the business of insurance from most federal regulation, including federal antitrust laws to a limited extent.; The regulation of insurance companies is placed in states' control. This has been controversial, as it limits competition.; The McCarran-Ferguson act contributes to a lack of competition in US; republicans always want to get rid of this free markets support this; limited the Federal authority of anti-trust laws, and left it in the jurisdiction of the States

State roles in regulating practitioners and providers; Discipline

a. Boards also have the responsibility of determining when a physician's professional conduct or ability to practice medicine warrants modification, suspension or revocation. 1. Disciplinary sanctions imposed by a board are reported to the Federation of State Medical Boards (FSMB), state and local medical and osteopathic societies, the American Medical Association, the American Osteopathic Association, the National Practitioner Data Bank and appropriate government agencies. 2. malpractice, sexual misconduct, rely on somebody to come/bring it in, doctors still can practice while under review

State roles in regulating practitioners and providers;Issues

a. Despite coordination attempts through the National Practitioner Data Bank and FSMB, coordination is still fragmented, and as a result, physicians with discipline records can still sometimes slip past enforcement by applying for licensure in a different state. 1. individuals are actually typing the information in manually so there are a lot if incomplete records b/c some are not accurately checked. b. A state medical board is usually composed of physicians. This reliance on professional peers raises the concern that state licensure is a form of self-regulation. 1. conflict of interest b/c they are doing things that can come back to them since physicians are policing themselves

Proposed rules

alerts interested entities/persons and allows for a public comment period

Prospective Payment Systems

any system that attempts to standardize payments based on some type of scale or algorithm -Medicare uses DRGs, RBRVS, even CPT (Keep in mind that CPT codes are managed by the AMA and the other two by CMS. CPT codes can be used to determine reimbursement, but are not as directly linked to costs as the other two.) -International Classification of Disease (ICD) codes are andInternational system similar to DRGs, created and maintained by the WHO.(The current version is ICD-10) -MedPAC (Medicare Payment Advisory Commission) is an agency (part of the legislative branch) that advises Congress on Medicare related issues (including payment reforms)

"act"

at the end is usually passed by congress

Medicare is funded and administered

by the federal government.

FBI

estimates that 3-10% of Medicare billings are fraudulent.(dollars)

The ACA

expands Medicaid coverage to include 138% of the poverty income level.

According to Field, the most common conflict that occurs in health care regulation in the US is the clash between

external regulation and free market discipline

In 2013,

federal health care fraud prevention and enforcement efforts recovered a record $4.3 billion in taxpayer dollars, the highest annual amount ever recovered.

Oligopoly

few sellers, often working together

Before the 1970s, practitioners and providers were not given much consideration with regard to anti-trust law because

health care was not operating in a for profit manner

HMO

health maintenance organization; A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency; No choice abt what, how, where you can get your services;Paying less to purchase product where doctor work for insurance company

The IOM (Academies of Medicine) has recommended that quality improvements in the hospital setting are best accomplished by

identifying and correcting systems in an organization, rather than punishing specific individuals.

Collusive, anti-competitive environments are

illegal, but competitive success that dominates a market is not

Regulations

implement, interpret, and specify how the law functions.

The dollars lost to Medicare fraud and abuse

increase the strain on the Medicare Trust Fund

Medicaid payments

increased to 100% of Medicare levels to primary care providers in 2013 and 2014 ; Expired in 2015; 15 states used state funds to retain higher rates

Medicare, A

inpatient, hospital coverage; automatic enrollment

Regulation

is a general statement issued by an agency, board, or commission that has the force and effect of law. Congress often grants agencies the authority to issue regulations. a. Laws and directives that outline the operation of an entity b. Typically conducted by the government c. Such as: proof of immunization before registration

The Accreditation Council for Graduate Medical Education (ACGME

is a private, non-profit organization that reviews and accredits graduate medical education (residency programs).

State roles in regulating practitioners and providers; Certificate of Need (CON) program

is a review process aimed at restraining health care facility costs and allowing coordinated planning of new services and construction. 2. 36 states require CON approval, under which hospitals are permitted to spend funds for new health care services, facilities, and equipment only if a need has been identifies for the region. 3. Example: if a plan foresaw the need for additional hospital beds in a region, then a hospital could add them. If it did not, then no addition of beds by any hospital would be permitted.

United States Medical Licensing Examination (USMLE)

is a standard licensing exam that physicians (M.D.) must pass.

Medicaid basics; Eligible

low income, pregnant women, disabled, children(CHIP or SCHIP (they are the same thing)

NPDB issues:

not accessible to the public, practitioners that are under investigation do not show up in the NPDB - it is only after a guilty verdict is reached that they appear, HMOs use their name in NPDB reporting documents, instead of the actual practitioner., there are <50,000 incomplete files

EPA

not in hhs; Environmental Protection Agency

OSHA

not in hhs; Occupational Safety and Health Administration

USDA

not in hhs; US Department of Agriculture

Monopsony

one buyer, many seller

Monopoly

one seller, many buyers

Trust

organizational structure where a number of individuals or businesses pool their resources to control some type of financial market; ex. "robin bearings" in history ; controls industries such as oil, coal, and railroads

Experience Rating

people at different risks are charged different risks; Method of determining the premium based on the insured's own past loss experience.

Capitation

per person per month; a payment arrangement for health care service providers such as physicians or nurse practitioners. It pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care

Regulators

perform functions of the three branches of government; legislation, execution, and adjudication. They are responsible both for "filling in the details" and for making sure organizations are obeying these details. It is currently very manual, time consuming work to audit organizations for regulation adherence.

PPO-

preferred provider org; preferred provider organization; A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan's network. You can use doctors, hospitals, and providers outside of the network for an additional cost.; Don't need referrals like hmo; A lot more choice = more broad and expensive; High deductibles-pay less

D

prescription Drug coverage; voluntary (optional - not part of standard Medicare)

Free Market Healthcare

prices for healthcare goods and services are set freely by agreement between patients and health care providers

hospital accreditation is usually accomplished through

private organizations

Final rules

published in Federal Register

The court case National Federation of Independent Business v. Sebelius (2012)

ruled that the federal government cannot dictate states to expand their Medicaid coverage - since states are involved in raising funds for Medicaid.; Supreme Court rules congress does not have authority to expand Medicaid; 19 states decide not expand Medicaid

Laws

statues that originate and are passed in Congress (Fed and State), and signed by the President (Fed) or Governor (State).; things that are written out

5 different hmos

that organized through private insurance companies

Health care is primarily regulated at the federal level by

the Department of Health and human services

Interim rules

to be immediately implemented; may become final after a comment period

Other Health-related Agencies (that are NOT in HHS)

usda, epa, osha,

Community Rating

when everybody in insurance plan pays the same price; A rule that prevents health insurers from varying premiums within a geographic area based on age, gender, health status or other factors; same insurance rate for everyone

POS

will never be a right answer; A point-of-service plan (POS) is a type of managed care plan that is a hybrid of HMO and PPO plans. Like an HMO, participants designate an in-network physician to be their primary care provider. But like a PPO, patients may go outside of the provider network for health care services. When patients venture out of the network, they'll have to pay most of the cost, unless the primary care provider has made a referral to the out-of-network provider. Then the medical plan will pick up the tab.