Intro UHS Quiz 2

Incentives for ACOs?

Mix of retrospective and prospective This mix of prospective and retrospective payments might lead ACOs to reduce unnecessary spending (via prospective) but with moderation (via retrospective) retrospective alone leads to over-use, but prospective alone probably leads to under-use

What has recently changed in regard to medicare balance billing?

More recently, Medicare has increased the payment to a nonparticipating physician from 80% to 95%. But now, there's a new upper limit of 15% on what physicians can balance bill patients. This so-called limiting charge is now 109.25%, which essentially equals an additional 15% above 95%.

Managed care contracts for physicians during the rise of managed care:

One main takeaway from these data is that the vast majority of physicians have some form of managed care contract. For instance, in the period 2004 to 2005, only 11.5% of physicians reported having no managed care contract physicians have multiple managed care contracts. It's not like they just have one contract with one plan. Average of 13. Average of 13 contracts might be a few PPO contracts with several different insurers, a few capitated HMO contracts with several other insurers and probably even other contracts with private Medicare plans and private Medicaid plans

Pie-chart from McKinsey shows:

Only 30% of exchange plans are broad. So many plans had narrow networks that McKinsey had to distinguish between regular old narrow networks and so-called ultra-narrow networks Broad: less than 30% of large hospitals participating Ultra-narrow: less than 70% not participating

What motivates a physicians behavior?

Patients well being Increasing their own income

How medicare used to pay physicians?

(UCR) usual customary and reasonable fee-for-service payment Medicare program would determine what the average fees were for physician services in a geographic market, and set the Medicare reimbursement level at that average, or UCR, amount

Concerns with ACOs?

--With patients free to choose any provider, how coordinated can care be? (some care will be within the ACO's providers, while other care will be outside that ACO's providers) --How will hospitals and physicians actually share the savings generated? (have to come together and agree on how they're going to split these rewards and penalties.) --Antitrust issues regarding provider consolidation's effect on competition? (concern that merging these hospitals and physicians together will give them too much combined market power and, in turn, charge higher prices to private payers or perhaps provide lower quality to public payers.)

Risk Adjustment

-Govt. transfers money from insurers with relatively healthy enrollees to insurers with relatively sick enrollees. Individual and small group plans -Tries to get rid of incentive to attract only healthy people Transferring money across private plans: 2010 ACA's state-based insurance exchanges (Topic #3) 1993 Health Security Act's "managed competition" from Bill Clinton (more in Topic #12) Making payments from public insurers: Medicare to private plans: Part C (Medicare Advantage), Part D drug plans (Topic #4) Medicaid to private Medicaid MCOs/HMOs (Topic #5) Medicare's MSSP payments to ACOs and CPC+ payments to PCPs (here in Topic #6)

How many medicare beneficiaries are in ACOs?

5.3 million Medicare beneficiaries-- about 10% of the Medicare population-- are in an ACO

Initial rollout of ACO shared savings program?

ACOs were initially permitted to select two-sided or one-sided models two-sided model has both rewards and penalties, while the one-sided model only has rewards with no penalties rewards from the two-sided model were larger than the rewards in the one-sided model after a preliminary rule from CMS was criticized by providers, the final rule's rewards increased, penalties decreased, and the quality metrics softened

5 hospital level adjustments to the IPPS/DRG calculation:

Account for costs across geographic area (NYC vs OK) IME: (indirect medical expense) costs of medical resident training. by # of residents per bed DSH: (disproportionate share) low payment rates for medicaid/ the uninsured. HRR: (Hospital readmissions reduction) penalty for excessively high 30-day readmission rates. HVBP: (Hospital value-based purchasing) modification to the payment based on an aggregate quality score

What does managed care refer to?

Anything that isn't FFS High and low deductible PPOs (so HDHPs), HMOs and POS

How do ACOs incorporate prospective and retrospective elements?

Award/penalty is based on whether actual FFS spending was lower or higher than a prospective risk-adjusted target level of medicare spending Actual FFS spending is the sum of the retrospective DRG and RBRVS payments still made to hospitals and physicians.

What are a providers incentives?

Because the payment is a fixed amount regardless of the amount of care actually provided, there is then some incentive for providers to want to reduce patient utilization. This arises because any increase in services provided to patients has to come out of the provider's bottom line.

MACRA 2015 (Medicare Access and CHIP Reauthorization Act)

Bipartisan Re-authorized CHIP funding through 2018 Repealed the SGR, or Sustainable Growth Rate, formula for physician payment and replaced it with some quality-oriented modifications so Physicians will pick one of two ways to be paid by Medicare starting 2019: Merit-Based Incentive Payment System (MIPS): FFS via RBRVS fee schedule with a new adjustment either upwards or downwards based on composite quality score Advanced Alternative Payment Model (APM): payments take on risk via outcomes: two-sided ACO, CPC+ (next slide), other specialties (ESRD, cancer, joint replacement)

Medicare payments to physicians, how have participation and assignment rates changed over time?

Both have increased from 1990 to 2011

Medicare payments to physicians

CMS sets a physician fee schedule While hospitals have no choice, Physicians can participate in the medicare program by accepting the assigned fee from CMS for all patients. For those that don't participate universally in the physician fee schedule, they can choose on a patient by patient basis whether to accept that CMS-assigned fee, or do something called balance billing, where they charge the patient a bit more than what Medicare pays.

HMO

Can use IPA or Staff model Compared to PPOs, are generally characterized by even smaller provider networks and frequently use primary care physicians as gatekeepers to first discern whether a patient can proceed to see a specialist. The goal of these two things is to further reduce utilization.

Why are quality metrics for readmission rate and cancer screenings used to determine the reward or penalty?

Concern that some ACOs would try to reduce spending by skimping on care rather than trying to wring out inefficiencies. The hope, then, is that these quality metrics would flag any skimping.

IPPS/DRG explanation

Continued effect of the 1984 implementation of Medicare's inpatient perspective payment system of fixed DRG payments. As discussed in the prior lecture, Medicare's movement away from cost-based reimbursement towards IPPS/DRGs yielded quite large reductions in length of stay among the Medicare population.

How does a patient view this as a more restrictive managed care plan?

Could see any doctor they wanted under the old system. Now, under a PPO, they have a more limited choice of doctors, but they pay a lower premium.

Big Picture of private health insurance plans:

Currently over 75% of private health insurance plans are the PPOs

Effect of 2010 ACA's payment reduction on medicare spending?

Decreasing the growth rate (the increases in base rate/market basket updates) has relatively small effects in the short term, but pretty large effects in the long term, due to the savings being compounded. So less spending - almost $100 billion dollars saved in 2019 providers are concerned with how they'll be able to cope with these payment reductions off into the future.

How did PPS/DRG affect skilled nursing facilities (SNFs) and home health services?

Evidence that SNFs and home health service utilization went up due to decrease in hospital (LOS) Still, overall healthcare spending fell. No evidence that quality of care decreased.

Quicker and sicker

Get a patient out quicker and with a sicker classification w/MCC or CC to get a higher payment.

How do ACA silver plans with similar cost sharing as other silver plans attract consumer looking for low premiums?

Get lower premiums by setting up a narrower network

Independent Practice Association (IPA) - HMO

HMO's enter into capitated contracts with different physicians. Some of these physicians might have their own solo practice, while other physicians would be part of a group practice

Staff Model - HMO

HMOs employ the physicians and pay them salaries. This is called a staff model HMO, and the classic example is Kaiser Permanente.

Sample DRGs

Higher weight yields higher payment and corresponds to a more costly service. Final column shows LOS

Lecture 7

Hospital Issues

PPO

Insurer says, these $100 fees under fee-for-service are resulting in really high premiums. Insurer sets up low cost sharing for patients when they visit in-network providers and high cost sharing for patients when they visit out of network providers. This could be a $5 co-pay for the former, but a $25 co-pay for the latter. Patients are probably going to be more likely to want to go in-network.

Retrospective payment

Hospital was reimbursed for all the actual costs that the hospital incurred. The hospital would then simply submit the claim to Medicare and be reimbursed retrospectively.

The problem with retrospective payments?

Hospitals faced incentives to increase patient utilization because they would be reimbursed for that increased utilization. Similar to the problems we discussed earlier with fee-for-service reimbursement from private health insurers.

Effect of PPS/DRGs on hospital length of stay? (LOS)

Implementation of DRG/PPS system lowered the annual days of hospital care per beneficiary. The reason why the total number of days fell was because the length of stay for any given admission fell.

Explanation for these trends?

Implementation of Medicare's IPPS/DRGs in 1984 Similar transition towards managed care in private health insurance in 1990s Newer less-invasive technologies to both shorten LOS for certain inpatient surgeries and shift other inpatient surgeries to the outpatient setting

How has the number of ACO applications changed since 2012?

Increasing

Managed care contracts for hospitals during the rise of managed care:

Inner-city and urban hospitals has the highest % of revenues coming from capitated contracts.

What is a providers incentive under a PPO?

Insurer is setting up a distinction between in-network and out-of-network. And is no longer going to pay a $100 fee. Instead they offer to pay the provider an $80 fee. Most physicians are going to want to ensure that they have adequate volume and accept that lower $80 fee and be listed in that PPO directory of patients as an in-network physician with a lower co-pay.

Reasoning for a bundled payment:

Let's review how payments currently work for, say, a knee replacement. We have a DRG payment to a hospital, but then separate RBRVS payments to the physicians for the operation during the admission-- one payment to the orthopedic surgeon, and another payment to the anesthesiologist. There's probably also going to be more RBRVS payments to the surgeon for post-operative follow-up visits after the discharge. Moreover, separate rehab providers would get separate payments, as well. There's also the possibility that there could be an additional DRG payment and RBRVS payments if that patient had to be readmitted to the hospital weeks after the initial discharge due to complications. The overarching goal behind a bundled payment is for the Medicare program to make just one payment to all these providers for all of this care. That one payment would be tailored to the longer episode of care and include all pre-operative, operative, and post-operative care for up to 90 days. As a result, there would be one payment made to hospitals and physicians together. But this also poses a challenge because these providers ultimately have to come together to make some kind of agreement about how to split up this payment received from CMS.

How are ACOs paid?

Look at graphic from NEJM ACO receives a reward or penalty based on whether actual fee-for-service spending was lower or higher than a benchmark amount This amount is a prospective risk-adjusted target level of Medicare spending per beneficiary in the ACO. actual benchmark amount is the sum of the retrospective DRG and RBRVS payments still made to hospitals and physicians the reward or penalty is a fraction of this difference between the target and the actual spending, but up to a cap for both the reward and the penalty. This fraction is also determined by how well the ACO meets certain quality metrics, such as a low readmission rate and a high rate of cancer screenings.

Co-morbidities MCC or CC

Major complications/co-morbidities Categorization in DRGs for multiple diseases. Allows for higher medicare payments.

Types of hospitals:

Majority are community hospitals Remainder (12%) are federal hospitals, psychiatric hospitals, long-term care hospitals, and prison hospitals

Variation in Medicaid fees across states

Medicaid pays on average about one third less than Medicare to physicians. These relatively low Medicaid rates may mean that physicians are relatively less likely to see Medicaid patients relative to Medicare or privately insured patients percent of physicians accepting Medicaid patients is positively associated with the fee, which probably isn't very surprising in and of itself. But it demonstrates the access problems many Medicaid enrollees face because their states pay relatively low rates to providers.

From APM, other payments geared towards specialists?

Payment models geared towards specialists. These include a new payment model approach for the treatment of end-stage renal disease, a new payment approach for cancer care, and a new payment approach for joint replacement.

IPPS/DRG calculation:

Payment= base rate X DRG weight X Adjustments base rate: converts DRG weight to a dollar amount, gets adjusted upward each year to account for inflation *base rate and DRG rate are the same in every US hospital

APM

Physician takes on some level of risk related to the patient's utilization. This can be the two-sided Medicare Shared Savings Program discussed earlier, where the physician would be part of an ACO, or it could be the CPC+ Program for primary care physicians, other specialties (ESRD, cancer, joint replacement)

MIPS

Physicians continue to be paid by the fee-for-service RBRVS fee schedule, but now with the relatively new value-based modifier adjustment, either upwards or downwards, based on composite quality scores for the physician.

What about PPS/DRG caused a dramatic change in hospital LOS?

Previously, cost-based reimbursement had little incentive to control costs. In fact, there were incentives to increase the length of stay and provide more services, because the hospital would get reimbursed. Fixed prospective payment nature of the DRG changed that, because the payment would then be the same, regardless of whether additional, low-value, inefficient services were provided or not. Instead, there's an incentive to be efficient and no longer keep patients around longer to rack up higher bills. The same argument I made about the incentives under capitation versus fee-for-service reimbursement definitely applies here.

1992 medicare reform to address UCR:

Primary goal was to determine the "true cost" of a physician's service (next slide) Secondary goal was to reduce balance billing through a 109.25% "limiting charge" (i.e., 15% cap on balance billing after paying them 95% of RBRVS). Policymakers were concerned that patients were paying too much for balance billing. But main concern was prevailing fees being inequitable between primary care and specialty care. Changed from UCR rates to RBRVS rates, with the overarching goal of this payment reform trying to determine the "true cost" of actually providing a physician service.

What were the primary and secondary problems with UCR?

Primary: UCR fees prevailing in the market may have actually been unfair or inequitable for primary care versus specialty care physicians. Specialist were getting paid more than primary care physicians. Still is a problem. Secondary: Many physicians weren't accepting the CMS-assigned fee. They were balance billing. This means a physician could ask for a fee higher than the UCR fee. Higher payment would get split between Medicare and a out-of-pocket payment made by the Medicare beneficiary. Historically, Medicare would reimburse nonparticipating physicians 80% of the UCR charge. So, for this example of a physician wanting to charge $120 when the UCR was $100, Medicare would pay that physician $80, and then the physician would balance bill the patient for an additional $40.

Lecture 6

Private and Public Reimbursement to Providers

Fee for service payment (FFS)

Private insurer's form of reimbursement to provider Providers are paid a fee for each service they supply to a patient. fee-for-service insurance involves some negotiation of the fee between insurers and physicians

How does the amount that medicare pays to hospitals compare to the amount private health insurers and medicaid pay?

Private insurers pay on average a lot more than Medicare. Medicaid pays on average, about the same as Medicare, again shown in black. Medicaid used to pay a bit less than Medicare, but in recent years, Medicaid is paying slightly more than Medicare. Medicare on average pays below 100% of costs. This makes hospitals say medicare isn't paying enough to cover their costs. Inverse relationship between public payments and private payments. More on this cost-shifting phenomenon at the end of the hospital lecture.

Capitation

Providers are given a pre-determined, fixed amount. And in return, agree to provide all the necessary services that their patients may require Involves a negotiation between the insurer and physician over the so-called per member per month amount (PMPM). Essentially, the amount the insurer pays to the provider every month, to ensure that the provider supplies that care to the patients

What is the positive-spin on capitation payments?

Providers have an incentive to keep their patients healthy, so they won't need more services and cost more money. Physician is rewarded financially for trying to do the right thing. Emphasizes PREVENTATIVE healthcare for the patient.

RUC (RVS update committee)

RVUs are updated by something called the RUC, or RVS Update Committee. The RUC is comprised of different specialty representatives within the AMA. These recommendations from the RUC then get evaluated for approval by CMS.

Where does the shared saving bonus come from?

Shared Savings Bonus of $500, which equals the 50% split of the $1,000 in savings from essentially having 1 fewer visit of 9 compared to 10.

Inpatient Prospective Payment System (IPPS)

Since 1984 Medicare has used an IPPS Fixed price per hospital admission, with that payment varying by diagnosis, where the fixed perspective nature of the payment was key Patients are assigned to one of 745 diagnosis-related groups, or DRGs

How did the 2010 ACA effect the base rate/market basket updates?

Specified smaller increases to the base rate by essentially assuming that the hospitals can be more productive in their use of these inputs. imagine expecting a 3% increase in your salary, but instead being told that you'll get a 2.75% increase instead, because you shouldn't have to work as hard this year. The effect of this payment update is pretty small at first, but it compounds over time.

Where did the RVUs come from?

Study by Harvard. Those study results were used to extrapolate them to over 7,000 services.

How does this work?

Suppose that under the status quo: Medicare FFS price is $1,000 The profit margin is 4% (i.e., $960 cost and $40 profit) Quantity is 10 services per year Thus, the total profit is $400 per patient per year (= $40 x 10) Suppose that under the Shared Savings Program: Medicare FFS price is still $1,000 Quantity falls to 9 services per year (somehow) The portion of the profit from FFS is $360 per patient per year (= $40 x 9) The additional Shared Savings Bonus is $500 (= 0.5 x $1,000 x (10 - 9)). Total profit is $860 per patient per year (= $360 + $500)

Distribution of types of health plans over time:

Survey of employer health benefits FFS is more generous PPO is more restrictive Shift from late 80s to 2006: fewer FFS and more PPOs Then, in 2006 HDHP enter the field and grow. They are essentially a PPO with a high-deductible and HSA

Bundled payments

The 2010 ACA authorized a voluntary pilot program for bundled payments to begin in 2013 HHS Secretary selected ten conditions to receive a bundled payment The bundled payment would cover preoperative, operative, and post-operative care for 90 days and span multiple providers Requires that hospitals and physicians come together to define sharing model because the bundled payment would span a 90-day period and not result in any additional payments from CMS for readmissions during this period of time, well, this ought to incentivize providers essentially avoid such READMISSIONS

Accountable Care Organization (ACO)

The 2010 ACA created the Medicare Shared Savings program Accountable Care Organizations (ACOs) can form to voluntarily contract with CMS Ideally, a collection of primary care physicians, specialists, and hospitals - all connected through electronic medical records At least 5,000 beneficiaries allocated to the ACO, determined retroactively by which primary care physicians (PCPs) the patients went to most for their care

How does the size of the PPO network affect the price of premiums?

The more narrow the network, the lower premiums are

Overview of hospital trends:

The number of hospitals has decreased The number of hospital beds per capita has decreased The number of hospital admissions per capita has either decreased or held steady: decreased until mid 1990s, then steady until late 2000s, and then decreased Hospital length of stay (LOS) has also either decreased or held steady: decreased until early 2000s and then held steady since then

2015 MACRA

There was a 21% payment cut scheduled for April 2015. Medicare Access and CHIP Reauthorization Act, or MACRA, repealed the SGR and strengthened the value-based modifier (VM) program described above

How are HMOs and POS similar?

They both use capitiation

VM (value-based modifier)

This program was introduced in 2015, and makes an upwards or downwards adjustment to the payment based on a composite score for quality and costs.

Physicians FFS vs Capitation?

Three variants for physicians under FFS: -physician creates his or her own list of charges from which insurers negotiate discounts. -insurers determine allowable fees with little, if any, negotiation -physicians and insurers negotiate mark-ups over Medicare's RBRVS schedule Under Capitation: for physicians under the capitation approach, this is more commonly used for primary care physicians than for specialists. And capitation is more commonly used for larger group practices than for smaller group practices.

Comprehensive Primary Care Plus or CPC+ Medical Home Program

Took effect Jan 1, 2017 in 20 regions CMS partners with commercial plans and state Medicaid programs to allow primary care physicians to voluntarily choose "Track 1" or "Track 2" (or maintain status quo of standard RBRVS): Track 1: Supplement current FFS payments with care management fees averaging $15/month (ranging from $6/month to $30/month based on patient risk quartiles), and incentive payments of $2.50 PBPM if meeting performance metrics for quality Track 2: Replace FFS with hybrid of fixed PBPM and lower FFS E&M fees; PBPM at $28/month (ranging from $9/month to $33/month for quartiles and $100 for top 10%), and incentive payments of $4 PBPM if meeting performance metrics for quality

What do HRR and HVBP do?

Try to incentivize hospitals to improve the quality of care.

Would a physician under capitation encourage a follow-up visit? How is this different from FFS?

Under capitation here, that physician might discourage follow-up visits. Under fee-for-service we agreed that the physician might encourage a follow-up visit in a month.

Hospitals FFS vs. Capitation?

Under fee-for-service approach, they actually create something called their charge master list of all of the potential billable items they can provide within the hospital. Insurers and hospitals don't actually have a negotiation over each individual service. Instead, the insurer will generally just accept the variation across all the services as the base. But then the insurers generally negotiate one universal discount off of all the items in this charge master list. Under the capitation approach, this is now quite rare, but it was used occasionally by HMOs during the 1990s and 2000s.

Point of service (POS)

Variant of an HMO, which actually offers the option for individuals to go outside of the HMO's network when they desire. A patient that is enrolled in a point-of-service plan could go to a doctor that's part of the HMO's narrow network and pay a small co-payment. Or, that patient could instead go to a physician outside of the HMO network, at the point of wanting a particular service provided, but pay significantly more. Less restrictive but more expensive

With PPS and DRGs do hospitals face an incentive to reduce the number of admissions?

While hospitals face improved incentives related to the care provided during an admission, hospitals still have no real incentive to reduce the number of admissions under this prospective payment system. More admissions still results in more revenue.

Why did the number of DRGs increase from 538 to 745 in 2007?

attempt to allow for more variation in procedure severity tied to a patient's extent of complications

CF from 1997 - 2015

conversion factor was determined by something called the Sustainable Growth Rate (SGR) formula, which led to a lot of angst among physicians and policymakers alike

RVU practice experience

cost of employing nurses, renting office space, and buying equipment

RVU malpractice

cost of purchasing malpractice insurance

Relation of decline in number of hospital beds to health care spending?

decline in the share of health care spending occurring in the hospital. Recall that in 1975, about 44% of all medical care spending was on hospitals, whereas in 2014, that fraction had shrunk to 35

GPCI

each of these three RVUs (work, malpractice, practice experience) gets its own GPCI adjustment, where GPCI, or Gypsy, stands for Geographic Price Cost Index. This accounts for variation across geographic locations in how much these things cost.

What was the problem with SGR

eventually led to negative updates rather than smaller positive ones. That is, the actual spending was so high relative to the target level of spending that the fee had to be cut in order to reach that target next year. Part of this was caused by higher volume of services that increased actual spending, while part of this was caused by lower targets of spending resulting from lower growth in GDP. Higher growth in volume (and slowed growth in GDP) generated payment cuts But Congressional "doc fixes" delayed these payment cuts 17 times from 2002-2015 (e.g., there was a 21% payment cut scheduled for April 2015)

Growth of physician-owned speciality hospitals

grew considerably in the 1990s and early 2000s, until a moratorium on new ones was implemented in 2007 most common specialty hospitals are in the areas of orthopedic and cardiac care. These physician owned specialty hospitals received a fair amount of scrutiny during the time leading up to that moratorium, because of concerns that they are profiting off of the Medicare DRG payment system.

CF (conversion factor)

he way in which RVUs get converted to dollars. As of 2015, this is pretty straightforward and gets updated each year to account for simple inflation.

Why would health providers voluntarily agree to be paid less money?

hope that while their revenue decreases, their costs incurred decrease even more

public hospitals

hospitals that are owned and operated by a city or county. Public hospitals tend to serve the role of providing uncompensated care to low-income, uninsured individuals.

SGR

in 1997, Congress passed a law, specifically the Balanced Budget Act, which identified an SGR, or sustainable growth rate, for Medicare Part B spending. It essentially established a target for Medicare Part B spending based on underlying price inputs and GDP growth. Value for CF was chosen so expected spending equaled the SGR target spending if actual spending exceeded the target for spending, then the fee schedules annual conversion factor update would be lowered a bit to get back onto the target.

Incentives physicians face in FFS?

incentives of the patient and the physician pretty much align to increase utilization. patient wants more services and utilization. physician wants to help and gets paid more by providing services a physician receiving fee-for-service stands to lose financially if they are successful in keeping their patients healthy So long as we're not talking about certain services which could potentially worsen health, or have really bad side effects.

RVU work

includes the costs of training, but also the time and effort a physician undertakes to provide a service. For a primary care physician, this is mainly cognitive. For specialists, particularly a surgeon, this might be the skill one uses with his or her hands

Market basket updates

increase in the base rate for inflation that occurs each year, based on inflation for the input prices Goal here is to have the payment go up to account for increases in input prices as measured by a hypothetical market basket of goods

What component of the RBRVS system mostly accounted for the decrease in the gap between what PCP and specialists were paid?

new work component of the RBRVS system. Under the prior UCR system, these specialists were paid fees that were arguably too high relative to the amount of actual work that really went into providing those physician services. And likewise, primary care physicians were paid fees that were arguably too low compared to the work that went into them, at least as measured by these relative value units within the RBRVS payment system.

Three types of community hospitals:

nonprofit, for-profit, and public hospitals Majority are nonprofit, then for-profit and public

Change in number of hospital beds over time?

noticeable decline in the number of beds per capita during this time period, as there were 2.47 beds for every 1,000 people in 2014, down considerably from 4.36 beds for every 1,000 people in 1975 Most of this decline occurred between 1985 to about 2000,

How has the number of hospital admissions changed over time?

number of hospital admissions per capita has either decreased or held steady. Specifically, they decreased slightly until the mid 1990s, and then were steady until the late 2000s, and then have decreased since.

Supplier induced demand

physicians act as agents in directing the care that the patients receive. For instance, a physician saying, please come back and see me in a month, when it's really not necessary.

What is a managed care modification to FFS called?

preferred provider organization, or PPO

Changes in distribution of hospital type over time?

proportion of nonprofit hospitals has been relatively steady at about 60%. There has been a decrease in the proportion of hospitals that are public hospitals over time, while there has been an increase in the proportion of hospitals that are for-profit, investor-owned hospitals. mix of several things: closures, openings, and conversions. There have been more closures than openings, and these conversions have mainly gone in one of two directions, out of the many potential permutations. They've mostly been public hospitals being converted to either nonprofit or for-profit hospitals, and also some nonprofit hospitals being converted to for-profit hospitals. You can also note here that there's been a gradual decrease in the number of hospitals over time.

What did the 1992 reform essentially do?

switching from UCR to RBRVS in 1992 essentially narrowed the gap between primary care payment rates and specialty care payment rates. important to stress specialists were paid more than PCPs prior to RBRVS, and specialists are still paid more than PCs following RBRVS. It's just that RBRVS narrowed the difference.

Method for calculating the RBRVS payment:

three main resource components measured using something called an RVU, or relative value unit. . These three resource components are work, practice expense, and malpractice And the GPCI Adjustments: VM & CFt Payment = RVUs X GPCIs X VM X CFt