In December 2011, Texas Health and Human Services Commission (HHSC) received federal approval of a Medicaid Section 1115(a) Demonstration Waiver, entitled “Texas Healthcare Transformation and Quality Improvement Program,” for the period starting with December 12, 2011 through September 20, 2016. The main objective of the 1115 Waiver is to improve access to and quality of health care by expanding Medicaid managed care programs and promoting health care delivery system reforms while containing cost growth. Specifically, the Waiver created two new pools of funding—Uncompensated Care (UC) and Delivery System Redesign and Innovation Payment (DSRIP) pools—by redirecting funds that were available under the old Upper Payment Limit (UPL) payment methodology. DSRIP funding is used to offer financial incentives to health care providers that develop and implement projects aimed at improving how care is delivered to low-income populations. Specifically, the providers (often referred to as the “performing providers” or “performers”) propose and execute projects like programs, strategies, and investments designed to enhance access to health care, quality of health care, cost-effectiveness of services, and health of the patients and families served. Based on the completion of their project milestones, they receive DSRIP payments. Milestones are objectives of the projects, comprised of metrics indicating their progress, and the providers must achieve the milestones in order to claim the associated incentive funds. DSRIP projects are spanned over five demonstration years, DY1 through DY5. And each demonstration year has separate project milestones, metrics, and incentive funds. If providers fail to fulfill certain milestones, the fund... ... middle of paper ... ...h outcome domain, and the providers choose the ones they want to focus on that will best reflect the success of their projects. For each of these DSRIP activities, providers must also select suitable milestone and metric options from the DSRIP menu. In addition to receiving payments for completing milestones associated with Category 1 and 2 projects, providers receive separate incentive payments for completing milestones associated with Category 3. Category 4 requires all hospital-based providers to use the same reporting measures. For example, providers must report data related to potentially preventable admissions, readmissions and complications, patient-centered health care and emergency department utilization. Hospitals that are exempt from the Category 4 requirements pursuant to PFM Protocol Sections 11.e. and 11.f do not have to report on these measures.
Phase I addressed basic statutory definitions, general prohibitions, and explanations of what constitutes a financial relationship between a physician and a health care entities providing DHS’. Phase II deals with the regulatory exceptions, reporting requirements, and public comments pertaining to Phase I. Finally, Phase III Final Regulations were published in September of 2007, and largely addressed comments made after publication of the Phase II rules and regulations. It also reduced some of the regulations placed upon the healthcare industry by explaining and modifying some of the exceptions related to financial relationships between physicians and DHS entities where there is minimal risk of abuse to the patient, Medicare or Medicaid.
With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).
Under the Social Security Act, it is required that hospitals report quality measures for a set of 10 indicators. If hospitals do not report quality measures to CMS there is a reduction in payments. In the hospital readmission area of investigation, OIG reviews Medicare claims in hospital readmission cases to identify trends and oversights of cases. Readmissions are cases in which the beneficiary is readmitted to the hospital less than 31 days after being discharged from the hospital. Hospitals are only entitled to one diagnosed-related group payment if there is a same-day readmission for symptoms related to prior hospital stay. Quality improvement organizations are required to review hospital readmission cases also this is to see if standard of care are met. For coded conditions as present on admission, it is required for acute hospital to report these diagnoses on Medicare claims. The OIG will review Medicare claims for types of facility or providers most frequently transferring patients to hospital
According to the Encyclopedia of Education, the program was first started in 1690. It became a way to deal with criminal court cases involving child abuse. Two years later the states and municipalities identified care for abused and neglected children as the responsibility of local government and private institutions. It was not until 1825, that the states enacted laws that gave social workers the right to remove children that had been neglected from their parents and their homes. The program has had several names since then. In 1835, it was the National Federation of Child Rescue, later in 1853; they founded the Children’s Aid Society which was a response to the problem of orphaned and abandoned children. In 1874, the “case of Mary Ellen” became the first child abuse case to be criminally prosecuted. In 1930, the Social Security addressed issues of abuse and neglect, which provided funding for intervention for “neglected and dependent children in danger of becoming delinquent.” Effective February 1, 2004, the name of the Texas Department of Protective and Regulatory Services was changed to the Texas Department of Family and Protective Services (Guthrie, Heyneman & Braxton, 2002). The Texas Department of Family and Protective Services, is a state agency that is run by the state government.
Pay-for-performance (P4P) is the compensation representation that compensates healthcare contributors for accomplishing pre-authorized objectives for the delivery of quality health care assistance by economic incentives. P4P is increasingly put into practice in the healthcare structure to support quality enhancements in healthcare systems. Thus, pay-for-performance can be seen as a means of attaching financial incentives to the main objectives of clinical care. However, reimbursement is a managed care payment by a third party to a beneficiary, hospital or other health care providers for services rendered to an insured or beneficiary. This paper discusses how reimbursement can be affected by the pay-for-performance approach and how system cost reductions impact the quality and efficiency of healthcare. In addition, it also addresses how pay-for-performance affects different healthcare providers and their customers. Finally, there will also be a discussion on the effects pay-for-performance will have on the future of healthcare.
Sommers, B. D., & Epstein, A. M. (2010). Medicaid expansion—the soft underbelly of health care reform. New England Journal of Medicine
Crowley, Ryan A., and William Golden. "Health Policy Basics: Medicaid Expansion." Annals Of Internal Medicine 160.6 (2014): 423-426. Academic Search Complete. Web. 18 Apr. 2014.
The notice must also tell you how to exercise your rights and how to file a complaint with your health care provider and with the DHHS Office of Civil Rights. HIPAA Requires Accounting for Disclosure Details. You have the right to know who has accessed your health records for the prior six years, however there are several exceptions to the accounting requirement. Accounting is not required when records are disclosed to persons who see your records for treatment, payment, and health care operations. These individuals do not need to be listed in the disclosure log.
The author also believes that the Medicaid expansion extends beyond the politics, and has an aim to impact the life, health, and financial stability for the state and individuals. Medicaid expansion can be beneficial to many countries that have a large proportion of low-income people that are uninsured and or with disabilities. This can aid in saving the state money because much of the cost is provided and covered by the federal government, that encourages healthier behavior and results to a reduction in chronic disease due to lower health care costs. Although Texas opted out in adopting the expansion, legislators should decide on the advantage and disadvantage of participating in the Medicaid expansion to improve the welfare of the state. The expansion of Medicaid coverage will give low-income pregnant women the chance to reduce the rate in infant mortality and provide an opportunity for those that were unable to get coverage to be
Medicaid is a broken system that is largely failing to serve its beneficiary’s needs. Despite its chronic failures to deliver quality health care, Medicaid is seemingly running up a gigantic tab for tax payers (Frogue, 2003). Medicaid’s budget woes are secondary to its insignificant structure, leaving its beneficiaries with limited choices, when arranging for their own health care. Instead, regulations are set in order to drive costs down; instead of allowing Medicaid beneficiaries free rein to choose whom they will seek care from (Frogue, 2003)
Obamacare, otherwise known as the ACA (Aaffordable Ccare Aact), will significantly change major aspects of theour health care system here in America. Without a doubt, our current system has its issues, especially the costs related to health insurance and medical care were rising far too quickly (Pattron, 2013). Some may believe chainsaws have been called in to fix issues that could possibly be fixed with a mere scalpel. In spite of everything, typically, our health care system contained many more strengths than weaknesses. Considering the number of patients that have come from various countries to seek medical care in the U.S., the entire world sincerely agrees. However, despite the many strengths, changes have and will arrive that will affect all who seek medical care in the U.S.
“Medicare and the New Health Care Law — What it Means for You.” (2010). Medicare Publications, http://www.medicare.gov/Publications/Pubs/pdf/11467.pdf
In 2015, the Centers for Medicaid and Medicare Services (CMS) released the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which implements the final rule which offers financial incentives for Medicare clinicians to deliver high-quality patient centered care.5 Essentially, taking the time to learn the patient’s goals and treatment preferences allows for the patient to walk away from the medical treatment or service feeling understood and cared for by the provider.4 Thus, resulting in a better, more comprehensive plan of care. Policy makers are hopeful that the new incentive-based payment system will accelerate improvement efforts.
Reforming the health care delivery system to progress the quality and value of care is indispensable to addressing the ever-increasing costs, poor quality, and increasing numbers of Americans without health insurance coverage. What is more, reforms should improve access to the right care at the right time in the right setting. They should keep people healthy and prevent common, preventable impediments of illnesses to the greatest extent possible. Thoughtfully assembled reforms would support greater access to health-improving care, in contrast to the current system, which encourages more tests, procedures, and treatments that are either
Reson took a new approach to manage their projects better. They gave priority to 6 important factors which need to be worked upon to achieve their objectives.