An Overview of the Hospital Value-Based Purchasing Program0

Section 3001(a) of the Affordable Care Act (ACA) includes a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) Program.

Under the VBP Program, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses under VBP Program. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement. … Read more →

Administrative, Children's Health, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Non Clinical, Regulatory, Technology

Understanding the Minimum Medical Loss Ratio0

Under the Affordable Care Act (ACA), in 2012 consumers anticipate the return of an estimated $1 billion in rebates from health insurance issuers (issuers).

Commonly referred to as the “80/20 provision” of the ACA, the regulations governing Medical Loss Ratio (MLR) rebates appear in Title 45 of the Code of Federal Regulations, Part 158. The minimum MLR (45 C.F.R. § 158.210) applies as follows:

  • Large group market:  For all policies issued in this market during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 85% (subject to adjustments as discussed below).
  • Small group market and individual market:  For all policies issued in these markets during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 80% (also subject to certain adjustments).

States, however, retain the option to set a higher MLR, provided the State ensures adequate participation by health insurance issuers, competition in that State’s health insurance market, and value for consumers to ensure that premiums are used for clinical services and quality improvements.  (45 C.F.R. § 158.211.)

While there are specific requirements relating to the aggregation of data in calculating an issuer’s MLR (45 C.F.R. § 158.220), generally an issuer’s MLR is: The ratio of the issuer’s incurred claims plus the issuer’s expenditures for activities that improve health care quality (the numerator) to the issuer’s premium revenue, less any Federal and State taxes as well as licensing and regulatory fees (the denominator). … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, News, Non Clinical, Regulatory

The War on Health Care0

This article first appeared in the Daily Journal on June 15, 2012.

Throughout history, America’s methods of providing health care have always had an understated yet powerful impact on the way she chooses to wage war.  And yet, this may be the first time that health care is itself under siege. Indeed, the specter of war has provided countless opportunities to test society’s mettle in battle, while forcing those in power to prioritize in terms of their country’s health care. As sides are drawn and campaigns evolve, the strategies of combat take shape in ways previously unforeseen. This is certainly true in contemporary America, though in our modern age of reform it is health care itself that has come under attack.

Medically speaking, advances in science, technology and the provision of health care have commandeered the new millennium, both in practice and politics. And yet, medicine’s inestimable progress since the Civil War is often largely taken for granted by both the decision makers and the recipients of a country that has come to expect state-of-the-art facilities and easy access to providers. A century and a half ago, the delivery of medicine was grossly misunderstood, frequently useless and often barbaric. “Civil War surgeons cleaned their instruments by periodically rinsing them with water, usually at the end of the day. . . . Typically, the operator wiped the blood and other material from his knife with a quick swipe across the front of his large apron, which was usually stained with blood and pus from prior sessions.”[1]

Such an abysmal depiction of health care in the middle of the nineteenth century serves to underscore the catastrophic losses endured by both North and South in the deadliest conflict on American soil, while highlighting the need for a potent, reliable and inclusive health care structure on which to rely.. Dr. Jonathan Letterman, Civil War medical director of the Army of the Potomac, offered a wise analogy describing the relationship between the science of medicine and our ability to deliver it:  “Without proper means, the Medical Department can no more take care of the wounded than the army can fight a battle without ammunition.”[2] … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, Miscellaneous, News, Non Clinical, Regulatory

Health Care Reform this Spring: The Good, the Bad and the Obscure1

This article first appeared in the Daily Journal on May 18, 2012.

iStock_000018849339XSmall-250x1651The lack of growth in health care spending over recent years stands in stark contrast to the onslaught of health care regulations released by the federal government this spring. Due to the volume of such changes, pouring through this new iteration of codified health care reform can seem as Sisyphean as achieving actual compliance. The vigor and enthusiasm with which the federal government continues to add dimension to the 2010 Affordable Care Act leads many to believe that health care reform is here to stay, regardless of the U.S. Supreme Court decision due in June. With this in mind, all health care professionals would do well to familiarize themselves with the new structure imposed upon our system by the effects of reform. Rather than fret about its future, health care counselors are better served by understanding the bare bones at the foundation of this new structure.

The Good

Earlier this month the federal government released final regulations easing hospital conditions of participation (CoPs) in an attempt to decrease the burdens faced by providers and suppliers participating in federal health care programs (Medicare and Medicaid (Medi-Cal for California) in particular). These modifications, set forth in 42 CFR Parts 482 and 485, seek to simplify and even eliminate certain CoPs consistent with President Barack Obama’s January 2011 Executive Order directing federal agencies to employ the least burdensome approach that minimizes costs, simplifies duplicative regulations, and yet is still mindful of the American public and the need to preserve its freedom of choice.

Hospitals must be in compliance with federal CoPs in order to receive Medicare and Medicaid payments, a determination usually made by one of three national accreditation programs, which include the Joint Commission, Healthcare Facilities Accreditation Program (HFAP) and, most recently, Det Norske Veritas Healthcare (DNV Healthcare). Through observations, interviews and document and record reviews that take place during accreditation surveys, hospitals must satisfy all appropriate standards to ensure that Medicare and Medicaid beneficiaries receive treatment that is both safe and superior.

Recent regulations have further revised and clarified the requirements for hospital governance, confirming that multi-hospital systems can maintain a central governing body where appropriate, provided that it includes one or more members of the hospital medical staff. The federal government commented: “[T]here is an important and essential symbiotic relationship that should exist between a hospital’s governing body and its medical staff.” The new regulations also permit a hospital’s medical staff to expand its membership to include non-physician practitioners (such as physician assistants, pharmacists and advanced practice registered nurses), provided such inclusions are consistent with hospital bylaws and state law (including scope of practice laws), and further allow podiatrists to take new leadership roles at a hospital. It should be noted, however, that registered dieticians might not be included in this pool of non-physician practitioners. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, Miscellaneous, News, Non Clinical, Regulatory

Healthcare Reform: A Time To Wait, or Expiate?0

This article first appeared in Becker’s Hospital Review on April 12, 2012.

If Dante Alighieri had written an epic poem describing the recent evolution of American healthcare, it might have much in common with his famous Purgatorio.   As the nine U.S. Supreme Court Justices continue deliberation  on the fate of the 2010 Affordable Care Act, it is unclear whether our nation’s healthcare system is heading toward Inferno or Paradiso. While experts on both sides of the aisle attempt to divine the secret codes shared between Justices over a record-breaking three days of oral argument, the rest of us have little choice but to wait until summer for clarity.

In the 25 months since President Obama signed the Patient Protection and Affordable Care Act into law, the structure of our modern American healthcare system has changed dramatically, dividing the nation down political lines amid questions of constitutionality. With the bill currently under debate in our highest court, now is the time to consider the practical implications of an adverse ruling, and what the resultant ramifications may entail for the future of both the Affordable Care Act and the patients for whom the legislation was designed to protect. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News

HAPPY ANNIVERSARY TO THE AFFORDABLE CARE ACT0

March 23 marks the two-year anniversary of President Barack Obama’s ambitious and controversial Patient Protection and Affordable Care Act. While the ultimate legacy of this landmark legislation remains to be seen, its fate will soon rest in the hands of the nine U.S. Supreme Court Justices, and then possibly the Electoral College.

With talk of constitutional challenges and potential repeal sharing headlines almost every day, now is the perfect opportunity to trace the changes in American health care over these past 24 months.

As our health care system continues to experience growing pains, certain basic tenets of reform have already made their mark, and may be difficult to retract in the event of the bill’s failure. The number of insured young adults under the age of 26 has continued to rise since 2010, as has the estimated 105 million Americans who no longer face lifetime limits on health benefits. Statistics also point to 50,000 newly insured who had in the past failed to qualify for health insurance due to pre-existing conditions.

Across the nation, individual states are gearing up for health insurance exchanges, while hospitals and physicians prepare for monumental changes in the Medicare reimbursement infrastructure as it transitions from a historically cost-based to a performance-driven platform.

Under the reform bill, the Federal Government has increased its presence with an unprecedented focus on eliminating health care fraud, abuse and waste.

Thanks to the Office of the Inspector General, Centers for Medicare & Medicaid Services and Department of Justice having procured health care fraud-related settlements and judgments in excess of $3 billion last year (capping the largest three-year streak in history with a total of $8.7 billion since January 2009), health care providers are now busy crafting or fine tuning their own custom-tailored compliance programs.  At the same time, providers must also fight off Medicare and Medicaid related audits from a number of newly created entities known only by their acronyms (RACs, MICs, MACs and ZPICs to name a few).

No matter what effects the Supreme Court’s decision and upcoming elections may hold for the Affordable Care Act, it is clear that American health care will never be the same.

Only time will offer any definitive perspective for us to evaluate the changes it has imposed upon the delivery of our nation’s health care.

Welcome to health care reform, year three, as it promises to be a busy one.

Administrative, Children's Health, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, Miscellaneous, News, Non Clinical, Regulatory, Technology

The Right to Strike vs. the Right to Care0

Modern day health care is a troubled industry. Enshrouded in a net of oft-conflicting regulations and entrusted with the safety of America’s sick and wounded, many of whom lack the necessary insurance to guarantee reimbursement to their providers, the financial stability of our nation’s medical facilities is called into question on a daily basis. Today’s hospital has the unenviable task of walking a fine line between caring for its patients and remaining solvent as a business, a laudable goal attainable at least in part by recognizing the inextricable connection between the institution itself and the nurses who form an infantry amongst its ranks. Even as these nurses form an ever-present “front line” on the hospital battlefield, their recent strike in California, threatened and averted strikes in New York, and a judicially-restrained “walk out” in Riverside County, California last month, shine a harsh if necessary light on certain issues plaguing our current health care system as it stands so precariously with one foot on either side of a dangerous fence.

The nature of the nurse’s role begs the question: does participation in a labor union extend to the right to strike? … Read more →

Administrative, Clinical, Health Care Reform, Hospitals, News, Regulatory

Our Fear of Health Care Reform and the Household Vacuum0

“That’s the nice thing about carousels, they always play the same songs.”  –The Catcher in the Rye by J.D. Salinger

This article first appeared on the PBS affiliated website This Emotional Life.

It starts with a vacuum.

The sudden, unfamiliar dissonance signals fear in his little mind, which grows quickly, magnified by the sight of an unexpected entanglement between the woman he trusts most and this monstrous machine. As he turns to run (or crawl), I find myself thankful to be just inches away, in perfect position to catch my 10-month old boy as he does his best to flee the frightful scene. His two outstretched arms secure a tight grip around my neck, while a sad face burrows deep into my chest. For one sharp moment I feel like a hero, a wholly necessary, trustworthy entity whose sole purpose is to be relied upon in times of trouble.

Fear is a formidable foe, and the ways in which we as grown ups react to its presence can often be inconsistent. Regardless of its origin, any meaningful cause for alarm typically signifies a commonality of chaos, to be first understood, and then vanquished. Though my son’s safety was obviously never compromised during his run-in with the vacuum cleaner, his reaction illustrates the fact that in the eyes of an infant the world is full of uncertainties. In the mind of a child, laughter and tears coexist every day, yet we seldom stop to consider how these emotions actually resonate. Rather, we tend to focus on the cause, which with luck might lead us to a solution, as a means to restore the calm and save the day. Indeed, some of the most seasoned parents have an entire cache of remedies upon which to rely when a crisis hits, and they wield them like weapons of precision, each one crafted and selected for just the right moment.

But what about the child in the midst of a trauma?  … Read more →

Children's Health, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, PBS This Emotional Life, Regulatory

Providing Care for the Uninsured Without the Federal Case0

The article first appeared in Becker’s Hospital Review.

Estimated at close to 50 million strong, the fate of America’s uninsured has caused quite a stir of late. As the media anxiously reports on the U.S. Supreme Court’s acquiescence to assess the constitutionality of certain tenets at the heart of healthcare reform, the nation sits anxiously on the sidelines, awaiting the outcome. Indeed, a suggested, unprecedented televised hearing on the insurance mandate could potentially attract even more viewers than the record-breaking 111 million football fans who watched the Green Bay Packers beat the Pittsburgh Steelers in Superbowl XLV on Feb. 6, 2011.

The uninsured conundrum

At the core of the debate lies an enormous price tag. The sheer volume in dollars it takes to provide medical treatment to the uninsured is astounding, and its ramifications affect many fundamental aspects of our healthcare structure. In 2008, uncompensated medical care in the United States approached an estimated $57 billion, of which nearly $43 billion was paid by federal, state and local governments from funds earmarked for this very purpose. Although the federal government typically foots close to half of this annual bill, its contribution equals only 2 percent of federal healthcare spending yearly. The great bulk of responsibility for America’s uninsured falls to our nation’s hospitals, who shoulder approximately 60 percent of uncompensated medical care, due largely to a regulatory structure mandating that emergency departments at hospitals participating in Medicare or Medicaid must treat just about anyone who arrives in need of medical care, regardless of citizenship, legal status or ability to pay.

To add to the friction, most Americans have a stronger grasp on the rules of professional cricket than they do the leading constitutional challenge to President Obama’s 2010 Patient Protection and Affordable Care Act. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

Tracing the Evolution of American Health Care Through Medicare0

This article first appeared in the journal Health, Culture and Society.

I. Before Medicare

Since its inception as a government sanctioned public health insurance program, Medicare has been both a bone of contention between political parties and a beacon from which to gauge the changes in American health care as a whole. Passed as part of the Social Security Amendments of 1965, Medicare had as its focus individuals sixty five years of age and older, with a similar yet state-run program, Medicaid, addressing the medical needs of people with certain disabilities and low income families. Over time, however, Medicare has grown to be the preeminent standard for our nation’s health care in its entirety, with nearly every substantive change to its core foundation signaling a corresponding restructuring of our overall health care system.

The modifications imposed on Medicare, both by market forces and federal legislation, stand as a series of growing pains from which to mark the evolution of the American health care model. By charting these changes through the decades we can better understand the ways in which health care as a whole has morphed from a cost based system to one of performance evaluation. In turn, this may provide us with a glimpse into health care’s future if certain fundamental issues are not addressed in current reform legislation.

The rise of the government’s role in providing health care to its citizens came relatively late in America’s history. For much of its first two centuries the burden of caring for the sick and injured fell to neighbors, friends and relatives, with additional support from individual communities and religious groups. Visits by an actual doctor were generally limited to the home and dictated by local demographics. Almshouses and charity wards provided a certain degree of medical service, as hospitals were few and far between, and often existed solely upon the largess of the surrounding vicinities. Those who had the opportunity to visit a hospital prior to the twentieth century more than likely did so after an accident or as the result of an unfortunate designation of insanity.

Read the complete article here.

 

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

1 … 8 9 10 11