Opportunities and Challenges for Payment Reform: Observations from Massachusetts.

PubMed

Mechanic, Robert E

2016-08-01

Policy makers and private health plans are expanding their efforts to implement new payment models that will encourage providers to improve quality and deliver health care more efficiently. Over the past five years, payment reforms have progressed faster in Massachusetts than in any other state. The reasons include a major effort by Blue Cross Blue Shield of Massachusetts to implement global payment, the presence of large integrated systems willing to take on financial risk, and a supportive state policy environment. By 2014, thirty-seven percent of Massachusetts's residents enrolled in health plans were covered under risk-based payment models tied to global budgets. But the expansion of payment reform in Massachusetts slowed between 2012 and 2015 because some commercial enrollment shifted from risk-based health maintenance organization products to fee-for-service preferred provider organization (PPO) plans, and the state Medicaid program fell short of its payment reform goals. Provider groups will not fully commit to population-based clinical models if they believe it will result in large reductions in fee-for-service revenue. The use of alternative payment models will accelerate in 2016 when Blue Cross begins implementing PPO payment reforms, but it is unknown how quickly other payers will follow. Massachusetts's experience illustrates the complexity of payment reform in pluralistic health care markets and the need for complementary efforts by public and private stakeholders. Copyright © 2016 by Duke University Press.

Outsourcing critical financial system operations.

PubMed

Cox, Nora; Pilbauer, Jan

2018-01-01

Payments Canada provides Canada's national payments systems and is responsible for the clearing and settlement infrastructure, processes and rules that underpin the exchange of billions of dollars each day through the Canadian economy. Strategic sourcing is a reality for this small organisation with a broad scope of national regulations and global standards to comply with. This paper outlines Payments Canada's approach to outsourcing its critical financial system operations, which centres on four key principles: strong relationship management; continuous learning, recording and reporting; evaluating the business landscape; and a commitment to evolving the organisation to greater resilience. This last point is covered in detail with an exploration of the organisation's resilience and security strategy as well as its risk appetite. As Payments Canada progresses to its future state, which includes modernising its core payment systems, underlying rules and standards, risk management for the industry as a whole will remain at the forefront of its collective mind. The expectation is that outsourcing will remain a fundamental element of its operating model in future, a strategy that will ensure the organisation can focus on its core business competencies and eliminate the need to develop and support in-house expertise in commodity areas.

Risk contracting and operational capabilities in large medical groups during national healthcare reform.

PubMed

Mechanic, Robert E; Zinner, Darren

2016-06-01

Little is known about the scope of alternative payment models outside of Medicare. This study measures the full complement of public and private payment arrangements in large, multi-specialty group practices as a barometer of payment reform among advanced organizations. We collected information from 33 large, multi-specialty group practices about the proportion of their total revenue in 7 payment models, physician compensation strategies, and the implementation of selected performance management initiatives. We grouped respondents into 3 categories based on the proportion of their revenue in risk arrangements: risk-based (45%-100%), mixed (10%-35%), and fee-for-service (FFS) (0%-10%). We analyzed changes in contracting and operating characteristics between 2011 and 2013. In 2013, 68% of groups' total patient revenue was from FFS payments and 32% was from risk arrangements (unweighted average). Risk-based groups had 26% FFS revenue, whereas mixed-payment and FFS groups had 75% and 98%, respectively. Between 2011 and 2013, 9 groups increased risk contract revenue by about 15 percentage points and 22 reported few changes. Risk-based groups reported more advanced implementation of performance management strategies and were more likely to have physician financial incentives for quality and patient experience. The groups in this study are well positioned to manage risk-based contracts successfully, but less than one-third receive a majority of their revenue from risk arrangements. The experience of these relatively advanced groups suggests that expanding risk-based arrangements across the US health system will likely be slower and more challenging than many people assume.

Insurance principles and the design of prospective payment systems.

PubMed

Ellis, R P; McGuire, T G

1988-09-01

This paper applies insurance principles to the issues of optimal outlier payments and designation of peer groups in Medicare's case-based prospective payment system for hospital care. Arrow's principle that full insurance after a deductible is optimal implies that, to minimize hospital risk, outlier payments should be based on hospital average loss per case rather than, as at present, based on individual case-level losses. The principle of experience rating implies defining more homogenous peer groups for the purpose of figuring average cost. The empirical significance of these results is examined using a sample of 470,568 discharges from 469 hospitals.

An empirical assessment of driver motivation and emotional states in perceived safety margins under varied driving conditions.

PubMed

Zhang, Yu; Kaber, David B

2013-01-01

Motivation models in driving behaviour postulate that driver motives and emotional states dictate risk tolerance under various traffic conditions. The present study used time and driver performance-based payment systems to manipulate motivation and risk-taking behaviour. Ten participants drove to a predefined location in a simulated driving environment. Traffic patterns (density and velocity) were manipulated to cause driver behaviour adjustments due to the need to conform with the social norms of the roadway. The driving environment complexity was investigated as a mediating factor in risk tolerance. Results revealed the performance-based payment system to closely relate to risk-taking behaviour as compared with the time-based payment system. Drivers conformed with social norms associated with specific traffic patterns. Higher roadway complexity led to a more conservative safety margins and speeds. This research contributes to the further development of motivational models of driver behaviour. This study provides empirical justification for two motivation factors in driver risk-taking decisions, including compliance with social norm and emotions triggered by incentives. Environment complexity was identified as a mediating factor in motivational behaviour model. This study also recommended safety margin measures sensitive to changes in driver risk tolerance.

Distribution and Determinants of 90-Day Payments for Multilevel Posterior Lumbar Fusion: A Medicare Analysis.

PubMed

Jain, Nikhil; Phillips, Frank M; Khan, Safdar N

2018-04-01

A retrospective, economic analysis. The objective of this article is to analyze the distribution of 90-day payments, sources of variation, and reimbursement for complications and readmissions for primary ≥3-level posterior lumbar fusion (PLF) from Medicare data. A secondary objective was to identify risk factors for complications. Bundled payments represent a single payment system to cover all costs associated with a single episode of care, typically over 90 days. The dollar amount spent on different health service providers and the variation in payments for ≥3-level PLF have not been analyzed from a bundled perspective. Administrative claims data were used to study 90-day Medicare (2005-2012) reimbursements for primary ≥3-level PLF for deformity and degenerative conditions of the lumbar spine. Distribution of payments, sources of variation, and reimbursements for managing complications were studied using linear regression models. Risk factors for complications were studied by stepwise multiple-variable logistic regression analysis. Hospital payments comprised 73.8% share of total 90-day payment. Adjusted analysis identified several factors for variation in index hospital payments. The average 90-day Medicare payment for all multilevel PLFs without complications was $35,878 per patient. The additional average cost of treating complications with/without revision surgery within 90 days period ranged from $17,284 to $68,963. A 90-day bundle for ≥3-level PLF with readmission ranges from $88,648 (3 levels) to $117,215 (8+ levels). Rates and risk factors for complications were also identified. The average 90-day payment per patient from Medicare was $35,878 with several factors such as levels of surgery, comorbidities, and development of complications influencing the cost. The study also identifies the risks and costs associated with complications and readmissions and emphasize the significant effect these would have on bundled payments (additional burden of up to 192% the cost of an average uncomplicated procedure over 90 days). Level 3.

A simple simulation model as a tool to assess alternative health care provider payment reform options in Vietnam.

PubMed

Cashin, Cheryl; Phuong, Nguyen Khanh; Shain, Ryan; Oanh, Tran Thi Mai; Thuy, Nguyen Thi

2015-01-01

Vietnam is currently considering a revision of its 2008 Health Insurance Law, including the regulation of provider payment methods. This study uses a simple spreadsheet-based, micro-simulation model to analyse the potential impacts of different provider payment reform scenarios on resource allocation across health care providers in three provinces in Vietnam, as well as on the total expenditure of the provincial branches of the public health insurance agency (Provincial Social Security [PSS]). The results show that currently more than 50% of PSS spending is concentrated at the provincial level with less than half at the district level. There is also a high degree of financial risk on district hospitals with the current fund-holding arrangement. Results of the simulation model show that several alternative scenarios for provider payment reform could improve the current payment system by reducing the high financial risk currently borne by district hospitals without dramatically shifting the current level and distribution of PSS expenditure. The results of the simulation analysis provided an empirical basis for health policy-makers in Vietnam to assess different provider payment reform options and make decisions about new models to support health system objectives.

The influence of risk and monetary payment on the research participation decision making process

PubMed Central

Bentley, J; Thacker, P

2004-01-01

Objectives: To determine the effects of risk and payment on subjects' willingness to participate, and to examine how payment influences subjects' potential behaviours and risk evaluations. Methods: A 3 (level of risk) x 3 (level of monetary payment), between subjects, completely randomised factorial design was used. Students enrolled at one of five US pharmacy schools read a recruitment notice and informed consent form for a hypothetical study, and completed a questionnaire. Risk level was manipulated using recruitment notices and informed consent documents from hypothetical biomedical research projects. Payment levels were determined using the payment models evaluated by Dickert and Grady as a guide. Five dependent variables were assessed in the questionnaire: willingness to participate, willingness to participate with no payment, propensity to neglect to tell about restricted activities, propensity to neglect to tell about negative effects, and risk rating. Results: Monetary payment had positive effects on respondents' willingness to participate in research, regardless of the level of risk. However, higher monetary payments did not appear to blind respondents to the risks of a study. Payment had some influence on respondents' potential behaviours regarding concealing information about restricted activities. However, payment did not appear to have a significant effect on respondents' propensity to neglect to tell researchers about negative effects. Conclusions: Monetary payments appear to do what they are intended to do: make subjects more willing to participate in research. Concerns about payments blinding subjects to risks could not be substantiated in the present study. However, the findings do raise other concerns—notably the potential for payments to diminish the integrity of a study's findings. Future research is critical to make sound decisions about the payment of research subjects. PMID:15173366

Comparing the performance of English mental health providers in achieving patient outcomes.

PubMed

Moran, Valerie; Jacobs, Rowena

2015-09-01

Evidence on provider payment systems that incorporate patient outcomes is limited for mental health care. In England, funding for mental health care services is changing to a prospective payment system with a future objective of linking some part of provider payment to outcomes. This research examines performance of mental health providers offering hospital and community services, in order to investigate if some are delivering better outcomes. Outcomes are measured using the Health of the Nation Outcome Scales (HoNOS) - a clinician-rated routine outcome measure (CROM) mandated for national use. We use data from the Mental Health Minimum Data Set (MHMDS) - a dataset on specialist mental health care with national coverage - for the years 2011/12 and 2012/13 with a final estimation sample of 305,960 observations with follow-up HoNOS scores. A hierarchical ordered probit model is used and outcomes are risk adjusted with independent variables reflecting demographic, need, severity and social indicators. A hierarchical linear model is also estimated with the follow-up total HoNOS score as the dependent variable and the baseline total HoNOS score included as a risk-adjuster. Provider performance is captured by a random effect that is quantified using Empirical Bayes methods. We find that worse outcomes are associated with severity and better outcomes with older age and social support. After adjusting outcomes for various risk factors, variations in performance are still evident across providers. This suggests that if the intention to link some element of provider payment to outcomes becomes a reality, some providers may gain financially whilst others may lose. The paper contributes to the limited literature on risk adjustment of outcomes and performance assessment of providers in mental health in the context of prospective activity-based payment systems. Copyright © 2015 Elsevier Ltd. All rights reserved.

Health care financing in Asia: key issues and challenges.

PubMed

Kwon, Soonman

2011-09-01

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.

Hospitals' quest for financial success is elusive, but not impossible.

PubMed

Heckler, T M

1984-09-01

As the hospital industry moves from a heavily regulated, cost-reimbursed payment system to a less-regulated, at-risk payment system, the financial and business acumen of boards and management will become increasingly important in the quest for adequate capital. This article discusses ways of reducing the need for, and increasing the supply of, debt and equity capital.

78 FR 70046 - Payment System Risk Policy; Daylight Overdraft Posting Rules

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-22

... INFORMATION CONTACT: Jeffrey D. Walker, Assistant Director (202-721-4559) or Michelle D. Olivier, Financial... Telecommunications Device for the Deaf (TDD) only, please call 202-263-4869. SUPPLEMENTARY INFORMATION: Background... debits and credits to institutions' Federal Reserve accounts for different payment types.\\1\\ The...

Diagnostic Risk Adjustment for Medicaid: The Disability Payment System

PubMed Central

Kronick, Richard; Dreyfus, Tony; Lee, Lora; Zhou, Zhiyuan

1996-01-01

This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored. PMID:10172665

Risk selection and cost shifting in a prospective physician payment system: evidence from Ontario.

PubMed

Kantarevic, Jasmin; Kralj, Boris

2014-04-01

We study the risk-selection and cost-shifting behavior of physicians in a unique capitation payment model in Ontario, using the incentive to enroll and care for complex and vulnerable patients as a case study. This incentive, which is incremental to the regular capitation payment, ceases after the first year of patient enrollment and may therefore impact on the physician's decision to continue to enroll the patient. Furthermore, because the enrolled patients in Ontario can seek care from any provider, the enrolling physician may shift some treatment costs to other providers. Using longitudinal administrative data and a control group of physicians in the fee-for-service model who were eligible for the same incentive, we find no evidence of either patient 'dumping' or cost shifting. These results highlight the need to re-examine the conventional wisdom about risk selection for physician payment models that significantly deviate from the stylized capitation model. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Health-Related Financial Catastrophe, Inequality and Chronic Illness in Bangladesh

PubMed Central

Rahman, Md. Mizanur; Gilmour, Stuart; Saito, Eiko; Sultana, Papia; Shibuya, Kenji

2013-01-01

Background Bangladesh has a high proportion of households incurring catastrophic health expenditure, and very limited risk sharing mechanisms. Identifying determinants of out-of-pocket (OOP) payments and catastrophic health expenditure may reveal opportunities to reduce costs and protect households from financial risk. Objective This study investigates the determinants of high healthcare expenditure and healthcare- related financial catastrophe. Methods A cross-sectional household survey was conducted in Rajshahi city, Bangladesh, in 2011. Catastrophic health expenditure was estimated separately based on capacity to pay and proportion of non-food expenditure. Determinants of OOP payments and financial catastrophe were estimated using double hurdle and Poisson regression models respectively. Results On average households spent 11% of their total budgets on health, half the residents spent 7% of the monthly per capita consumption expenditure for one illness, and nearly 9% of households faced financial catastrophe. The poorest households spent less on health but had a four times higher risk of catastrophe than the richest households. The risk of financial catastrophe and the level of OOP payments were higher for users of inpatient, outpatient public and private facilities respectively compared to using self-medication or traditional healers. Other determinants of OOP payments and catastrophic expenses were economic status, presence of chronic illness in the household, and illness among children and adults. Conclusion Households that received inpatient or outpatient private care experienced the highest burden of health expenditure. The poorest members of the community also face large, often catastrophic expenses. Chronic illness management is crucial to reducing the total burden of disease in a household and its associated increased risk of level of OOP payments and catastrophic expenses. Households can only be protected from these situations by reducing the health system's dependency on OOP payments and providing more financial risk protection. PMID:23451102

42 CFR 422.310 - Risk adjustment data.

Code of Federal Regulations, 2011 CFR

2011-10-01

... risk adjustment factors used to adjust payments, as required under §§ 422.304(a) and (c). CMS also may... submission of risk adjustment data. Risk adjustment factors for each payment year are based on risk... factors for affected individuals to determine if adjustments to payments are necessary. Risk adjustment...

42 CFR 422.310 - Risk adjustment data.

Code of Federal Regulations, 2010 CFR

2010-10-01

... risk adjustment factors used to adjust payments, as required under §§ 422.304(a) and (c). CMS also may... submission of risk adjustment data. Risk adjustment factors for each payment year are based on risk... factors for affected individuals to determine if adjustments to payments are necessary. Risk adjustment...

Defining payments associated with the treatment of colorectal cancer.

PubMed

Gani, Faiz; Cerullo, Marcelo; Canner, Joseph K; Conca-Cheng, Alison; Harzman, Alan E; Husain, Syed G; Cirocco, William C; Arnold, Mark W; Traugott, Amber; Johnston, Fabian M; Pawlik, Timothy M

2017-12-01

While bundled payments aim to reduce variations in health care spending across the continuum of care, data reporting on variations in payments for privately insured patients undergoing treatment for colon cancer (CC) are lacking. The current study sought to characterize variations in payments received for the treatment of CC using a cohort of commercially insured patients. Patients who underwent a colectomy for CC were identified using the MarketScan Database for 2010-2014. Multivariable regression analysis was used to calculate and compare risk-adjusted payments between patients. A total of 18,337 patients were identified who met inclusion criteria. The median risk-adjusted payment for surgery was $26,408 (IQR: $19,193-$38,037) ranging from $19,762 (IQR: $15,595-$25,636) among patients in the lowest quartile of payments to $33,809 (IQR: $24,783-$48,254) for patients in the highest (+△71.1%). The median risk-adjusted payment for chemotherapy was $70,090 (IQR: $57,813-$83,216); compared with patients in the lowest quartile of payments, payments associated with chemotherapy were 40.4% higher among patients in the highest quartile of payments (Q1 versus Q4: $56,827 [IQR: 49,173-65,353] versus $79,801 [IQR: 67,270-90,999]). When stratified by treatment type, patients in the highest two quartiles of risk-adjusted payments accounted for a total of 58.5% of all payments, whereas patients in the lower two quartiles of risk-adjusted payments accounted for only 41.5% of all payments. A younger patient age, increasing patient comorbidity and undergoing an open operation were associated with higher overall payments. Wide variations in payments exist for the treatment for colon cancer. Episode-based bundle payments for surgery and chemotherapy may differentially impact reimbursement for CC. Copyright © 2017 Elsevier Inc. All rights reserved.

Hospital inpatient prospective payment system: incorporating new technology.

PubMed

Durthaler, Jeffrey M; Miller, Alicia

2003-11-01

New technologies in the impatient prospective payment system are discussed. On December 21, 2000, Congress passed Public Law 106-554 that includes a requirement to establish a mechanism to more expeditiously incorporate the costs and establish qualifying criteria for payment of new services and technologies into the hospital inpatient prospective payment system. The final ruling of this law states that a new service or technology must demonstrate substantial improvement, be inadequately paid under the DRG system, and be "new." The intent of these criteria is to identify new technologies that offer substantial improvement over existing technologies and to provide supplemental payment that encourages physicians and hospitals to utilize the new technology. In November 2001, drotrecogin alfa (activated) received fast-track FDA approval because of the robust findings from the PROWESS trial. Drotrecogin alfa (activated) is the first agent proven to reduce mortality in patients suffering from severe sepsis associated with acute organ dysfunction who are at a high risk of death (i.e., APACHE II score > 24). In August 2002, drotrecogin alfa (activated) was one of four such new technologies and the first agent approved for new technology payment under the prospective payment system (PPS). This decision offers confidence that the PPS is effectively striving to incorporate new medical services and technologies at a pace similar to that of innovation. Providers may receive up to $3400 in additional reimbursement when drotrecogin alfa (activated) is administered in the Medicare population. Pharmacy and patient accounting personnel should develop a collaborative process to identify, document, and capture this new source of payment.

42 CFR 417.584 - Payment to HMOs or CMPs with risk contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... CMP. (a) Principle of payment. CMS makes monthly advance payments equivalent to the HMO's or CMP's per... subsequent monthly payments to take account of the difference. (d) Reduction of payments. If an HMO or CMP... 1998, HMOs or CMPs with risk contracts will be paid in accordance with principles contained in subpart...

Surgical Adverse Events, Risk Management, and Malpractice Outcome: Morbidity and Mortality Review Is Not Enough

PubMed Central

Morris, John A.; Carrillo, Ysela; Jenkins, Judith M.; Smith, Philip W.; Bledsoe, Sandy; Pichert, James; White, Andrew

2003-01-01

Objective To review all admissions (age > 13) to three surgical patient care centers at a single academic medical center between January 1, 1995, and December 6, 1999, for significant surgical adverse events. Summary Background Data Little data exist on the interrelationships between surgical adverse events, risk management, malpractice claims, and resulting indemnity payments to plaintiffs. The authors hypothesized that examination of this process would identify performance improvement opportunities overlooked by standard medical peer review; the risk of litigation would be constant across the three homogeneous patient care centers; and the risk management process would exceed the performance improvement process. Methods Data collected included patient demographics (age, gender, and employment status), hospital financials (hospital charges, costs, and financial class), and outcome. Outcome categories were medical (disability: <1 month, 1–6 months, permanent/death), legal (no legal action, settlement, summary judgment), financial (indemnity payments, legal fees, write-offs), and cause and effect analysis. Cause and effect analysis attempts to identify system failures contributing to adverse outcomes. This was determined by two independent analysts using the 17 Harvard criteria and subdividing these into subsystem causative factors. Results The study group consisted of 130 patients with surgical adverse events resulting in total liabilities of $8.2 million. The incidence of adverse events per 1,000 admissions across the three patient care centers was similar, but indemnity payments per 1,000 admissions varied (cardiothoracic = $30, women’s health = $90, trauma = $520). Patient demographics were not predictive of high-risk subgroups for adverse events or litigation. In terms of medical outcome, 51 patients had permanent disability or death, accounting for 98% of the indemnity payments. In terms of legal outcome, 103 patients received no indemnity payments, 15 patients received indemnity payments, four suits remain open, and in eight cases charges were written off ($0.121 million). To date, no cases have been adjudicated in court. Cause and effect analysis identified 390 system failures contributing to the adverse events (mean 3.0 failures per adverse event); there were 4.7 failures per adverse event in the 15 indemnity cases. Five categories of causes accounted for 75% of the failures (patient management, n = 104; communication, n = 89; administration, n = 33; documentation, n = 32; behavior, n = 23). The current medical review process would have identified 104 of 390 systems failures (37%). Conclusions This study demonstrates no rational link between the tort system and the reduction of adverse events. Sixty-three percent of contributing causes to adverse events were undetected by current medical review processes. Adverse events occur at the interface between different systems or disciplines and result from multiple failures. Indemnity costs per hospital day vary dramatically by patient care center (range $3.60–97.60 a day). The regionalization of healthcare is in jeopardy from the burden of high indemnity payments. PMID:12796581

How to Pay for Health Care.

PubMed

Porter, Michael E; Kaplan, Robert S

2016-01-01

The United States stands at a crossroads in how to pay for health care. Fee for service, the dominant payment model in the U.S. and many other countries, is now widely recognized as perhaps the single biggest obstacle to improving health care delivery. A battle is currently raging, outside of the public eye, between the advocates of two radically different payment approaches: capitation and bundled payments. The stakes are high, and the outcome will define the shape of the health care system for many years to come, for better or for worse. In this article, the authors argue that although capitation may deliver modest savings in the short run, it brings significant risks and will fail to fundamentally change the trajectory of a broken system. The bundled payment model, in contrast, triggers competition between providers to create value where it matters--at the individual patient level--and puts health care on the right path. The authors provide robust proof-of-concept examples of bundled payment initiatives in the U.S. and abroad, address the challenges of transitioning to bundled payments, and respond to critics' concerns about obstacles to implementation.

Effects of the DRG-based prospective payment system operated by the voluntarily participating providers on the cesarean section rates in Korea.

PubMed

Lee, Kwangsoo; Lee, Sangil

2007-05-01

This study explored the effects of the diagnosis-related group (DRG)-based prospective payment system (PPS) operated by voluntarily participating organizations on the cesarean section (CS) rates, and analyzed whether the participating health care organizations had similar CS rates despite the varied participation periods. The study sample included delivery claims data from the Korean national health insurance program for the year 2003. Risk factors were identified and used in the adjustment model to distinguish the main reason for CS. Their risk-adjusted CS rates were compared by the reimbursement methods, and the organizations' internal and external environments were controlled. The final risk-adjustment model for the CS rates meets the criteria for an effective model. There were no significant differences of CS rates between providers in the DRG and fee-for-service system after controlling for organizational variables. The CS rates did not vary significantly depending on the providers' DRG participation periods. The results provide evidence that the DRG payment system operated by volunteering health care organizations had no impact on the CS rates, which can lower the quality of care. Although the providers joined the DRG system in different years, there were no differences in the CS rates among the DRG providers. These results support the future expansion of the DRG-based PPS plan to all health care services in Korea.

Sharing risk between payer and provider by leasing health technologies: an affordable and effective reimbursement strategy for innovative technologies?

PubMed

Edlin, Richard; Hall, Peter; Wallner, Klemens; McCabe, Christopher

2014-06-01

The challenge of implementing high-cost innovative technologies in health care systems operating under significant budgetary pressure has led to a radical shift in the health technology reimbursement landscape. New reimbursement strategies attempt to reduce the risk of making the wrong decision, that is, paying for a technology that is not good value for the health care system, while promoting the adoption of innovative technologies into clinical practice. The remaining risk, however, is not shared between the manufacturer and the health care payer at the individual purchase level; it continues to be passed from the manufacturer to the payer at the time of purchase. In this article, we propose a health technology payment strategy-technology leasing reimbursement scheme-that allows the sharing of risk between the manufacturer and the payer: the replacing of up-front payments with a stream of payments spread over the expected duration of benefit from the technology, subject to the technology delivering the claimed health benefit. Using trastuzumab (Herceptin) in early breast cancer as an exemplar technology, we show how a technology leasing reimbursement scheme not only reduces the total budgetary impact of the innovative technology but also truly shares risk between the manufacturer and the health care system, while reducing the value of further research and thus promoting the rapid adoption of innovative technologies into clinical practice. Copyright © 2014 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

42 CFR 422.208 - Physician incentive plans: requirements and limitations.

Code of Federal Regulations, 2013 CFR

2013-10-01

... difference between the maximum potential payments and the minimum potential payments is more than 25 percent... have the effect of reducing or limiting the services provided to any plan enrollee. Potential payments... considered in this determination. (2) Risk threshold. The risk threshold is 25 percent of potential payments...

42 CFR 422.208 - Physician incentive plans: requirements and limitations.

Code of Federal Regulations, 2014 CFR

2014-10-01

... difference between the maximum potential payments and the minimum potential payments is more than 25 percent... have the effect of reducing or limiting the services provided to any plan enrollee. Potential payments... considered in this determination. (2) Risk threshold. The risk threshold is 25 percent of potential payments...

42 CFR 422.208 - Physician incentive plans: requirements and limitations.

Code of Federal Regulations, 2012 CFR

2012-10-01

... difference between the maximum potential payments and the minimum potential payments is more than 25 percent... have the effect of reducing or limiting the services provided to any plan enrollee. Potential payments... considered in this determination. (2) Risk threshold. The risk threshold is 25 percent of potential payments...

45 CFR 153.510 - Risk corridors establishment and payment methodology.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Risk corridors establishment and payment methodology. 153.510 Section 153.510 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS....510 Risk corridors establishment and payment methodology. (a) General requirement. A QHP issuer must...

Emerging lessons from regional and state innovation in value-based payment reform: balancing collaboration and disruptive innovation.

PubMed

Conrad, Douglas A; Grembowski, David; Hernandez, Susan E; Lau, Bernard; Marcus-Smith, Miriam

2014-09-01

In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers' limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected "honest broker" that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a "burning bridge" between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of "reformed" fee-for-service with bundled payments and global payments. © 2014 Milbank Memorial Fund.

46 CFR 308.507 - Security for payment of premiums.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 46 Shipping 8 2013-10-01 2013-10-01 false Security for payment of premiums. 308.507 Section 308.507 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.507 Security for payment of...

46 CFR 308.507 - Security for payment of premiums.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 8 2014-10-01 2014-10-01 false Security for payment of premiums. 308.507 Section 308.507 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Open Policy War Risk Cargo Insurance § 308.507 Security for payment of...

46 CFR 308.507 - Security for payment of premiums.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 46 Shipping 8 2010-10-01 2010-10-01 false Security for payment of premiums. 308.507 Section 308.507 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.507 Security for payment of...

46 CFR 308.507 - Security for payment of premiums.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 46 Shipping 8 2012-10-01 2012-10-01 false Security for payment of premiums. 308.507 Section 308.507 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.507 Security for payment of...

46 CFR 308.507 - Security for payment of premiums.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 46 Shipping 8 2011-10-01 2011-10-01 false Security for payment of premiums. 308.507 Section 308.507 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.507 Security for payment of...

The effect of competition on the relationship between the introduction of the DRG system and quality of care in Korea.

PubMed

Kim, Seung Ju; Park, Eun-Cheol; Kim, Sun Jung; Han, Kyu-Tae; Han, Euna; Jang, Sung-In; Kim, Tae Hyun

2016-02-01

The diagnosis-related group-based prospective payment programme was introduced in Korea in 1997 as a pilot programme to control health spending. In July 2013, the programme was implemented throughout the nation. The aim of our study is to evaluate the relationship between quality of care and market competition following the introduction of the new payment system in Korea. We conduct an observational analysis using National Health Insurance claim data from 2011 to 2014. We analyse data on readmission within 30 days, length of stay, and number of outpatient visits for 1742 hospitals and 821 912 cases. We use a generalized estimating equation model to evaluate readmission within 30 days and number of outpatient visits and a multi-level regression model to assess length of stay. Total readmission within 30 days is 10 727 (1.3%). High competition areas present a lower risk of readmission [odds ratio (OR): 0.95, P: 0.0277], a longer length of stay (1%, P < 0.0001), and an increased number of outpatient visits (Relative Risk: 1.11, P: 0.0011) as compared with moderate competition areas. Risk of readmission is higher in low competition areas as compared with moderate competition areas (OR: 1.21, P < 0.0001). The effects of the introduction of the new payment system differed by degree of market competition. Thus, evaluation about the effect of new payment system on hospital performance should be measured in combination with the degree of hospital market structure. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Financial Regulatory Reform: Systemic Risk and the Federal Reserve

DTIC Science & Technology

2010-05-26

financial holding company. The Fed would be required to consider the following criteria when determining if a firm should be designated Tier 1: “(i) the ...Systemic Risk and the Federal Reserve Congressional Research Service 17 Regulation of “Systemically Important ” Payment, Clearing, and Settlement...Federal Reserve Congressional Research Service 19 The council would also identify systemically important firms to be subject to stricter prudential

Catastrophic healthcare payments and impoverishment in the occupied Palestinian territory.

PubMed

Mataria, Awad; Raad, Firas; Abu-Zaineh, Mohammad; Donaldson, Cam

2010-01-01

Financial protection from the risks of ill health has globally recognized importance as a principal performance goal of any health system. This type of financial protection involves minimizing catastrophic payments for healthcare and their associated impoverishing effects. Realization of this performance goal is heavily influenced by factors related to the overall policy environment and sociopolitical context in each country. To examine the incidence and intensity of catastrophic and impoverishing healthcare payments borne by Palestinian households between 1998 and 2007. The incidence and intensity of these effects are examined within the historically unique policy and socioeconomic context of the occupied Palestinian territory. A healthcare payment was considered catastrophic if it exceeded 10% of household resources, or 40% of resources net of food expenditures. The impoverishing effect of healthcare was examined by comparing poverty incidence and intensity before and after healthcare payments. The data source was a series of annual expenditure and consumption surveys covering 1998 and 2004-7, and including representative samples of Palestinian households (n = 1231-3098, per year). Total household expenditure was used as a proxy for household level of resources; and the sum of household expenses on a comprehensive list of medical goods and services was used to estimate healthcare payments. While only around 1% of the surveyed households spent ≥40% of their total household expenditures (net of food expenses) on healthcare in 1998, the percentage was almost doubled in 2007. In terms of impoverishing effect, while 11.8% of surveyed households fell into deep poverty in 1998 due to healthcare payments, 12.5% of households entered deep poverty for the same reason in 2006. Over the same period, the monthly amount by which poor households failed to reach the deep poverty line due to healthcare payments increased from $US9.4 to $US12.9. The inability of the Palestinian healthcare system to protect against the financial risks of ill health could be attributed to the prevailing sociopolitical conditions of the occupied Palestinian territory, and to some intrinsic system characteristics. It is recommended that pro-poor financing schemes be pursued to mitigate the negative impact of the recurrent health shocks affecting Palestinian households.

Emerging Lessons From Regional and State Innovation in Value-Based Payment Reform: Balancing Collaboration and Disruptive Innovation

PubMed Central

Conrad, Douglas A; Grembowski, David; Hernandez, Susan E; Lau, Bernard; Marcus-Smith, Miriam

2014-01-01

Policy Points: Public and private purchasersmust create a "burning bridge" of countervailing pressure that signals "no turning back" to fee-for-service in order to sustain the momentum for value-based payment. Multi-stakeholder coalitions must establish a defined set of quality, outcomes, and cost performance measures and the interoperable information systems to support data collection and reporting of value-based payment schemes. Anti-trust vigilance is necessary to find the "sweet spot" of competition and cooperation among health plans and health care providers. Provider and health plan transparency of price and quality, supported by all-payer claims data, are critical in driving value-based payment innovation and cost constraint. Context In recent decades, practitioners and policymakers have turned to value-based payment initiatives to help contain spending on health care and to improve the quality of care. The Robert Wood Johnson Foundation funded 7 grantees across the country to design and implement value-based, multistakeholder payment reform projects in 6 states and 3 regions of the United States. Methods As the external evaluator of these projects, we reviewed documents, conducted Internet searches, interviewed key stakeholders, cross-validated factual and narrative interpretation, and performed qualitative analyses to derive cross-site themes and implications for policy and practice. Findings The nature of payment reform and its momentum closely reflects the environmental context of each project. Federal legislation such as the Patient Protection and Affordable Care Act and federal and state support for the development of the patient-centered medical home and accountable care organizations encourage value-based payment innovation, as do local market conditions for payers and providers that combine a history of collaboration with independent innovation and experimentation by individual organizations. Multistakeholder coalitions offer a useful facilitating structure for galvanizing payment reform. But to achieve the objectives of reduced cost and improved quality, multistakeholder payment innovation must overcome such barriers as incompatible information systems, the technical difficulties and transaction costs of altering existing billing and payment systems, competing stakeholder priorities, insufficient scale to bear population health risk, providers’ limited experience with risk-bearing payment models, and the failure to align care delivery models with the form of payment. Conclusions From the evidence adduced in this article, multistakeholder, value-based payment reform requires a trusted, widely respected “honest broker” that can convene and maintain the ongoing commitment of health plans, providers, and purchasers. Change management is complex and challenging, and coalition governance requires flexibility and stable leadership, as market conditions and stakeholder engagement and priorities shift over time. Another significant facilitator of value-based payment reform is outside investment that enables increased investment in human resources, information infrastructure, and care management by provider organizations and their collaborators. Supportive community and social service networks that enhance population health management also are important enablers of value-based payment reform. External pressure from public and private payers is fueling a “burning bridge” between the past of fee-for-service payment models and the future of payments based on value. Robust competition in local health plan and provider markets, coupled with an appropriate mix of multistakeholder governance, pressure from organized purchasers, and regulatory oversight, has the potential to spur value-based payment innovation that combines elements of “reformed” fee-for-service with bundled payments and global payments. PMID:25199900

Integrating Risk Adjustment and Enrollee Premiums in Health Plan Payment

PubMed Central

McGuire, Thomas G.; Glazer, Jacob; Newhouse, Joseph P.; Normand, Sharon-Lise; Shi, Julie; Sinaiko, Anna D.; Zuvekas, Samuel

2013-01-01

In two important health policy contexts – private plans in Medicare and the new state-run “Exchanges” created as part of the Affordable Care Act (ACA) – plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS). PMID:24308878

High and low-risk specialties experience with the U.S. medical malpractice system

PubMed Central

2013-01-01

Background “High-liability risk specialties” tend to be the focus of medical malpractice system research and debate, but concerns and fears are not limited to this group. The objective of this study was to examine whether “high-liability risk” medical specialties have a different experience with the malpractice system than “low-liability risk” specialties. Methods We reviewed claims data from the Physician Insurers Association of America’s Data Sharing Project between January 1985 and December 2008. We used linear regression, controlling for year, to determine how liability risk affected outcomes of interest. Results In high-liability risk specialties, 33% of claims result in indemnity payments compared to 28% for low-liability risk specialties (p < 0.001). The average indemnity payment for high-liability risk specialties was $315,314 compared to $267,146 for low-liability risk specialties (p = 0.25). Although only a small percentage of claims go to trial, low-liability risk specialties have significantly more claims that are ultimately dropped, withdrawn or dismissed, while high-liability risk specialties have significantly more claims that result in plaintiff settlement (p < 0.001). Conclusions Malpractice risk exists for all specialties. Variability in indemnity costs are found in both high- and low-liability risk specialties. Differences in the reasons for which claims are initiated for high- and low-liability risk specialties likely necessitate different risk management solutions. PMID:24192524

Determinants Of Impoverishment Due To Out Of Pocket Payments In Nigeria.

PubMed

Aregbeshola, Bolaji Samson; Khan, Samina Mohsin

2017-01-01

Poverty is an extreme consequence of out of pocket payments in countries with health systems that do not provide financial risk protection through mandatory health insurance coverage for people in both the formal and informal sectors. The study assessed the determinants of impoverishment due to out of pocket payments in Nigeria. Secondary data from the Harmonized Nigeria Living Standard Survey (HNLSS) of 2009/10 was utilized to assess factors associated with impoverishment in Nigeria. Household and individual characteristics associated with impoverishment were determined using binary logistic regression. A significance level of p<0.05 was used. Results show that lack of health insurance, having a member above 65 years, large household size, household socio-economic status, type of illness suffered, type of health facility visited, geo-political zones, education of household heads and location were major determinants of impoverishment due to out of pocket health expenditure. Findings from the study show that most households and individuals are vulnerable to financial risk due to this regressive source of payments for health care services. This explains why the level of poverty keeps increasing in spite of the numerous poverty alleviation programs across the country. Policy makers and political actors need to design a new health system financing policy that will increase financial risk protection for people in both the formal and informal sectors. Governments and decision makers have to focus on health as a determinant of economic well-being.

Integrating risk adjustment and enrollee premiums in health plan payment.

PubMed

McGuire, Thomas G; Glazer, Jacob; Newhouse, Joseph P; Normand, Sharon-Lise; Shi, Julie; Sinaiko, Anna D; Zuvekas, Samuel H

2013-12-01

In two important health policy contexts - private plans in Medicare and the new state-run "Exchanges" created as part of the Affordable Care Act (ACA) - plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS). Copyright © 2013 Elsevier B.V. All rights reserved.

ORANGES evaluation phase I risk assessment report : phase I of the US DOT sponsored evaluation of the ORANGES electronic payment system field operational test

DOT National Transportation Integrated Search

2004-03-11

This document is the US DOT evaluation Risk Assessment report for Phase I of the ORANGES field operational test. This document consolidates working papers and incorporates an assessment of issues, risks, mitigation strategies and lessons learned look...

Design and impact of bundled payment for detox and follow-up care.

PubMed

Quinn, Amity E; Hodgkin, Dominic; Perloff, Jennifer N; Stewart, Maureen T; Brolin, Mary; Lane, Nancy; Horgan, Constance M

2017-11-01

Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care. Copyright © 2017 Elsevier Inc. All rights reserved.

Are health-based payments a feasible tool for addressing risk segmentation?

PubMed

Rogal, D L; Gauthier, A K

1998-01-01

As they attempt to increase health insurance coverage and improve the efficiency of the market, researchers, policymakers, and health plan representatives have been addressing the issue of risk segmentation. Many risk assessment tools and risk-adjusted payment methodologies have been developed and demonstrated for a variety of populations and payers experiencing various market constraints. The evidence shows that risk-adjusted payments are feasible for most populations receiving acute care, while technical obstacles, political issues, and some research gaps remain.

Needs for further improvement: risk adjustment in the German health insurance system.

PubMed

Buchner, Florian; Wasem, Jürgen

2003-07-01

The German risk adjustment mechanism is used only within the public system. It was introduced in two steps, 1994 and 1995. Because of the income-related contribution, which the insured pay directly to their sickness fund, income of the insured is equalized by the mechanism and causes the biggest part of the payments among the sickness funds. On the expenditure side age, gender, disability and entitlement for sickness allowances are used as risk adjusters. The mechanism is retrospective, calculating average costs for each of the 670 risk cells defined by the risk adjusters and using these "standardized expenditures" as a base for the payment a single sickness fund gets because of its risk structure. There do still exist incentives for risk selection. The experience shows that mostly the young and healthy are willing to change sickness funds motivated by lower contribution rates. This can be used and is used for self-selection. Another cause of risk selection is regional differences. The central suggestion of an expertise on behalf of the German Ministry of Health on experiences and improvement proposals is the change to a direct modeling of morbidity.

Drivers behind widespread informal payments in the Romanian public health care system: From tolerance to corruption to socio-economic and spatial patterns.

PubMed

Horodnic, Adrian V; Mazilu, Sorin; Oprea, Liviu

2018-03-15

In order to explain informal payments in public health care services in Romania, this paper evaluates the relationship between extra payments or valuable gifts (apart from official fees) and the level of tolerance to corruption, as well as the socio-economic and spatial patterns across those individuals offering informal payments. To evaluate this, a survey undertaken in 2013 is reported. Using logistic regression analysis, the findings are that patients with a high tolerance to corruption, high socio-economic risk (those divorced, separated, or with other form of marital status, and those not working), and located in rural or less affluent areas are more likely to offer (apart from official fees) extra payments or valuable gifts for health care services. The paper concludes by discussing the health policy implications. Copyright © 2018 John Wiley & Sons, Ltd.

Competitive bidding for health insurance contracts.

PubMed

Keijser, G M; Kirkman-Liff, B L

1992-05-01

The determination of the payment or premium to be paid to the insurer by a large purchaser of care must accurately represent the risk of the enrolled persons. One approach is a risk-adjusted payment established by a mathematical formula, which estimates the effect of many variables on total care costs, and for different groups of persons determine an average cost. This method has several problems, and an alternative is competitive bidding. Market forces pressure providers to offer the lowest possible bids while attempting to remain fiscally viable and provide high-quality services. Research from the U.S. demonstrates that competitive contracting effectively lowered the costs of health care for those sectors of the health care system that used this strategy. Bidding by area gave far more equitable results than could have been obtained with a state-wide system with crude adjustments for each area. It is an alternative which can create strong incentives for innovation and cost-containment, and at the same time allows insurers to take into account local variation in supply and demand of care. As a potential alternative to a regulatory system, competitive bidding should be considered for regional experimentation in health insurer payment.

Out-of-pocket medical expenses for inpatient care among beneficiaries of the National Health Insurance Program in the Philippines.

PubMed

Tobe, Makoto; Stickley, Andrew; del Rosario, Rodolfo B; Shibuya, Kenji

2013-08-01

OBJECTIVE The National Health Insurance Program (NHIP) in the Philippines is a social health insurance system partially subsidized by tax-based financing which offers benefits on a fee-for-service basis up to a fixed ceiling. This paper quantifies the extent to which beneficiaries of the NHIP incur out-of-pocket expenses for inpatient care, and examines the characteristics of beneficiaries making these payments and the hospitals in which these payments are typically made. METHODS Probit and ordinary least squares regression analyses were carried out on 94 531 insurance claims from Benguet province and Baguio city during the period 2007 to 2009. RESULTS Eighty-six per cent of claims involved an out-of-pocket payment. The median figure for out-of-pocket payments was Philippine Pesos (PHP) 3016 (US$67), with this figure varying widely [inter-quartile range (IQR): PHP 9393 (US$209)]. Thirteen per cent of claims involved very large out-of-pocket payments exceeding PHP 19 213 (US$428)-the equivalent of 10% of the average annual household income in the region. Membership type, disease severity, age and residential location of the patient, length of hospitalization, and ownership and level of the hospital were all significantly associated with making out-of-pocket payments and/or the size of these payments. CONCLUSION Although the current NHIP reduces the size of out-of-pocket payments, NHIP beneficiaries are not completely free from the risk of large out-of-pocket payments (as the size of these payments varies widely and can be extremely large), despite NHIP's attempts to mitigate this by setting different benefit ceilings based on the level of the hospital and the severity of the disease. To reduce these large out-of-pocket payments and to increase financial risk protection further, it is essential to ensure more investment for health from social health insurance and/or tax-based government funding as well as shifting the provider payment mechanism from a fee-for-service to a case-based payment method (which up until now has only been partially implemented).

Comparison of cost accounting methods from different DRG systems and their effect on health care quality.

PubMed

Leister, Jan Eric; Stausberg, Jürgen

2005-09-28

Diagnosis related groups (DRGs) are a well-established provider payment system. Because of their imminent potential of cost reduction, they have been widely introduced. In addition to cost cutting, several social objectives - e.g., improving overall health care quality - feed into the DRG system. The WHO compared different provider payment systems with regard to the following objectives: prevention of further health problems, providing services and solving health problems, and responsiveness to people's legitimate expectations. However, no study has been published which takes the impact of different cost accounting systems across the DRG systems into account. We compared the impact of different cost accounting methods within DRG-like systems by developing six criteria: integration of patients' health risk into pricing practice, incentives for quality improvement and innovation, availability of high class evidence based therapy, prohibition of economically founded exclusions, reduction of fragmentation incentives, and improvement of patient oriented treatment. We set up a first overview of potential and actual impacts of the pricing practices within Yale-DRGs, AR-DRGs, G-DRGs, Swiss AP-DRGs adoption and Swiss MIPP. It could be demonstrated that DRGs are not only a 'homogenous' group of similar provider payment systems but quite different by fulfilling major health care objectives connected with the used cost accounting methods. If not only the possible cost reduction is used to put in a good word for DRG-based provider payment systems, maximum accurateness concerning the method of cost accounting should prevail when implementing a new DRG-based provider payment system.

Multiple Sources of Prescription Payment and Risky Opioid Therapy Among Veterans.

PubMed

Becker, William C; Fenton, Brenda T; Brandt, Cynthia A; Doyle, Erin L; Francis, Joseph; Goulet, Joseph L; Moore, Brent A; Torrise, Virginia; Kerns, Robert D; Kreiner, Peter W

2017-07-01

Opioid overdose and other related harms are a major source of morbidity and mortality among US Veterans, in part due to high-risk opioid prescribing. We sought to determine whether having multiple sources of payment for opioids-as a marker for out-of-system access-is associated with risky opioid therapy among veterans. Cross-sectional study examining the association between multiple sources of payment and risky opioid therapy among all individuals with Veterans Health Administration (VHA) payment for opioid analgesic prescriptions in Kentucky during fiscal year 2014-2015. Source of payment categories: (1) VHA only source of payment (sole source); (2) sources of payment were VHA and at least 1 cash payment [VHA+cash payment(s)] whether or not there was a third source of payment; and (3) at least one other noncash source: Medicare, Medicaid, or private insurance [VHA+noncash source(s)]. Our outcomes were 2 risky opioid therapies: combination opioid/benzodiazepine therapy and high-dose opioid therapy, defined as morphine equivalent daily dose ≥90 mg. Of the 14,795 individuals in the analytic sample, there were 81.9% in the sole source category, 6.6% in the VHA+cash payment(s) category, and 11.5% in the VHA+noncash source(s) category. In logistic regression, controlling for age and sex, persons with multiple payment sources had significantly higher odds of each risky opioid therapy, with those in the VHA+cash having significantly higher odds than those in the VHA+noncash source(s) group. Prescribers should examine the prescription monitoring program as multiple payment sources increase the odds of risky opioid therapy.

Payment reform to finance a medical home: comment on "Achieving cost control, care coordination, and quality improvement through incremental payment system reform".

PubMed

McGuire, Thomas G

2010-01-01

This commentary on R. F. Averill et al. (2010) addresses their idea of risk and quality adjusting fee-for-service payments to primary care physicians in order to improve the efficiency of primary care and take a step toward financing a "medical home"for patients. I show how their idea can create incentives for efficient practice styles. Pairing this with an active beneficiary choice of primary care physician with an enrollment fee would make the idea easier to implement and provide an incentive and the financing for elements of service not covered by procedure-based fees.

42 CFR 422.208 - Physician incentive plans: requirements and limitations.

Code of Federal Regulations, 2011 CFR

2011-10-01

... of reducing or limiting the services provided to any plan enrollee. Potential payments means the... determination. (2) Risk threshold. The risk threshold is 25 percent of potential payments. (3) Arrangements that...) Withholds greater than 25 percent of potential payments. (ii) Withholds less than 25 percent of potential...

42 CFR 422.208 - Physician incentive plans: requirements and limitations.

Code of Federal Regulations, 2010 CFR

2010-10-01

... of reducing or limiting the services provided to any plan enrollee. Potential payments means the... determination. (2) Risk threshold. The risk threshold is 25 percent of potential payments. (3) Arrangements that...) Withholds greater than 25 percent of potential payments. (ii) Withholds less than 25 percent of potential...

Risk Adjustment May Lessen Penalties On Hospitals Treating Complex Cardiac Patients Under Medicare's Bundled Payments.

PubMed

Markovitz, Adam A; Ellimoottil, Chandy; Sukul, Devraj; Mullangi, Samyukta; Chen, Lena M; Nallamothu, Brahmajee K; Ryan, Andrew M

2017-12-01

To reduce variation in spending, Medicare has considered implementing a cardiac bundled payment program for acute myocardial infarction and coronary artery bypass graft. Because the proposed program does not account for patient risk factors when calculating hospital penalties or rewards ("reconciliation payments"), it might unfairly penalize certain hospitals. We estimated the impact of adjusting for patients' medical complexity and social risk on reconciliation payments for Medicare beneficiaries hospitalized for the two conditions in the period 2011-13. Average spending per episode was $29,394. Accounting for medical complexity substantially narrowed the gap in reconciliation payments between hospitals with high medical severity (from a penalty of $1,809 to one of $820, or a net reduction of $989), safety-net hospitals (from a penalty of $217 to one of $87, a reduction of $130), and minority-serving hospitals (from a penalty of $70 to a reward of $56, an improvement of $126) and their counterparts. Accounting for social risk alone narrowed these gaps but had minimal incremental effects after medical complexity was accounted for. Risk adjustment may preserve incentives to care for patients with complex conditions under Medicare bundled payment programs.

Health-Based Capitation Risk Adjustment in Minnesota Public Health Care Programs

PubMed Central

Gifford, Gregory A.; Edwards, Kevan R.; Knutson, David J.

2004-01-01

This article documents the history and implementation of health-based capitation risk adjustment in Minnesota public health care programs, and identifies key implementation issues. Capitation payments in these programs are risk adjusted using an historical, health plan risk score, based on concurrent risk assessment. Phased implementation of capitation risk adjustment for these programs began January 1, 2000. Minnesota's experience with capitation risk adjustment suggests that: (1) implementation can accelerate encounter data submission, (2) administrative decisions made during implementation can create issues that impact payment model performance, and (3) changes in diagnosis data management during implementation may require changes to the payment model. PMID:25372356

42 CFR 422.252 - Terminology.

Code of Federal Regulations, 2011 CFR

2011-10-01

... a nationally average risk profile for the factors described in § 422.308(c), and this amount is... risk profile for the risk factors CMS applies to payment calculations as set forth at § 422.308(c) of... eligible beneficiary with a nationally average risk profile for the risk factors CMS applies to payment...

42 CFR 412.540 - Method of payment for preadmission services under the long-term care hospital prospective payment...

Code of Federal Regulations, 2010 CFR

2010-10-01

... the long-term care hospital prospective payment system. 412.540 Section 412.540 Public Health CENTERS... PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals... payment system. The prospective payment system includes payment for inpatient operating costs of...

Congressional Oversight of Intelligence: Current Structure and Alternatives

DTIC Science & Technology

2012-03-14

Intelligence Information, by Richard A. Best Jr.; CRS Report RL33639, Sources of Systemic Risk in Large Value Interbank Payment Systems, by Edward V. Murphy...Numerous initiatives to change Congress’s oversight structure have materialized in the meantime, including, most importantly, the creation of parallel... Risk : Report, available at http://www.preventionwmd.gov/report, p. 9. 12 Kay King, Congress and National Security, Council on Foreign Relations

A Sea Change in Medicine: Current Shifts in the Delivery and Payment of Medical Care.

PubMed

Bruch, Richard

2016-01-01

The Patient Protection and Affordable Care Act and the Triple Aim are driving a shift toward value-based care. Significant financial risk is being transferred from commercial insurers and government payers to hospital systems and independent physician groups. Medicare has developed bundled payment programs, but legislative barriers still impede the implementation of value-based health care. ©2016 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

PACE and the Medicare+Choice risk-adjusted payment model.

PubMed

Temkin-Greener, H; Meiners, M R; Gruenberg, L

2001-01-01

This paper investigates the impact of the Medicare principal inpatient diagnostic cost group (PIP-DCG) payment model on the Program of All-Inclusive Care for the Elderly (PACE). Currently, more than 6,000 Medicare beneficiaries who are nursing home certifiable receive care from PACE, a program poised for expansion under the Balanced Budget Act of 1997. Overall, our analysis suggests that the application of the PIP-DCG model to the PACE program would reduce Medicare payments to PACE, on average, by 38%. The PIP-DCG payment model bases its risk adjustment on inpatient diagnoses and does not capture adequately the risk of caring for a population with functional impairments.

42 CFR 423.329 - Determination of payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... subsidy payments as provided under paragraph (d) of this section. (b) Health status risk adjustment—(1) Establishment of risk factors. CMS establishes an appropriate methodology for adjusting the standardized bid... risk adjustment factors under § 422.312(a)(1)(ii) of this chapter, CMS publishes the risk adjusters...

42 CFR 423.329 - Determination of payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... subsidy payments as provided under paragraph (d) of this section. (b) Health status risk adjustment—(1) Establishment of risk factors. CMS establishes an appropriate methodology for adjusting the standardized bid... risk adjustment factors under § 422.312(a)(1)(ii) of this chapter, CMS publishes the risk adjusters...

46 CFR 308.515 - Payment in event of loss.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Open Policy War Risk Cargo Insurance § 308.515 Payment in event of loss. All... claims must be supported by the customary documents required in connection with war risk insurance claims...

Legal and ethical implications of health care provider insurance risk assumption.

PubMed

Cox, Thomas

2010-01-01

From bedside to boardroom, nurses deal with the consequences of health care provider insurance risk assumption. Professional caregiver insurance risk refers to insurance risks assumed through contracts with third parties, federal and state Medicare and Medicaid program mandates, and the diagnosis-related groups and Prospective Payment Systems. This article analyzes the financial, legal, and ethical implications of provider insurance risk assumption by focusing on the degree to which patient benefits are reduced.

46 CFR 308.513 - Payment of premiums and fees.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Open Policy War Risk Cargo Insurance § 308.513 Payment of premiums and fees. The... ”Maritime Administration, Department of Transportation.” ...

76 FR 13292 - Medicare Program: Changes to the Hospital Outpatient Prospective Payment System and CY 2011...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-11

... Prospective Payment System and CY 2011 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Changes to Payments to Hospitals for Graduate Medical Education Costs..., 2010, entitled ``Medicare Program: Hospital Outpatient Prospective Payment System and CY 2011 Payment...

Assessing the catastrophic effects of out-of-pocket healthcare payments prior to the uptake of a nationwide health insurance scheme in Ghana

PubMed Central

Akazili, James; McIntyre, Diane; Kanmiki, Edmund W.; Gyapong, John; Oduro, Abraham; Sankoh, Osman; Ataguba, John E.

2017-01-01

ABSTRACT Background: Financial risk protection against the cost of unforeseen healthcare has gained global attention in recent years. Although Ghana implemented a nationwide health insurance scheme with a goal of reducing financial barriers to accessing healthcare and addressing impoverishing effects of out-of-pocket (OOP) healthcare payments, there is a paucity of knowledge on the extent of financial catastrophe of such payments in Ghana. Thus, this paper assesses the catastrophic effect of OOP healthcare payments in Ghana. Methods: Ghana Living Standard Survey (GLSS 5) data collected in 2005/2006 are used in this study. Catastrophic effect of OOP healthcare payments is assessed using various thresholds of total household expenditure and non-food expenditure. Furthermore, four indices, namely the catastrophic payment headcount, catastrophic payment gap, weighted catastrophic payment headcount and weighted catastrophic payment gap, are defined and computed. Results: As at 2005/2006, it was estimated that 11.0% of households in Ghana spent over 5% of their total household expenditure on healthcare OOP. However, after adjusting for the concentration of such spending, it decreased to 10.9%. Also 10.7% of households spent more than 10% of their non-food consumption expenditure on OOP healthcare payments. Furthermore, about 2.6% of households are observed to have spent in excess of 20% of their total household income on healthcare OOP. With the exception of the 5% threshold of household expenditure, because the concentration indices of these expenditures are negative, the burden of such expenditures rests more on the poor. Conclusions: Significant levels of financial catastrophe existed in Ghana prior to the uptake of the national health insurance scheme. Poorer households were at a higher risk than the relatively well-off households. The results of this study present baseline assessment of the impact of Ghana’s health insurance policy on catastrophic healthcare payments. Thus, there is a need for continuous monitoring of financial catastrophe in the system to ensure that households are adequately protected. PMID:28485675

PQRS Mess.

PubMed

Sorrel, Amy Lynn

2016-03-01

One-quarter of physicians who participate in the Physician Quality Reporting System and the value modifier program risked payment cuts stemming from difficulties the Centers for Medicare & Medicaid Services had with collecting and analyzing 2014 quality data.

Integrating payer and provider risk through capitation.

PubMed

Barth, S M

1997-01-01

Capitation payment mechanisms promote conservative use of medical resources by transferring risk to the decision maker, the physician. However, there is another view of capitation: defining common risk between provider-driven organizations (i.e., physician/hospital organizations (PHOs) or integrated delivery systems (IDS), and risk-managing entities such as HMOs or insurance companies. This article discusses a strategy to align provider and risk manager incentives to share the risks and rewards for a total book of business or population.

42 CFR 423.315 - General payment provisions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336. (f...). (2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do...

42 CFR 423.315 - General payment provisions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336. (f...). (2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do...

42 CFR 423.315 - General payment provisions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336. (f...). (2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do...

42 CFR 423.315 - General payment provisions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336. (f...). (2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do...

42 CFR 423.315 - General payment provisions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... following payment year based on the relationship of the Part D plan's adjusted allowable risk corridor costs to predetermined risk corridor thresholds in the coverage year as provided in § 423.336. (f...). (2) Exemption from risk corridor provisions. The provisions of § 423.336 regarding risk sharing do...

46 CFR 308.515 - Payment in event of loss.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.515 Payment in event of loss. All... claims must be supported by the customary documents required in connection with war risk insurance claims...

46 CFR 308.515 - Payment in event of loss.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.515 Payment in event of loss. All... claims must be supported by the customary documents required in connection with war risk insurance claims...

A model to determine payments associated with radiology procedures.

PubMed

Mabotuwana, Thusitha; Hall, Christopher S; Thomas, Shiby; Wald, Christoph

2017-12-01

Across the United States, there is a growing number of patients in Accountable Care Organizations and under risk contracts with commercial insurance. This is due to proliferation of new value-based payment models and care delivery reform efforts. In this context, the business model of radiology within a hospital or health system context is shifting from a primary profit-center to a cost-center with a goal of cost savings. Radiology departments need to increasingly understand how the transactional nature of the business relates to financial rewards. The main challenge with current reporting systems is that the information is presented only at an aggregated level, and often not broken down further, for instance, by type of exam. As such, the primary objective of this research is to provide better visibility into payments associated with individual radiology procedures in order to better calibrate expense/capital structure of the imaging enterprise to the actual revenue or value-add to the organization it belongs to. We propose a methodology that can be used to determine technical payments at a procedure level. We use a proportion based model to allocate payments to individual radiology procedures based on total charges (which also includes non-radiology related charges). Using a production dataset containing 424,250 radiology exams we calculated the overall average technical charge for Radiology to be $873.08 per procedure and the corresponding average payment to be $326.43 (range: $48.27 for XR and $2750.11 for PET/CT) resulting in an average payment percentage of 37.39% across all exams. We describe how charges associated with a procedure can be used to approximate technical payments at a more granular level with a focus on Radiology. The methodology is generalizable to approximate payment for other services as well. Understanding payments associated with each procedure can be useful during strategic practice planning. Charge-to-total charge ratio can be used to approximate radiology payments at a procedure level. Copyright © 2017 Elsevier B.V. All rights reserved.

Customer-Specific Transaction Risk Management in E-Commerce

NASA Astrophysics Data System (ADS)

Ruch, Markus; Sackmann, Stefan

Increasing potential for turnover in e-commerce is inextricably linked with an increase in risk. Online retailers (e-tailers), aiming for a company-wide value orientation should manage this risk. However, current approaches to risk management either use average retail prices elevated by an overall risk premium or restrict the payment methods offered to customers. Thus, they neglect customer-specific value and risk attributes and leave turnover potentials unconsidered. To close this gap, an innovative valuation model is proposed in this contribution that integrates customer-specific risk and potential turnover. The approach presented evaluates different payment methods using their risk-turnover characteristic, provides a risk-adjusted decision basis for selecting payment methods and allows e-tailers to derive automated risk management decisions per customer and transaction without reducing turnover potential.

48 CFR 215.404-71-3 - Contract type risk and working capital adjustment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... provisions for performance-based payments, do not compute a working capital adjustment. (d) Evaluation... working capital adjustment. 215.404-71-3 Section 215.404-71-3 Federal Acquisition Regulations System... CONTRACTING BY NEGOTIATION Contract Pricing 215.404-71-3 Contract type risk and working capital adjustment. (a...

48 CFR 952.223-76 - Conditional payment of fee or profit-safeguarding restricted data and other classified...

Code of Federal Regulations, 2011 CFR

2011-10-01

..., which may be included in the DOE approved contractor Integrated Safety Management System (ISMS). The... DOE directives actually resulting in, or creating a risk of, loss, compromise, or unauthorized... compartmented information (SCI), or high risk nuclear weapons-related data. (ii) Contractor actions that result...

Effect of medicare payment on rural health care systems.

PubMed

McBride, Timothy D; Mueller, Keith J

2002-01-01

Medicare payments constitute a significant share of patient-generated revenues for rural providers, more so than for urban providers. Therefore, Medicare payment policies influence the behavior of rural providers and determine their financial viability. Health services researchers need to contribute to the understanding of the implications of changes in fee-for-service payment policy, prospects for change because of the payment to Medicare+Choice risk plans, and implications for rural providers inherent in any restructuring of the Medicare program. This article outlines the basic policy choices, implications for rural providers and Medicare beneficiaries, impacts of existing research, and suggestions for further research. Topics for further research include implications of the Critical Access Hospital program, understanding how changes in payment to rural hospitals affect patient care, developing improved formulas for paying rural hospitals, determining the payment-to-cost ratio for physicians, measuring the impact of changes in the payment methodology used to pay for services delivered by rural health clinics and federally qualified health centers, accounting for the reasons for differences in historical Medicare expenditures across rural counties and between rural and urban counties, explicating all reasons for Medicare+Choice plans withdrawing from some rural areas and entering others, measuring the rural impact of proposals to add a prescription drug benefit to the Medicare program, and measuring the impact of Medicare payment policies on rural economies.

For-profit medicare home health agencies' costs appear higher and quality appears lower compared to nonprofit agencies.

PubMed

Cabin, William; Himmelstein, David U; Siman, Michael L; Woolhandler, Steffie

2014-08-01

For-profit, or proprietary, home health agencies were banned from Medicare until 1980 but now account for a majority of the agencies that provide such services. Medicare home health costs have grown rapidly since the implementation of a risk-based prospective payment system in 2000. We analyzed recent national cost and case-mix-adjusted quality outcomes to assess the performance of for-profit and nonprofit home health agencies. For-profit agencies scored slightly but significantly worse on overall quality indicators compared to nonprofits (77.18 percent and 78.71 percent, respectively). Notably, for-profit agencies scored lower than nonprofits on the clinically important outcome "avoidance of hospitalization" (71.64 percent versus 73.53 percent). Scores on quality measures were lowest in the South, where for-profits predominate. Compared to nonprofits, proprietary agencies also had higher costs per patient ($4,827 versus $4,075), were more profitable, and had higher administrative costs. Our findings raise concerns about whether for-profit agencies should continue to be eligible for Medicare payments and about the efficiency of Medicare's market-oriented, risk-based home care payment system. Project HOPE—The People-to-People Health Foundation, Inc.

Association Between State Medical Malpractice Environment and Surgical Quality and Cost in the United States.

PubMed

Bilimoria, Karl Y; Sohn, Min-Woong; Chung, Jeanette W; Minami, Christina A; Oh, Elissa H; Pavey, Emily S; Holl, Jane L; Black, Bernard S; Mello, Michelle M; Bentrem, David J

2016-06-01

The US medical malpractice system is designed to deter negligence and encourage quality of care through threat of liability. To examine whether state-level malpractice environment is associated with outcomes and costs of colorectal surgery. Observational study of 116,977 Medicare fee-for-service beneficiaries who underwent colorectal surgery using administrative claims data. State-level malpractice risk was measured using mean general surgery malpractice insurance premiums; paid claims per surgeon; state tort reforms; and a composite measure. Associations between malpractice environment and postoperative outcomes and price-standardized Medicare payments were estimated using hierarchical logistic regression and generalized linear models. thirty-day postoperative mortality; complications (pneumonia, myocardial infarction, venous thromboembolism, acute renal failure, surgical site infection, postoperative sepsis, any complication); readmission; total price-standardized Medicare payments for index hospitalization and 30-day postdischarge episode-of-care. Few associations between measures of state malpractice risk environment and outcomes were identified. However, analyses using the composite measure showed that patients treated in states with greatest malpractice risk were more likely than those in lowest risk states to experience any complication (OR: 1.31; 95% CI: 1.22-1.41), pneumonia (OR: 1.36; 95%: CI, 1.16-1.60), myocardial infarction (OR: 1.44; 95% CI: 1.22-1.70), venous thromboembolism (OR:2.11; 95% CI: 1.70-2.61), acute renal failure (OR: 1.34; 95% CI; 1.22-1.47), and sepsis (OR: 1.38; 95% CI: 1.24-1.53; all P < 0.001). There were no consistent associations between malpractice environment and Medicare payments. There were no consistent associations between state-level malpractice risk and higher quality of care or Medicare payments for colorectal surgery.

77 FR 21775 - Risk Adjustment Meeting-May 7, 2012 and May 8, 2012

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-11

... notice announces a meeting on the risk adjustment program, which is open to the public. The purpose of... plan average actuarial risk, calculation of payments and charges, data collection approach, and the..., calculation of payments and charges, data collection approach, and the schedule for running risk adjustment...

46 CFR 308.513 - Payment of premiums and fees.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.513 Payment of premiums and fees... payable to the order of the “Maritime Administration, Department of Transportation.” ...

46 CFR 308.513 - Payment of premiums and fees.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.513 Payment of premiums and fees... payable to the order of the “Maritime Administration, Department of Transportation.” ...

46 CFR 308.513 - Payment of premiums and fees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.513 Payment of premiums and fees... payable to the order of the “Maritime Administration, Department of Transportation.” ...

46 CFR 308.513 - Payment of premiums and fees.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.513 Payment of premiums and fees... payable to the order of the “Maritime Administration, Department of Transportation.” ...

Medicare home health care patient case-mix before and after the Balanced Budget Act of 1997: effect on dual eligible beneficiaries.

PubMed

Shih, Huai-Che; Temkin-Greener, Helena; Votava, Kathryn; Friedman, Bruce

2014-01-01

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.

42 CFR 412.110 - Total Medicare payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.110 Total Medicare payment. Under the prospective payment systems, Medicare... 42 Public Health 2 2010-10-01 2010-10-01 false Total Medicare payment. 412.110 Section 412.110...

What Financial Incentives Will Be Created by Medicare Bundled Payments for Total Hip Arthroplasty?

PubMed

Clement, R Carter; Kheir, Michael M; Soo, Adrianne E; Derman, Peter B; Levin, L Scott; Fleisher, Lee A

2016-09-01

Bundled payments are gaining popularity in arthroplasty as a tactic for encouraging providers and hospitals to work together to reduce costs. However, this payment model could potentially motivate providers to avoid unprofitable patients, limiting their access to care. Rigorous risk adjustment can prevent this adverse effect, but most current bundling models use limited, if any, risk-adjustment techniques. This study aims to identify and quantify the financial incentives that are likely to develop with total hip arthroplasty (THA) bundled payments that are not accompanied by comprehensive risk stratification. Financial data were collected for all Medicare-eligible patients (age 65+) undergoing primary unilateral THA at an academic center over a 2-year period (n = 553). Bundles were considered to include operative hospitalizations and unplanned readmissions. Multivariate regression was performed to assess the impact of clinical and demographic factors on the variable cost of THA episodes, including unplanned readmissions. (Variable costs reflect the financial incentives that will emerge under bundled payments). Increased costs were associated with advanced age (P < .001), elevated body mass index (BMI; P = .005), surgery performed for hip fracture (P < .001), higher American Society of Anaesthesiologists (ASA) Physical Classification System grades (P < .001), and MCCs (Medicare modifier for major complications; P < .001). Regression coefficients were $155/y, $107/BMI point, $2775 for fracture cases, $2137/ASA grade, and $4892 for major complications. No association was found between costs and gender or race. If generalizable, our results suggest that Centers for Medicare and Medicaid Services bundled payments encompassing acute inpatient care should be adjusted upward by the aforementioned amounts (regression coefficients above) for advanced age, increasing BMI, cases performed for fractures, elevated ASA grade, and major complications (as defined by Medicare MCC modifiers). Furthermore, these figures likely underestimate costs in many bundling models which incorporate larger proportions of postdischarge care. Failure to adjust for factors affecting costs may create barriers to care for specific patient populations. Copyright © 2016 Elsevier Inc. All rights reserved.

42 CFR 412.604 - Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment system for inpatient rehabilitation facilities. 412.604 Section 412.604 Public Health CENTERS FOR... SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment for Inpatient Rehabilitation Hospitals and Rehabilitation Units § 412.604 Conditions for payment under the prospective payment system for inpatient...

An E-payment system based on quantum group signature

NASA Astrophysics Data System (ADS)

Xiaojun, Wen

2010-12-01

Security and anonymity are essential to E-payment systems. However, existing E-payment systems will easily be broken into soon with the emergence of quantum computers. In this paper, we propose an E-payment system based on quantum group signature. In contrast to classical E-payment systems, our quantum E-payment system can protect not only the users' anonymity but also the inner structure of customer groups. Because of adopting the two techniques of quantum key distribution, a one-time pad and quantum group signature, unconditional security of our E-payment system is guaranteed.

75 FR 50041 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-16

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals...

42 CFR 412.125 - Effect of change of ownership on payments under the prospective payment systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... prospective payment systems. 412.125 Section 412.125 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.125 Effect of change of...

Assessment of Conflicts of Interest in Robotic Surgical Studies: Validating Author's Declarations With the Open Payments Database.

PubMed

Patel, Sunil V; Yu, David; Elsolh, Basheer; Goldacre, Ben M; Nash, Garrett M

2017-07-11

Accurate conflict of interest (COI) statements are important, as a known COI may invalidate study results due to the potential risk of bias. To determine the accuracy of self-declared COI statements in robotic studies and identify risk factors for undeclared payments. Robotic surgery studies were identified through EMBASE and MEDLINE and included if published in 2015 and had at least one American author. Undeclared COI were determined by comparing the author's declared COI with industry reported payments found in the "Open Payments" database for 2013 and 2014. Undeclared payments and discrepancies in the COI statement were determined. Risk factors were assessed for an association with undeclared payments at the author and study level. A total of 458 studies (2253 authors) were included. Approximately, 240 (52%) studies had 1 or more author receive undeclared payments and included 183 where "no COI" was explicitly declared, and 57 with no declaration statement present. Moreover, 21% of studies and 18% of authors with a COI declared it so in a COI statement. Studies that had undeclared payments from Intuitive were more likely to recommend robotic surgery compared with those that declared funding (odds ratio 4.29, 95% confidence interval 2.55-7.21). We found that it was common for payments from Intuitive to be undeclared in robotic surgery articles. Mechanisms for accountability in COI reporting need to be put into place by journals to achieve appropriate transparency to those reading the journal article.

Early experience with a new model of employer group purchasing in Minnesota.

PubMed

Christianson, J; Feldman, R; Weiner, J P; Drury, P

1999-01-01

The Buyers Health Care Action Group (BHCAG) in the Twin Cities has implemented a new purchasing initiative that offers employees a choice among care systems with nonoverlapping networks of primary care providers. These systems offer a standardized benefit package, submit annual bids, and are paid on a risk-adjusted basis. Employees are provided with information on quality and other differences among systems, and most have financial incentives to choose lower-cost systems. Generally, providers have responded favorably to direct contracting and to risk-adjusted payments but have concerns about the risk-adjustment mechanism used and, more importantly, the strength of employers' commitment to the purchasing model.

46 CFR 308.515 - Payment in event of loss.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.515 Payment in event of loss. All..., together with appropriate declarations as required by Clause 9, and such further data as may now or...

46 CFR 308.515 - Payment in event of loss.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Risk Cargo Insurance Ii-Open Policy War Risk Cargo Insurance § 308.515 Payment in event of loss. All..., together with appropriate declarations as required by Clause 9, and such further data as may now or...

Capitation and risk adjustment in health care financing: an international progress report.

PubMed

Rice, N; Smith, P C

2001-01-01

In every system of health care, capitation payments have become the accepted tool used by health care purchasers in much of the developed world to determine prospective budgets. The policy prescription of capitation is perceived to address both equity objectives (of great importance in publicly funded systems of health care) and efficiency objectives (the dominant concern in competitive insurance markets). An examination of the current state of the art in 20 countries outside the United States in which health care capitation has been implemented confirms that capitation has assumed central importance within diverse systems of health care. In practice, however, the setting of capitation payments has been heavily constrained to date by poor data availability and unsatisfactory analytic methodology.

US approaches to physician payment: the deconstruction of primary care.

PubMed

Berenson, Robert A; Rich, Eugene C

2010-06-01

The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the "hamster on a treadmill" problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients' best interests. Most payers don't employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, "time is money;" extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes.

Impact of nitrogen reduction measures on nitrogen surplus, income and production of German agriculture.

PubMed

Gömann, H; Kreins, P; Møller, C

2004-01-01

Among the numerous non-point sources of diffuse water pollution with nitrogen, agriculture is counted one of the main sources. The agricultural policies of the Agenda 2000 and a decoupling of direct payments for farmers from their production decisions are exemplarily evaluated as nitrogen reduction measures using the Regional Agricultural and Environmental Information System RAUMIS. The results show that until the target year 2010 the risk of diffuse pollution of water bodies with nitrogen is a regional problem in Germany. These problems are neither mitigated by the policies of Agenda 2000 nor by a decoupling of direct payments from production decisions of farmers. While total nitrogen surplus reduces considerably after a decoupling of direct payments due to decreases of land-use the nitrogen surplus on the remaining cultivated area increases resulting from structural changes. Granting the same amount of direct payments to farmers in both policy alternatives the agricultural sector income would be higher after a decoupling of direct payments opposed to the Agenda 2000 resulting from a more efficient allocation of inputs.

20 CFR 411.525 - What payments are available under each of the EN payment systems?

Code of Federal Regulations, 2012 CFR

2012-04-01

... EN payment systems? 411.525 Section 411.525 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.525 What payments... beneficiary. For each month during the beneficiary's outcome payment period for which Social Security...

20 CFR 411.525 - What payments are available under each of the EN payment systems?

Code of Federal Regulations, 2013 CFR

2013-04-01

... EN payment systems? 411.525 Section 411.525 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.525 What payments... beneficiary. For each month during the beneficiary's outcome payment period for which Social Security...

20 CFR 411.525 - What payments are available under each of the EN payment systems?

Code of Federal Regulations, 2014 CFR

2014-04-01

... EN payment systems? 411.525 Section 411.525 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.525 What payments... beneficiary. For each month during the beneficiary's outcome payment period for which Social Security...

75 FR 64173 - Notice of Proposed Rulemaking Implementing Certain Orderly Liquidation Authority Provisions of...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-19

... Title II reflects the Dodd-Frank Act's mandate of transparency in the liquidation of failing systemic... in all other cases. This procedure is similar to that which is applied to systemic risk... payments will be enforced. Parties who are familiar with the liquidation of insured depository institutions...

75 FR 61252 - Proposed Information Collection (Create Payment Request for the VA Funding Fee Payment System (VA...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-04

... Payment Request for the VA Funding Fee Payment System (VA FFPS); A Computer Generated Funding Fee Receipt... Payment Request for the VA Funding Fee Payment System (VA FFPS); A Computer Generated Funding Fee Receipt... information through the Federal Docket Management System (FDMS) at http://www.Regulations.gov or to Nancy J...

75 FR 61859 - Proposed Information Collection (Create Payment Request for the VA Funding Fee Payment System (VA...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-06

... Payment Request for the VA Funding Fee Payment System (VA FFPS); A Computer Generated Funding Fee Receipt... Payment Request for the VA Funding Fee Payment System (VA FFPS); A Computer Generated Funding Fee Receipt... information through the Federal Docket Management System (FDMS) at http://www.Regulations.gov or to Nancy J...

42 CFR 412.300 - Scope of subpart and definition.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment... payment system for inpatient hospital capital-related costs. Under this system, payment is made on the... hospitals subject to the prospective payment system under subpart B of this part. (b) Definition. For...

41 CFR 301-73.301 - How do we obtain travel payment system services?

Code of Federal Regulations, 2010 CFR

2010-07-01

... payment system services? 301-73.301 Section 301-73.301 Public Contracts and Property Management Federal... PROGRAMS Travel Payment System § 301-73.301 How do we obtain travel payment system services? You may participate in GSA's or another Federal agency's travel payment system services program or you may contract...

A Third-Party E-payment Protocol Based on Quantum Multi-proxy Blind Signature

NASA Astrophysics Data System (ADS)

Niu, Xu-Feng; Zhang, Jian-Zhong; Xie, Shu-Cui; Chen, Bu-Qing

2018-05-01

A third-party E-payment protocol is presented in this paper. It is based on quantum multi-proxy blind signature. Adopting the techniques of quantum key distribution, one-time pad and quantum multi-proxy blind signature, our third-party E-payment system could protect user's anonymity as the traditional E-payment systems do, and also have unconditional security which the classical E-payment systems can not provide. Furthermore, compared with the existing quantum E-payment systems, the proposed system could support the E-payment which using the third-party platforms.

Medicare overpayments to private plans, 1985-2012: shifting seniors to private plans has already cost Medicare US$282.6 billion.

PubMed

Hellander, Ida; Himmelstein, David U; Woolhandler, Steffie

2013-01-01

Previous research has documented Medicare overpayments to the private Medicare Advantage (MA) plans that compete with traditional fee-for-service Medicare. This research has assessed individual categories of overpayment for, at most, a few years. However, no study has calculated the total overpayments to private plans since the program's inception. Prior to 2004, selective enrollment of healthier seniors was the major source of excess payments. We estimate this has added US$41 billion to Medicare's costs since 1985. Medicare adopted a risk-adjustment scheme in 2004, but this has not curbed private plans' ability to game the payment system. This has added US$122.5 billion to Medicare's costs since 2004. Congress mandated increased payment to private plans in the 2003 Medicare Modernization Act, which was mitigated, to a degree, by the subsequent Affordable Care Act. In total, we find that Medicare has overpaid private insurers by US$282.6 billion since 1985. Risk adjustment does not work in for-profit MA plans, which have a financial incentive, the data, and the ingenuity to game whatever system Medicare devises. It is time to end Medicare's costly experiment with privatization. The U.S. needs to adopt a single-payer national health insurance program with effective methods for controlling costs.

75 FR 55801 - Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-14

... 0938-AP87 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing... Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2011.'' DATES: Effective... illustrate the skilled nursing facility (SNF) prospective payment system (PPS) payment rate computations for...

77 FR 60315 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-03

... Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality... entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and...

Credit risk and the instability of the financial system: An ensemble approach

NASA Astrophysics Data System (ADS)

Schmitt, Thilo A.; Chetalova, Desislava; Schäfer, Rudi; Guhr, Thomas

2014-02-01

The instability of the financial system as experienced in recent years and in previous periods is often linked to credit defaults, i.e., to the failure of obligors to make promised payments. Given the large number of credit contracts, this problem is amenable to be treated with approaches developed in statistical physics. We introduce the idea of ensemble averaging and thereby uncover generic features of credit risk. We then show that the often advertised concept of diversification, i.e., reducing the risk by distributing it, is deeply flawed when it comes to credit risk. The risk of extreme losses remains due to the ever present correlations, implying a substantial and persistent intrinsic danger to the financial system.

42 CFR 412.115 - Additional payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.115 Additional payments. (a) Bad debts. An additional payment is made to each... 42 Public Health 2 2010-10-01 2010-10-01 false Additional payments. 412.115 Section 412.115 Public...

Erythropoietin-Stimulating Agents and Survival in End-Stage Renal Disease: Comparison of Payment Policy Analysis, Instrumental Variables, and Multiple Imputation of Potential Outcomes

PubMed Central

Dore, David D.; Swaminathan, Shailender; Gutman, Roee; Trivedi, Amal N.; Mor, Vincent

2013-01-01

Objective To compare the assumptions and estimands across three approaches to estimating the effect of erythropoietin-stimulating agents (ESAs) on mortality. Study Design and Setting Using data from the Renal Management Information System, we conducted two analyses utilizing a change to bundled payment that we hypothesized mimicked random assignment to ESA (pre-post, difference-in-difference, and instrumental variable analyses). A third analysis was based on multiply imputing potential outcomes using propensity scores. Results There were 311,087 recipients of ESAs and 13,095 non-recipients. In the pre-post comparison, we identified no clear relationship between bundled payment (measured by calendar time) and the incidence of death within six months (risk difference -1.5%; 95% CI - 7.0% to 4.0%). In the instrumental variable analysis, the risk of mortality was similar among ESA recipients (risk difference -0.9%; 95% CI -2.1 to 0.3). In the multiple imputation analysis, we observed a 4.2% (95% CI 3.4% to 4.9%) absolute reduction in mortality risk with use of ESAs, but closer to the null for patients with baseline hematocrit >36%. Conclusion Methods emanating from different disciplines often rely on different assumptions, but can be informative about a similar causal contrast. The implications of these distinct approaches are discussed. PMID:23849152

75 FR 78806 - Agency Information Collection (Create Payment Request for the VA Funding Fee Payment System (VA...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-16

... Payment Request for the VA Funding Fee Payment System (VA FFPS); a Computer Generated Funding Fee Receipt.... 2900-0474.'' SUPPLEMENTARY INFORMATION: Title: Create Payment Request for the VA Funding Fee Payment System (VA FFPS); a Computer Generated Funding Fee Receipt, VA Form 26-8986. OMB Control Number: 2900...

78 FR 50495 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-19

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care; Hospital Prospective Payment... Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective... prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to...

Some hospitals are falling behind in meeting 'meaningful use' criteria and could be vulnerable to penalties in 2015.

PubMed

DesRoches, Catherine M; Worzala, Chantal; Bates, Scott

2013-08-01

With nearly $30 billion in incentives available, it is critical to know to what extent US hospitals have been able to respond to those incentives by adopting electronic health record (EHR) systems that meet Medicare's criteria for their "meaningful use." Medicare has provided aggregate incentive payment data, but still missing is an understanding of how these payments are distributed across hospital types and years. Our analysis of Medicare data found a substantial increase in the percentage of hospitals receiving EHR incentive payments between 2011 (17.4 percent) and 2012 (36.8 percent). However, this increase was not uniform across all hospitals, and the overall proportion of hospitals receiving a payment for meaningful use was low. Critical-access, smaller, and publicly owned or nonprofit hospitals appeared to be at particular risk for failing to meet Medicare's meaningful-use criteria, and the overall proportion of hospitals receiving a payment for meaningful use was low. Starting in 2015, hospitals that fail to meet the criteria will be subject to financial penalties. To address the needs of institutions in danger of incurring these penalties, policy makers could implement targeted grant programs and provide additional information technology workforce support. In addition, the capacity of EHR system vendors should be carefully monitored to ensure that these institutions have access to the technology they need.

Payments to Normal Healthy Volunteers in Phase 1 Trials: Avoiding Undue Influence While Distributing Fairly the Burdens of Research Participation

PubMed Central

2009-01-01

Clinical investigators must engage in just subject recruitment and selection and avoid unduly influencing research participation. There may be tension between the practice of keeping payments to participants low to avoid undue influence and the requirements of justice when recruiting normal healthy volunteers for phase 1 drug studies. By intentionally keeping payments low to avoid unduly influenced participation, investigators, on the recommendation or insistence of institutional review boards, may be targeting or systematically recruiting healthy adult members of lower socio-economic groups for participation in phase 1 studies. Investigators are at risk of routinely failing to fulfill the obligation of justice, which prohibits the systematic targeting and recruiting of subjects for reasons unrelated to the nature of the study. Insofar as we take seriously the obligation to engage in just subject recruitment and selection, I argue that we must acknowledge the implications low payments might have for subject recruitment and selection and examine the effect of low payments. If low payments de facto target the less well-off for phase 1 studies, we must defend the priority ranking of the obligation to avoid undue influence over the obligation of justice or adopt an alternative recruitment approach. This paper identifies a number of alternatives to the current system of low-value payments to research participants. PMID:19190076

Should catastrophic risks be included in a regulated competitive health insurance market?

PubMed

van de Ven, W P; Schut, F T

1994-11-01

In 1988 the Dutch government launched a proposal for a national health insurance based on regulated competition. The mandatory benefits package should be offered by competing insurers and should cover both non-catastrophic risks (like hospital care, physician services and drugs) and catastrophic risks (like several forms of expensive long-term care). However, there are two arguments to exclude some of the catastrophic risks from the competitive insurance market, at least during the implementation process of the reforms. Firstly, the prospects for a workable system of risk-adjusted payments to the insurers that should take away the incentives for cream skimming are, at least during the next 5 years, more favorable for the non-catastrophic risks than for the catastrophic risks. Secondly, even if a workable system of risk-adjusted payments can be developed, the problem of quality skimping may be relevant for some of the catastrophic risks, but not for non-catastrophic risks. By 'quality skimping' we mean the reduction of the quality of care to a level which is below the minimum level that is acceptable to society. After 5 years of health care reforms in the Netherlands new insights have resulted in a growing support to confine the implementation of the reforms to the non-catastrophic risks. In drawing (and redrawing) the exact boundaries between different regulatory regimes for catastrophic and non-catastrophic risks, the expected benefits of a cost-effective substitution of care have to be weighted against the potential harm caused by cream skimming and quality skimping.

Out of pocket payments and social health insurance for private hospital care: Evidence from Greece.

PubMed

Grigorakis, Nikolaos; Floros, Christos; Tsangari, Haritini; Tsoukatos, Evangelos

2016-08-01

The Greek state has reduced their funding on health as part of broader efforts to limit the large fiscal deficits and rising debt ratios to GDP. Benefits cuts and limitations of Social Health Insurance (SHI) reimbursements result in substantial Out of Pocket (OOP) payments in the Greek population. In this paper, we examine social health insurance's risk pooling mechanisms and the catastrophic impact that OOP payments may have on insured's income and well-being. Using data collected from a cross sectional survey in Greece, we find that the OOP payments for inpatient care in private hospitals have a positive relationship with SHI funding. Moreover, we show that the SHI funding is inadequate to total inpatient financing. We argue that the Greek health policy makers have to give serious consideration to the perspective of a SHI system which should be supplemented by the Private Health Insurance (PHI) sector. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

78 FR 59771 - Proposed Information Collection (Create Payment Request for the VA Funding Fee Payment System (VA...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-27

... Payment Request for the VA Funding Fee Payment System (VA FFPS); a Computer Generated Funding Fee Receipt.... Title: Create Payment Request for the VA Funding Fee Payment System (VA FFPS); A Computer Generated Funding Fee Receipt, VA Form 26-8986. OMB Control Number: 2900-0474. Type of Review: Revision of a...

US Approaches to Physician Payment: The Deconstruction of Primary Care

PubMed Central

Berenson, Robert A.

2010-01-01

The purpose of this paper is to address why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home, and the relevance of such payment reforms as pay-for-performance and episodes/bundling. The review illustrates why prevalent physician payment mechanisms in the US have failed to adequately support primary care and why innovative approaches to primary care payment play such a prominent role in the PCMH discussion. FFS payment for office visits has never effectively rewarded all the activities that comprise prototypical primary care and may contribute to the “hamster on a treadmill” problems in current medical practice. Capitation payments are associated with risk adjustment challenges and, perhaps, public perceptions of conflict with patients’ best interests. Most payers don’t employ and therefore cannot generally place physicians on salary; while in theory such salary payments might neutralize incentives, operationally, “time is money;” extra effort devoted to meeting the needs of a more complex patient will likely reduce the services available to others. Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well. Yet, the conceptual alternative payment approaches, modified fee-for-service (including fee bundles), capitation, and salary, each have their own problems. Accordingly, new payment models will likely be required to support restoration of primary care to its proper role in the US health care system, and to promote and sustain the development of patient-centered medical homes. PMID:20467910

42 CFR 412.505 - Conditions for payment under the prospective payment system for long-term care hospitals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment system for long-term care hospitals. 412.505 Section 412.505 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.505 Conditions for...

A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries.

PubMed

Andoh-Adjei, Francis-Xavier; Spaan, Ernst; Asante, Felix A; Mensah, Sylvester A; van der Velden, Koos

2016-12-01

To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries. We did narrative review and synthesis of the literature on the effects of capitation payment on primary care. Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship. The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care. Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352.

An Indoor Positioning-Based Mobile Payment System Using Bluetooth Low Energy Technology

PubMed Central

Winata, Doni

2018-01-01

The development of information technology has paved the way for faster and more convenient payment process flows and new methodology for the design and implementation of next generation payment systems. The growth of smartphone usage nowadays has fostered a new and popular mobile payment environment. Most of the current generation smartphones support Bluetooth Low Energy (BLE) technology to communicate with nearby BLE-enabled devices. It is plausible to construct an Over-the-Air BLE-based mobile payment system as one of the payment methods for people living in modern societies. In this paper, a secure indoor positioning-based mobile payment authentication protocol with BLE technology and the corresponding mobile payment system design are proposed. The proposed protocol consists of three phases: initialization phase, session key construction phase, and authentication phase. When a customer moves toward the POS counter area, the proposed mobile payment system will automatically detect the position of the customer to confirm whether the customer is ready for the checkout process. Once the system has identified the customer is standing within the payment-enabled area, the payment system will invoke authentication process between POS and the customer’s smartphone through BLE communication channel to generate a secure session key and establish an authenticated communication session to perform the payment transaction accordingly. A prototype is implemented to assess the performance of the proposed design for mobile payment system. In addition, security analysis is conducted to evaluate the security strength of the proposed protocol. PMID:29587399

An Indoor Positioning-Based Mobile Payment System Using Bluetooth Low Energy Technology.

PubMed

Yohan, Alexander; Lo, Nai-Wei; Winata, Doni

2018-03-25

The development of information technology has paved the way for faster and more convenient payment process flows and new methodology for the design and implementation of next generation payment systems. The growth of smartphone usage nowadays has fostered a new and popular mobile payment environment. Most of the current generation smartphones support Bluetooth Low Energy (BLE) technology to communicate with nearby BLE-enabled devices. It is plausible to construct an Over-the-Air BLE-based mobile payment system as one of the payment methods for people living in modern societies. In this paper, a secure indoor positioning-based mobile payment authentication protocol with BLE technology and the corresponding mobile payment system design are proposed. The proposed protocol consists of three phases: initialization phase, session key construction phase, and authentication phase. When a customer moves toward the POS counter area, the proposed mobile payment system will automatically detect the position of the customer to confirm whether the customer is ready for the checkout process. Once the system has identified the customer is standing within the payment-enabled area, the payment system will invoke authentication process between POS and the customer's smartphone through BLE communication channel to generate a secure session key and establish an authenticated communication session to perform the payment transaction accordingly. A prototype is implemented to assess the performance of the proposed design for mobile payment system. In addition, security analysis is conducted to evaluate the security strength of the proposed protocol.

48 CFR 432.1007 - Administration and payment of performance-based payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 4 2010-10-01 2010-10-01 false Administration and payment of performance-based payments. 432.1007 Section 432.1007 Federal Acquisition Regulations System....1007 Administration and payment of performance-based payments. The responsibility for receiving...

42 CFR 422.300 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... for making payments to Medicare Advantage (MA) organizations offering local and regional MA plans, including calculation of MA capitation rates and benchmarks, conditions under which payment is based on plan....458 in subpart J for rules on risk sharing payments to MA regional organizations. ...

Reliability of hospital cost profiles in inpatient surgery.

PubMed

Grenda, Tyler R; Krell, Robert W; Dimick, Justin B

2016-02-01

With increased policy emphasis on shifting risk from payers to providers through mechanisms such as bundled payments and accountable care organizations, hospitals are increasingly in need of metrics to understand their costs relative to peers. However, it is unclear whether Medicare payments for surgery can reliably compare hospital costs. We used national Medicare data to assess patients undergoing colectomy, pancreatectomy, and open incisional hernia repair from 2009 to 2010 (n = 339,882 patients). We first calculated risk-adjusted hospital total episode payments for each procedure. We then used hierarchical modeling techniques to estimate the reliability of total episode payments for each procedure and explored the impact of hospital caseload on payment reliability. Finally, we quantified the number of hospitals meeting published reliability benchmarks. Mean risk-adjusted total episode payments ranged from $13,262 (standard deviation [SD] $14,523) for incisional hernia repair to $25,055 (SD $22,549) for pancreatectomy. The reliability of hospital episode payments varied widely across procedures and depended on sample size. For example, mean episode payment reliability for colectomy (mean caseload, 157) was 0.80 (SD 0.18), whereas for pancreatectomy (mean caseload, 13) the mean reliability was 0.45 (SD 0.27). Many hospitals met published reliability benchmarks for each procedure. For example, 90% of hospitals met reliability benchmarks for colectomy, 40% for pancreatectomy, and 66% for incisional hernia repair. Episode payments for inpatient surgery are a reliable measure of hospital costs for commonly performed procedures, but are less reliable for lower volume operations. These findings suggest that hospital cost profiles based on Medicare claims data may be used to benchmark efficiency, especially for more common procedures. Copyright © 2016 Elsevier Inc. All rights reserved.

Malpractice Risk Among US Pediatricians

PubMed Central

Chandra, Amitabh; Seabury, Seth A.

2013-01-01

OBJECTIVE: To characterize malpractice risk among US pediatricians. METHODS: We analyzed malpractice claims of all pediatricians and other physicians covered by a nationwide liability insurer from 1991 to 2005 (n = 1630 pediatricians; 40 916 total physicians). We characterized annual malpractice risk among pediatricians compared with other physicians. We characterized claims according to patient age, injury type, months required to resolve the claim, and whether an indemnity payment was made. We estimated how patient age and injury type were associated with whether a claim resulted in payment to a patient (and if so, payment size) and the time required to resolve the claim. RESULTS: The annual percentage of pediatricians facing a malpractice claim was 3.1% (7.4% among other physicians, P < .001). Among 404 claims, 83 (20.5%) resulted in an indemnity payment and 15 (3.7%) resulted in a payment exceeding $1 million. Annual rates of indemnity were lower among pediatricians (0.5%) than other physicians (1.6%, P < .001), whereas rates of payments exceeding $1 million were similar (0.13% among pediatricians and 0.11% among other physicians, P = .57). The mean indemnity payment was $562 180 (SD $667 962). Cases with permanent injury (n = 172) had larger mean payments ($703 373) compared with fatalities ($559 102; n = 131) or temporary or psychological injuries ($127 663; n = 101), P < .05. The mean time to resolution was 23.4 months (SD 21.8 months). CONCLUSIONS: Indemnity payments among pediatricians are infrequent but large, particularly in cases with permanent patient injury rather than death or temporary injury. The time required to resolve claims may be considered to be long. PMID:23650293

42 CFR 412.120 - Reductions to total payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.120 Reductions to total payments. (a) Deductible and coinsurance... 42 Public Health 2 2010-10-01 2010-10-01 false Reductions to total payments. 412.120 Section 412...

Designing a Community-Based Population Health Model.

PubMed

Durovich, Christopher J; Roberts, Peter W

2018-02-01

The pace of change from volume-based to value-based payment in health care varies dramatically among markets. Regardless of the ultimate disposition of the Affordable Care Act, employers and public-private payers will continue to increase pressure on health care providers to assume financial risk for populations in the form of shared savings, bundled payments, downside risk, or even capitation. This article outlines a suggested road map and practical considerations for health systems that are building or planning to build population health capabilities to meet the needs of their local markets. The authors review the traditional core capabilities needed to address the medical determinants of health for a population. They also share an innovative approach to community service integration to address the social determinants of health and the engagement of families to improve their own health and well-being. The foundational approach is to connect insurance products, the health care delivery system, and community service agencies around the family's well-being goals using human-centered design strategy.

Notification: Risk Assessment of CSB’s Purchase Card Usage and CSB’s Compliance with the Improper Payments Legislation

EPA Pesticide Factsheets

November 6, 2014. The EPA's OIG for the U.S. Chemical Safety and Hazard Investigation Board (CSB) plans to begin its risk assessment of CSB's purchase card usage and CSB's compliance with the improper payments legislation.

45 CFR 153.410 - Requests for reinsurance payment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Requests for reinsurance payment. 153.410 Section 153.410 Public Welfare Department of Health and Human Services REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE CARE...

45 CFR 153.410 - Requests for reinsurance payment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Requests for reinsurance payment. 153.410 Section 153.410 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE CARE...

45 CFR 153.240 - Disbursement of reinsurance payments.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Disbursement of reinsurance payments. 153.240 Section 153.240 Public Welfare Department of Health and Human Services REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE...

45 CFR 153.240 - Disbursement of reinsurance payments.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Disbursement of reinsurance payments. 153.240 Section 153.240 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE...

45 CFR 153.240 - Disbursement of reinsurance payments.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Disbursement of reinsurance payments. 153.240 Section 153.240 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE...

45 CFR 153.410 - Requests for reinsurance payment.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Requests for reinsurance payment. 153.410 Section 153.410 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE AFFORDABLE CARE...

46 CFR 308.407 - Premiums and payment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 46 Shipping 8 2014-10-01 2014-10-01 false Premiums and payment. 308.407 Section 308.407 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE War Risk... in § 308.2(d), by check payable to the order of “Maritime Administration, Department of...

20 CFR 411.597 - Will SSA periodically review the outcome payment system and the outcome-milestone payment system...

Code of Federal Regulations, 2012 CFR

2012-04-01

....597 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.597 Will SSA periodically review the outcome payment system and the...

20 CFR 411.597 - Will SSA periodically review the outcome payment system and the outcome-milestone payment system...

Code of Federal Regulations, 2011 CFR

2011-04-01

....597 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.597 Will SSA periodically review the outcome payment system and the...

20 CFR 411.597 - Will SSA periodically review the outcome payment system and the outcome-milestone payment system...

Code of Federal Regulations, 2010 CFR

2010-04-01

....597 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.597 Will SSA periodically review the outcome payment system and the...

20 CFR 411.597 - Will SSA periodically review the outcome payment system and the outcome-milestone payment system...

Code of Federal Regulations, 2014 CFR

2014-04-01

....597 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.597 Will SSA periodically review the outcome payment system and the...

20 CFR 411.597 - Will SSA periodically review the outcome payment system and the outcome-milestone payment system...

Code of Federal Regulations, 2013 CFR

2013-04-01

....597 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.597 Will SSA periodically review the outcome payment system and the...

Payment methods for outpatient care facilities

PubMed Central

Yuan, Beibei; He, Li; Meng, Qingyue; Jia, Liying

2017-01-01

Background Outpatient care facilities provide a variety of basic healthcare services to individuals who do not require hospitalisation or institutionalisation, and are usually the patient's first contact. The provision of outpatient care contributes to immediate and large gains in health status, and a large portion of total health expenditure goes to outpatient healthcare services. Payment method is one of the most important incentive methods applied by purchasers to guide the performance of outpatient care providers. Objectives To assess the impact of different payment methods on the performance of outpatient care facilities and to analyse the differences in impact of payment methods in different settings. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2016, Issue 3, part of the Cochrane Library (searched 8 March 2016); MEDLINE, OvidSP (searched 8 March 2016); Embase, OvidSP (searched 24 April 2014); PubMed (NCBI) (searched 8 March 2016); Dissertations and Theses Database, ProQuest (searched 8 March 2016); Conference Proceedings Citation Index (ISI Web of Science) (searched 8 March 2016); IDEAS (searched 8 March 2016); EconLit, ProQuest (searched 8 March 2016); POPLINE, K4Health (searched 8 March 2016); China National Knowledge Infrastructure (searched 8 March 2016); Chinese Medicine Premier (searched 8 March 2016); OpenGrey (searched 8 March 2016); ClinicalTrials.gov, US National Institutes of Health (NIH) (searched 8 March 2016); World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (searched 8 March 2016); and the website of the World Bank (searched 8 March 2016). In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via ISI Web of Science to find other potentially relevant studies. We also contacted authors of the main included studies regarding any further published or unpublished work. Selection criteria Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for outpatient health facilities. We defined outpatient care facilities in this review as facilities that provide health services to individuals who do not require hospitalisation or institutionalisation. We only included methods used to transfer funds from the purchaser of healthcare services to health facilities (including groups of individual professionals). These include global budgets, line-item budgets, capitation, fee-for-service (fixed and unconstrained), pay for performance, and mixed payment. The primary outcomes were service provision outcomes, patient outcomes, healthcare provider outcomes, costs for providers, and any adverse effects. Data collection and analysis At least two review authors independently extracted data and assessed the risk of bias. We conducted a structured synthesis. We first categorised the comparisons and outcomes and then described the effects of different types of payment methods on different categories of outcomes. We used a fixed-effect model for meta-analysis within a study if a study included more than one indicator in the same category of outcomes. We used a random-effects model for meta-analysis across studies. If the data for meta-analysis were not available in some studies, we calculated the median and interquartile range. We reported the risk ratio (RR) for dichotomous outcomes and the relative change for continuous outcomes. Main results We included 21 studies from Afghanistan, Burundi, China, Democratic Republic of Congo, Rwanda, Tanzania, the United Kingdom, and the United States of health facilities providing primary health care and mental health care. There were three kinds of payment comparisons. 1) Pay for performance (P4P) combined with some existing payment method (capitation or different kinds of input-based payment) compared to the existing payment method We included 18 studies in this comparison, however we did not include five studies in the effects analysis due to high risk of bias. From the 13 studies, we found that the extra P4P incentives probably slightly improved the health professionals' use of some tests and treatments (adjusted RR median = 1.095, range 1.01 to 1.17; moderate-certainty evidence), and probably led to little or no difference in adherence to quality assurance criteria (adjusted percentage change median = -1.345%, range -8.49% to 5.8%; moderate-certainty evidence). We also found that P4P incentives may have led to little or no difference in patients' utilisation of health services (adjusted RR median = 1.01, range 0.96 to 1.15; low-certainty evidence) and may have led to little or no difference in the control of blood pressure or cholesterol (adjusted RR = 1.01, range 0.98 to 1.04; low-certainty evidence). 2) Capitation combined with P4P compared to fee-for-service (FFS) One study found that compared with FFS, a capitated budget combined with payment based on providers' performance on antibiotic prescriptions and patient satisfaction probably slightly reduced antibiotic prescriptions in primary health facilities (adjusted RR 0.84, 95% confidence interval 0.74 to 0.96; moderate-certainty evidence). 3) Capitation compared to FFS Two studies compared capitation to FFS in mental health centres in the United States. Based on these studies, the effects of capitation compared to FFS on the utilisation and costs of services were uncertain (very low-certainty evidence). Authors' conclusions Our review found that if policymakers intend to apply P4P incentives to pay health facilities providing outpatient services, this intervention will probably lead to a slight improvement in health professionals' use of tests or treatments, particularly for chronic diseases. However, it may lead to little or no improvement in patients' utilisation of health services or health outcomes. When considering using P4P to improve the performance of health facilities, policymakers should carefully consider each component of their P4P design, including the choice of performance measures, the performance target, payment frequency, if there will be additional funding, whether the payment level is sufficient to change the behaviours of health providers, and whether the payment to facilities will be allocated to individual professionals. Unfortunately, the studies included in this review did not help to inform those considerations. Well-designed comparisons of different payment methods for outpatient health facilities in low- and middle-income countries and studies directly comparing different designs (e.g. different payment levels) of the same payment method (e.g. P4P or FFS) are needed. Payment methods for outpatient care facilities Review aim The aim of this Cochrane review was to assess the effect of different payment systems for outpatient care facilities. We collected and analysed all relevant studies to answer this question and included 21 studies. Key messages Pay-for-performance systems probably have only small benefits or make little or no difference to healthcare provider behaviour or patients' use of healthcare services. We are uncertain whether they cause harm. We are uncertain about the benefits and harms of other payments systems because the research is lacking or of very low certainty. What was studied in the review? Many healthcare services are offered to patients through outpatient facilities rather than to inpatients in hospitals. Outpatient facilities are also known as ambulatory care facilities, and include primary healthcare centres, outpatient clinics, urgent care centres, family planning centres, mental health centres, and dental clinics. Different systems to reimburse outpatient (ambulatory) care facilities for their services are available to governments and health insurers. These systems include: • budget systems, where the facility is given a fixed amount of money in advance to cover expenses for a fixed period; • capitation payment systems, where the facility is paid a fixed amount of money in advance to provide specific services to each enrolled patient for a fixed period; • fee-for-service systems, where payment is based on the specific services that the healthcare facility provides; • pay-for-performance systems, where payment is partly based on the performance of the facility's healthcare providers. Different payment systems can have different effects on how healthcare facilities deliver care. These changes can be intentional or unintentional and can lead to both benefits and harms. At best, a payment system can encourage healthcare providers to offer the right healthcare services to the right patients in the best and most cost-efficient way. However, payment systems can also lead providers to offer poor-quality, expensive, and unnecessary care, which can ultimately have a negative impact on patients' health. This Cochrane review assessed the effect of different payment systems for outpatient care facilities. Other Cochrane reviews have assessed the effect of different payment systems for individual healthcare professionals and for inpatient facilities. Main results We found 21 relevant studies from the United Kingdom, the United States, Rwanda, Burundi, Tanzania, Afghanistan, China, and Democratic Republic of Congo. Most of the studies were from primary healthcare facilities. The studies assessed capitation systems, fee-for-service systems, and different types of pay-for-performance systems. Pay-for-performance systems: • probably slightly improve providers' use of some tests and treatments; • probably lead to little or no difference in providers' compliance with quality assurance criteria; • may lead to little or no difference in patients' use of health services; • may lead to little or no difference in patients' health status. Capitation combined with a pay-for-performance system targeted at reducing antibiotic use probably slightly reduces antibiotic prescriptions when compared to a fee-for-service system. Two studies compared capitation with fee-for-service systems, however, we assessed the certainty of the evidence as very low. We did not find any relevant studies that assessed budget systems. How up-to-date is this review? We searched for studies that had been published up to March 2016. PMID:28253540

Medicare's post-acute care payment: a review of the issues and policy proposals.

PubMed

Linehan, Kathryn

2012-12-07

Medicare spending on post-acute care provided by skilled nursing facility providers, home health providers, inpatient rehabilitation facility providers, and long-term care hospitals has grown rapidly in the past several years. The Medicare Payment Advisory Commission and others have noted several long-standing problems with the payment systems for post-acute care and have suggested refinements to Medicare's post-acute care payment systems that are intended to encourage the delivery of appropriate care in the right setting for a patient's condition. The Patient Protection and Affordable Care Act of 2010 contained several provisions that affect the Medicare program's post-acute care payment systems and also includes broader payment reforms, such as bundled payment models. This issue brief describes Medicare's payment systems for post-acute care providers, evidence of problems that have been identified with the payment systems, and policies that have been proposed or enacted to remedy those problems.

Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China.

PubMed

Zhao, Cuirong; Wang, Chao; Shen, Chengwu; Wang, Qian

2018-05-13

Fee for services (FFS) is the prevailing method of payment in most Chinese public hospitals. Under this retrospective payment system, medical care providers are paid based on medical services and tend to over-treat to maximize their income, thereby contributing to rising medical costs and uncontrollable health expenditures to a large extent. Payment reform needs to be promptly implemented to move to a prospective payment plan. The diagnosis-related group (DRG)-based case-mix payment system, with its superior efficiency and containment of costs, has garnered increased attention and it represents a promising alternative. This article briefly describes the DRG-based case-mix payment system, it comparatively analyzes differences between FFS and case-mix funding systems, and it describes the implementation of DRGs in China. China's social and economic conditions differ across regions, so establishment of a national payment standard will take time and involve difficulties. No single method of provider payment is perfect. Measures to monitor and minimize the negative ethical implications and unintended effects of a DRG-based case-mix payment system are essential to ensuring the lasting social benefits of payment reform in Chinese public hospitals.

20 CFR 411.582 - Can a State VR agency receive payment under the cost reimbursement payment system if a continuous...

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false Can a State VR agency receive payment under... Systems § 411.582 Can a State VR agency receive payment under the cost reimbursement payment system if a...? Yes. If a State VR agency provides services to a beneficiary under 34 CFR part 361, and elects payment...

20 CFR 411.582 - Can a State VR agency receive payment under the cost reimbursement payment system if a continuous...

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false Can a State VR agency receive payment under... Systems § 411.582 Can a State VR agency receive payment under the cost reimbursement payment system if a...? Yes. If a State VR agency provides services to a beneficiary under 34 CFR part 361, and elects payment...

20 CFR 411.582 - Can a State VR agency receive payment under the cost reimbursement payment system if a continuous...

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Can a State VR agency receive payment under... Systems § 411.582 Can a State VR agency receive payment under the cost reimbursement payment system if a...? Yes. If a State VR agency provides services to a beneficiary under 34 CFR part 361, and elects payment...

20 CFR 411.582 - Can a State VR agency receive payment under the cost reimbursement payment system if a continuous...

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Can a State VR agency receive payment under... Systems § 411.582 Can a State VR agency receive payment under the cost reimbursement payment system if a...? Yes. If a State VR agency provides services to a beneficiary under 34 CFR part 361, and elects payment...

20 CFR 411.582 - Can a State VR agency receive payment under the cost reimbursement payment system if a continuous...

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Can a State VR agency receive payment under... Systems § 411.582 Can a State VR agency receive payment under the cost reimbursement payment system if a...? Yes. If a State VR agency provides services to a beneficiary under 34 CFR part 361, and elects payment...

42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as long-term care hospital... 42 Public Health 2 2011-10-01 2011-10-01 false Method of payment under the long-term care hospital... SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the long...

42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

Code of Federal Regulations, 2014 CFR

2014-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as long-term care hospital... 42 Public Health 2 2014-10-01 2014-10-01 false Method of payment under the long-term care hospital... SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the long...

42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

Code of Federal Regulations, 2013 CFR

2013-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as long-term care hospital... 42 Public Health 2 2013-10-01 2013-10-01 false Method of payment under the long-term care hospital... SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the long...

42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as long-term care hospital... 42 Public Health 2 2010-10-01 2010-10-01 false Method of payment under the long-term care hospital... SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the long...

42 CFR 412.541 - Method of payment under the long-term care hospital prospective payment system.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as long-term care hospital... 42 Public Health 2 2012-10-01 2012-10-01 false Method of payment under the long-term care hospital... SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.541 Method of payment under the long...

Variation in Bariatric Surgery Episode Costs in the Commercially Insured: Implications for Bundled Payments in the Private Sector.

PubMed

Kelsall, Alexander C; Cassidy, Ruth; Ghaferi, Amir A

2017-08-01

To describe hospital-level variation in roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in Michigan. Bariatric surgery is an increasingly prevalent elective surgical procedure that will likely be considered for future bundled payment programs, both public and private. Past research in the Medicare population found that the index hospitalization is responsible for the majority of payment variation among hospitals. However, this research largely excluded SG, now the most commonly performed bariatric surgery procedure nationally. We used data from a state-wide quality collaborative to calculate the average risk and price-adjusted 30-day episode payment for patients undergoing RYGB and SG procedures at Michigan hospitals between January 2009 and October 2014. We organized hospitals into quintiles and compared the variation in payments between highest and lowest-cost quintiles, and also the payment categories that drove this variation. We identified 9035 patients undergoing RYGB (n = 4194) or SG (n = 4841) procedures at 31 hospitals. The average price and risk-adjusted episode payment ranged from $11,874 in the lowest hospital quintile to $13,394 in the highest quintile, representing a difference of $1519 (12.8%). Payments for the index hospitalization accounted for the largest share of total episode costs for both procedure types. Despite representing 2.7% to 6.0% of payments across quintiles, postdischarge payments explained 22.6% of hospital variation in SG. Similarly, readmissions explained 24.5% of payment variation for SG episodes, despite representing between 1.2% and 4.4% of payments. Collectively, our findings suggest that there are previously underappreciated differences in episode payment variation between bariatric surgery procedures. SG may be more amenable to cost containment under bundled payment initiatives by virtue of the greater share of variation explained by readmission and postdischarge payments, components of episode payment more likely to be influenced by provider discretion.

45 CFR 153.100 - State notice of benefit and payment parameters.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false State notice of benefit and payment parameters. 153.100 Section 153.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE...

45 CFR 153.100 - State notice of benefit and payment parameters.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false State notice of benefit and payment parameters. 153.100 Section 153.100 Public Welfare Department of Health and Human Services REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE...

45 CFR 153.100 - State notice of benefit and payment parameters.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false State notice of benefit and payment parameters. 153.100 Section 153.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK ADJUSTMENT UNDER THE...

Effects of Medicare payment reform: evidence from the home health interim and prospective payment systems.

PubMed

Huckfeldt, Peter J; Sood, Neeraj; Escarce, José J; Grabowski, David C; Newhouse, Joseph P

2014-03-01

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service toward episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The home health interim payment system in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The home health prospective payment system in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality. Copyright © 2014 Elsevier B.V. All rights reserved.

Effects of Medicare Payment Reform: Evidence from the Home Health Interim and Prospective Payment Systems

PubMed Central

Huckfeldt, Peter J; Sood, Neeraj; Escarce, José J; Grabowski, David C; Newhouse, Joseph P

2014-01-01

Medicare continues to implement payment reforms that shift reimbursement from fee-for-service towards episode-based payment, affecting average and marginal payment. We contrast the effects of two reforms for home health agencies. The Home Health Interim Payment System in 1997 lowered both types of payment; our conceptual model predicts a decline in the likelihood of use and costs, both of which we find. The Home Health Prospective Payment System in 2000 raised average but lowered marginal payment with theoretically ambiguous effects; we find a modest increase in use and costs. We find little substantive effect of either policy on readmissions or mortality. PMID:24395018

A Machine Learning Framework for Plan Payment Risk Adjustment.

PubMed

Rose, Sherri

2016-12-01

To introduce cross-validation and a nonparametric machine learning framework for plan payment risk adjustment and then assess whether they have the potential to improve risk adjustment. 2011-2012 Truven MarketScan database. We compare the performance of multiple statistical approaches within a broad machine learning framework for estimation of risk adjustment formulas. Total annual expenditure was predicted using age, sex, geography, inpatient diagnoses, and hierarchical condition category variables. The methods included regression, penalized regression, decision trees, neural networks, and an ensemble super learner, all in concert with screening algorithms that reduce the set of variables considered. The performance of these methods was compared based on cross-validated R 2 . Our results indicate that a simplified risk adjustment formula selected via this nonparametric framework maintains much of the efficiency of a traditional larger formula. The ensemble approach also outperformed classical regression and all other algorithms studied. The implementation of cross-validated machine learning techniques provides novel insight into risk adjustment estimation, possibly allowing for a simplified formula, thereby reducing incentives for increased coding intensity as well as the ability of insurers to "game" the system with aggressive diagnostic upcoding. © Health Research and Educational Trust.

Risk-adjusted capitation funding models for chronic disease in Australia: alternatives to casemix funding.

PubMed

Antioch, K M; Walsh, M K

2002-01-01

Under Australian casemix funding arrangements that use Diagnosis-Related Groups (DRGs) the average price is policy based, not benchmarked. Cost weights are too low for State-wide chronic disease services. Risk-adjusted Capitation Funding Models (RACFM) are feasible alternatives. A RACFM was developed for public patients with cystic fibrosis treated by an Australian Health Maintenance Organization (AHMO). Adverse selection is of limited concern since patients pay solidarity contributions via Medicare levy with no premium contributions to the AHMO. Sponsors paying premium subsidies are the State of Victoria and the Federal Government. Cost per patient is the dependent variable in the multiple regression. Data on DRG 173 (cystic fibrosis) patients were assessed for heteroskedasticity, multicollinearity, structural stability and functional form. Stepwise linear regression excluded non-significant variables. Significant variables were 'emergency' (1276.9), 'outlier' (6377.1), 'complexity' (3043.5), 'procedures' (317.4) and the constant (4492.7) (R(2)=0.21, SE=3598.3, F=14.39, Prob<0.0001. Regression coefficients represent the additional per patient costs summed to the base payment (constant). The model explained 21% of the variance in cost per patient. The payment rate is adjusted by a best practice annual admission rate per patient. The model is a blended RACFM for in-patient, out-patient, Hospital In The Home, Fee-For-Service Federal payments for drugs and medical services; lump sum lung transplant payments and risk sharing through cost (loss) outlier payments. State and Federally funded home and palliative services are 'carved out'. The model, which has national application via Coordinated Care Trials and by Australian States for RACFMs may be instructive for Germany, which plans to use Australian DRGs for casemix funding. The capitation alternative for chronic disease can improve equity, allocative efficiency and distributional justice. The use of Diagnostic Cost Groups (DCGs) is a promising alternative classification system for capitation arrangements.

42 CFR 413.210 - Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... disease (ESRD) prospective payment system. 413.210 Section 413.210 Public Health CENTERS FOR MEDICARE... REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs...

42 CFR 413.210 - Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... disease (ESRD) prospective payment system. 413.210 Section 413.210 Public Health CENTERS FOR MEDICARE... REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs...

42 CFR 413.210 - Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Code of Federal Regulations, 2012 CFR

2012-10-01

... disease (ESRD) prospective payment system. 413.210 Section 413.210 Public Health CENTERS FOR MEDICARE... REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs...

42 CFR 413.210 - Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Code of Federal Regulations, 2013 CFR

2013-10-01

... disease (ESRD) prospective payment system. 413.210 Section 413.210 Public Health CENTERS FOR MEDICARE... REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs...

42 CFR 413.210 - Conditions for payment under the end-stage renal disease (ESRD) prospective payment system.

Code of Federal Regulations, 2014 CFR

2014-10-01

... disease (ESRD) prospective payment system. 413.210 Section 413.210 Public Health CENTERS FOR MEDICARE... REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs...

42 CFR 412.112 - Payments determined on a per case basis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.112 Payments determined on a per case basis. A hospital is... 42 Public Health 2 2010-10-01 2010-10-01 false Payments determined on a per case basis. 412.112...

Shortcuts in complex engineering systems: a principal-agent approach to risk management.

PubMed

Garber, Russ; Paté-Cornell, Elisabeth

2012-05-01

In this article, we examine the effects of shortcuts in the development of engineered systems through a principal-agent model. We find that occurrences of illicit shortcuts are closely related to the incentive structure and to the level of effort that the agent is willing to expend from the beginning of the project to remain on schedule. Using a probabilistic risk analysis to determine the risks of system failure from these shortcuts, we show how a principal can choose optimal settings (payments, penalties, and inspections) that can deter an agent from cutting corners and maximize the principal's value through increased agent effort. We analyze the problem for an agent with limited liability. We consider first the case where he is risk neutral; we then include the case where he is risk averse. © 2011 Society for Risk Analysis.

20 CFR 411.550 - How are the outcome payments calculated under the outcome payment system?

Code of Federal Regulations, 2010 CFR

2010-04-01

... 20 Employees' Benefits 2 2010-04-01 2010-04-01 false How are the outcome payments calculated under the outcome payment system? 411.550 Section 411.550 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.550 How are...

20 CFR 411.550 - How are the outcome payments calculated under the outcome payment system?

Code of Federal Regulations, 2011 CFR

2011-04-01

... 20 Employees' Benefits 2 2011-04-01 2011-04-01 false How are the outcome payments calculated under the outcome payment system? 411.550 Section 411.550 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.550 How are...

20 CFR 411.550 - How are the outcome payments calculated under the outcome payment system?

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false How are the outcome payments calculated under the outcome payment system? 411.550 Section 411.550 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.550 How are...

20 CFR 411.550 - How are the outcome payments calculated under the outcome payment system?

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false How are the outcome payments calculated under the outcome payment system? 411.550 Section 411.550 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.550 How are...

20 CFR 411.550 - How are the outcome payments calculated under the outcome payment system?

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false How are the outcome payments calculated under the outcome payment system? 411.550 Section 411.550 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.550 How are...

42 CFR 412.20 - Hospital services subject to the prospective payment systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment systems. 412.20 Section 412.20 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Hospital Services Subject to and Excluded From the Prospective Payment Systems for Inpatient...

The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm.

PubMed

Kim, Kelvin; Iorio, Richard

2017-06-01

Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms. We summarize a number of experiences and lessons learned since the implementation of Bundled Payments for Care Improvement at our institution. Our experience has led to the development of more refined clinical pathways and coordination of care through evidence-based approaches. We have established that the success of the bundled payment program rests on the following 5 main clinical pillars: (1) optimizing patient selection and comorbidities; (2) optimizing care coordination, patient education, shared decision making, and patient expectations; (3) using a multimodal pain management protocol and minimizing narcotic use to facilitate rapid rehabilitation; (4) optimizing blood management, and standardizing venous thromboembolic disease prophylaxis treatment by risk standardizing patients and minimizing the use of aggressive anticoagulation; and (5) minimizing post-acute facility and resource utilization, and maximizing home resources for patient recovery. From our extensive experience with bundled payment models, we have established 5 clinical pillars of value for bundled payments. Our hope is that these principles will help ease the transition to value-based care for less-experienced healthcare systems. Copyright © 2017 Elsevier Inc. All rights reserved.

Medicare program: changes to the hospital outpatient prospective payment system and CY 2008 payment rates, the ambulatory surgical center payment system and CY 2008 payment rates, the hospital inpatient prospective payment system and FY 2008 payment rates; and payments for graduate medical education for affiliated teaching hospitals in certain emergency situations Medicare and Medicaid programs: hospital conditions of participation; necessary provider designations of critical access hospitals. Interim and final rule with comment period.

PubMed

2007-11-27

This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. We describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2008. In addition, the rule sets forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which the final policies of the ASC payment system apply, and other pertinent rate setting information for the CY 2008 ASC payment system. Furthermore, this final rule with comment period will make changes to the policies relating to the necessary provider designations of critical access hospitals and changes to several of the current conditions of participation requirements. The attached document also incorporates the changes to the FY 2008 hospital inpatient prospective payment system (IPPS) payment rates made as a result of the enactment of the TMA, Abstinence Education, and QI Programs Extension Act of 2007, Public Law 110-90. In addition, we are changing the provisions in our previously issued FY 2008 IPPS final rule and are establishing a new policy, retroactive to October 1, 2007, of not applying the documentation and coding adjustment to the FY 2008 hospital-specific rates for Medicare-dependent, small rural hospitals (MDHs) and sole community hospitals (SCHs). In the interim final rule with comment period in this document, we are modifying our regulations relating to graduate medical education (GME) payments made to teaching hospitals that have Medicare affiliation agreements for certain emergency situations.

42 CFR 419.20 - Hospitals subject to the hospital outpatient prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... prospective payment system. 419.20 Section 419.20 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL... Outpatient Prospective Payment System § 419.20 Hospitals subject to the hospital outpatient prospective...

42 CFR 412.304 - Implementation of the capital prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs General Provisions § 412.304 Implementation of the capital prospective payment system. (a) General rule. As described in §§ 412.312 through 412.370...

42 CFR 412.6 - Cost reporting periods subject to the prospective payment systems.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment systems. 412.6 Section 412.6 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES... prospective payment system for inpatient operating costs, the reasonable costs of services furnished before...

31 CFR 132.3 - Designated payment systems.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 31 Money and Finance: Treasury 1 2010-07-01 2010-07-01 false Designated payment systems. 132.3 Section 132.3 Money and Finance: Treasury Regulations Relating to Money and Finance PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING § 132.3 Designated payment systems. The following payment systems could...

14 CFR 198.13 - Premium insurance-payment of premiums.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 3 2012-01-01 2012-01-01 false Premium insurance-payment of premiums. 198.13 Section 198.13 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) WAR RISK INSURANCE AVIATION INSURANCE § 198.13 Premium insurance—payment of premiums. The insured...

46 CFR 308.3 - Applications for insurance; warranties; supporting documents; payment of binder fees.

Code of Federal Regulations, 2012 CFR

2012-10-01

... documents; payment of binder fees. 308.3 Section 308.3 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE General § 308.3 Applications for insurance; warranties; supporting documents; payment of binder fees. (a) Application, binder forms. A single application for War...

46 CFR 308.3 - Applications for insurance; warranties; supporting documents; payment of binder fees.

Code of Federal Regulations, 2014 CFR

2014-10-01

... documents; payment of binder fees. 308.3 Section 308.3 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE General § 308.3 Applications for insurance; warranties; supporting documents; payment of binder fees. (a) Application, binder forms. A single application for War...

46 CFR 308.3 - Applications for insurance; warranties; supporting documents; payment of binder fees.

Code of Federal Regulations, 2010 CFR

2010-10-01

... documents; payment of binder fees. 308.3 Section 308.3 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE General § 308.3 Applications for insurance; warranties; supporting documents; payment of binder fees. (a) Application, binder forms. A single application for War...

46 CFR 308.3 - Applications for insurance; warranties; supporting documents; payment of binder fees.

Code of Federal Regulations, 2013 CFR

2013-10-01

... documents; payment of binder fees. 308.3 Section 308.3 Shipping MARITIME ADMINISTRATION, DEPARTMENT OF TRANSPORTATION EMERGENCY OPERATIONS WAR RISK INSURANCE General § 308.3 Applications for insurance; warranties; supporting documents; payment of binder fees. (a) Application, binder forms. A single application for War...

Measuring Provider Performance for Physicians Participating in the Merit-Based Incentive Payment System.

PubMed

Squitieri, Lee; Chung, Kevin C

2017-07-01

In 2017, the Centers for Medicare and Medicaid Services began requiring all eligible providers to participate in the Quality Payment Program or face financial reimbursement penalty. The Quality Payment Program outlines two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. For the first performance period beginning in January of 2017, the Centers for Medicare and Medicaid Services estimates that approximately 83 to 90 percent of eligible providers will not qualify for participation in an Advanced Alternative Payment Model and therefore must participate in the Merit-Based Incentive Payment System program. The Merit-Based Incentive Payment System path replaces existing quality-reporting programs and adds several new measures to evaluate providers using four categories of data: (1) quality, (2) cost/resource use, (3) improvement activities, and (4) advancing care information. These categories will be combined to calculate a weighted composite score for each provider or provider group. Composite Merit-Based Incentive Payment System scores based on 2017 performance data will be used to adjust reimbursed payment in 2019. In this article, the authors provide relevant background for understanding value-based provider performance measurement. The authors also discuss Merit-Based Incentive Payment System reporting requirements and scoring methodology to provide plastic surgeons with the necessary information to critically evaluate their own practice capabilities in the context of current performance metrics under the Quality Payment Program.

Diagnosis-Based Risk Adjustment for Medicare Capitation Payments

PubMed Central

Ellis, Randall P.; Pope, Gregory C.; Iezzoni, Lisa I.; Ayanian, John Z.; Bates, David W.; Burstin, Helen; Ash, Arlene S.

1996-01-01

Using 1991-92 data for a 5-percent Medicare sample, we develop, estimate, and evaluate risk-adjustment models that utilize diagnostic information from both inpatient and ambulatory claims to adjust payments for aged and disabled Medicare enrollees. Hierarchical coexisting conditions (HCC) models achieve greater explanatory power than diagnostic cost group (DCG) models by taking account of multiple coexisting medical conditions. Prospective models predict average costs of individuals with chronic conditions nearly as well as concurrent models. All models predict medical costs far more accurately than the current health maintenance organization (HMO) payment formula. PMID:10172666

Much ado about nothing? The financial impact of physician-owned specialty hospitals.

PubMed

Chakravarty, Sujoy

2016-06-01

The U.S. hospital industry has recently witnessed a number of policy changes aimed at aligning hospital payments to costs and these can be traced to significant concerns regarding selection of profitable patients and procedures by physician-owned specialty hospitals. The policy responses to specialty hospitals have alternated between payment system reforms and outright moratoriums on hospital operations including one in the recently enacted Affordable Care Act. A key issue is whether physician-owned specialty hospitals pose financial strain on the larger group of general hospitals through cream-skimming of profitable patients, yet there is no study that conducts a systematic analysis relating such selection behavior by physician-owners to financial impacts within hospital markets. The current paper takes into account heterogeneity in specialty hospital behavior and finds some evidence of their adverse impact on profit margins of competitor hospitals, especially for-profit hospitals. There is also some evidence of hospital consolidation in response to competitive pressures by specialty hospitals. Overall, these findings underline the importance of the payment reforms aimed at correcting distortions in the reimbursement system that generate incentives for risk-selection among providers groups. The identification techniques will also inform empirical analysis on future data testing the efficacy of these payment reforms.

45 CFR 153.110 - Standards for the State notice of benefit and payment parameters.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Standards for the State notice of benefit and payment parameters. 153.110 Section 153.110 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK...

45 CFR 153.230 - Calculation of reinsurance payments made under the national contribution rate.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Calculation of reinsurance payments made under the national contribution rate. 153.230 Section 153.230 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK...

45 CFR 153.230 - Calculation of reinsurance payments made under the national contribution rate.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Calculation of reinsurance payments made under the national contribution rate. 153.230 Section 153.230 Public Welfare Department of Health and Human Services REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK...

45 CFR 153.110 - Standards for the State notice of benefit and payment parameters.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Standards for the State notice of benefit and payment parameters. 153.110 Section 153.110 Public Welfare Department of Health and Human Services REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK...

45 CFR 153.110 - Standards for the State notice of benefit and payment parameters.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Standards for the State notice of benefit and payment parameters. 153.110 Section 153.110 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIREMENTS RELATING TO HEALTH CARE ACCESS STANDARDS RELATED TO REINSURANCE, RISK CORRIDORS, AND RISK...

75 FR 36089 - Payment System Risk Policy; Daylight Overdraft Posting Rules

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-24

... and includes only Accounts Receivable Entry (ARC), Back Office Conversion Entry (BOC), Point-of... account balance and daylight overdraft balance in Account Management Information (AMI), which is a service... under the authority delegated to the Board by the Office of Management and Budget. No collections of...

77 FR 22666 - Payment System Risk Policy; Daylight Overdraft Posting Rules

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-17

... of separately-sorted savings bonds and to eliminate a reference to the contractual clearing balance... clearing balance program are effective July 12, 2012. FOR FURTHER INFORMATION CONTACT: Susan V. Foley... account balances according to a set of ``posting rules'' that determine the intraday timing of debits and...

75 FR 24384 - Reserve Requirements of Depository Institutions Policy on Payment System Risk

Federal Register 2010, 2011, 2012, 2013, 2014

2010-05-05

... balances. Institutions eligible to receive earnings on their balances in accounts at Federal Reserve Banks... general level of short-term interest rates. Term deposits are separate and distinct from balances... maintained in an excess balance account. Term deposits do not satisfy an institution's required reserve...

48 CFR 970.5215-3 - Conditional payment of fee, profit, and other incentives-facility management contracts

Code of Federal Regulations, 2010 CFR

2010-10-01

... Acquisition Regulations System DEPARTMENT OF ENERGY AGENCY SUPPLEMENTARY REGULATIONS DOE MANAGEMENT AND.... Financial incentives for timely mission accomplishment or cost effectiveness shall never compromise or..., undue risk to the common defense and security. In addition, this category includes performance failures...

48 CFR 970.5215-3 - Conditional payment of fee, profit, and other incentives-facility management contracts

Code of Federal Regulations, 2011 CFR

2011-10-01

... Acquisition Regulations System DEPARTMENT OF ENERGY AGENCY SUPPLEMENTARY REGULATIONS DOE MANAGEMENT AND.... Financial incentives for timely mission accomplishment or cost effectiveness shall never compromise or..., undue risk to the common defense and security. In addition, this category includes performance failures...

48 CFR 970.5215-3 - Conditional payment of fee, profit, and other incentives-facility management contracts

Code of Federal Regulations, 2014 CFR

2014-10-01

... Acquisition Regulations System DEPARTMENT OF ENERGY AGENCY SUPPLEMENTARY REGULATIONS DOE MANAGEMENT AND.... Financial incentives for timely mission accomplishment or cost effectiveness shall never compromise or..., undue risk to the common defense and security. In addition, this category includes performance failures...

42 CFR 413.217 - Items and services included in the ESRD prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payment system. 413.217 Section 413.217 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT....217 Items and services included in the ESRD prospective payment system. The following items and services are included in the ESRD prospective payment system effective January 1, 2011: (a) Renal dialysis...

42 CFR § 510.320 - Treatment of incentive programs or add-on payments under existing Medicare payment systems.

Code of Federal Regulations, 2010 CFR

2017-10-01

... INFRASTRUCTURE AND MODEL PROGRAMS COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL Pricing and Payment § 510.320 Treatment of incentive programs or add-on payments under existing Medicare payment systems. The CJR model... 42 Public Health 5 2017-10-01 2017-10-01 false Treatment of incentive programs or add-on payments...

42 CFR § 510.320 - Treatment of incentive programs or add-on payments under existing Medicare payment systems.

Code of Federal Regulations, 2010 CFR

2016-10-01

... INFRASTRUCTURE AND MODEL PROGRAMS COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL Pricing and Payment § 510.320 Treatment of incentive programs or add-on payments under existing Medicare payment systems. The CJR model... 42 Public Health 5 2016-10-01 2016-10-01 false Treatment of incentive programs or add-on payments...

42 CFR 412.432 - Method of payment under the inpatient psychiatric facility prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR... inpatient psychiatric facility receives payment under this subpart for inpatient operating cost and capital-related costs for each inpatient stay following submission of a bill. (b) Periodic interim payments (PIP...

Socioeconomic inequalities in informal payments for health care: An assessment of the 'Robin Hood' hypothesis in 33 African countries.

PubMed

Kankeu, Hyacinthe Tchewonpi; Ventelou, Bruno

2016-02-01

In almost all African countries, informal payments are frequently made when accessing health care. Some literature suggests that the informal payment system could lead to quasi-redistribution among patients, with physicians playing a 'Robin Hood' role, subsidizing the poor at the expense of the rich. We empirically tested this assumption with data from the rounds 3 and 5 of the Afrobarometer surveys conducted in 18 and 33 African countries respectively, from 2005 to 2006 for round 3 and from 2011 to 2013 for round 5. In these surveys, nationally representative samples of people aged 18 years or more were randomly selected in each country, with sizes varying between 1048 and 2400 for round 3 and between 1190 and 2407 for round 5. We used the 'normalized' concentration index, the poor/rich gap and the odds ratio to assess the level of inequality in the payment of bribes to access care at the local public health facility and implemented two decomposition techniques to identify the contributors to the observed inequalities. We obtained that: i) the socioeconomic gradient in informal payments is in favor of the rich in almost all countries, indicating a rather regressive system; ii) this is mainly due to the socioeconomic disadvantage itself, to poor/rich differences in supply side factors like lack of medicines, absence of doctors and long waiting times, as well as regional disparities. Although essentially empirical, the paper highlights the need for African health systems to undergo substantial country-specific reforms in order to better protect the worse-off from financial risk when they seek care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; quality reporting requirements for specific providers; reasonable compensation equivalents for physician services in excluded hospitals and certain teaching hospitals; provider administrative appeals and judicial review; enforcement provisions for organ transplant centers; and electronic health record (EHR) incentive program. Final rule.

PubMed

2014-08-22

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of these changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act), the Protecting Access to Medicare Act of 2014, and other legislation. These changes are applicable to discharges occurring on or after October 1, 2014, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits are effective for cost reporting periods beginning on or after October 1, 2014. We also are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes to the LTCH PPS under the Affordable Care Act and the Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 and the Protecting Access to Medicare Act of 2014. In addition, we discuss our proposals on the interruption of stay policy for LTCHs and on retiring the "5 percent" payment adjustment for collocated LTCHs. While many of the statutory mandates of the Pathway for SGR Reform Act apply to discharges occurring on or after October 1, 2014, others will not begin to apply until 2016 and beyond. In addition, we are making a number of changes relating to direct graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revising requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, and LTCHs) that are participating in Medicare. We are updating policies relating to the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reduction Program, and the Hospital-Acquired Condition (HAC) Reduction Program. In addition, we are making technical corrections to the regulations governing provider administrative appeals and judicial review; updating the reasonable compensation equivalent (RCE) limits, and revising the methodology for determining such limits, for services furnished by physicians to certain teaching hospitals and hospitals excluded from the IPPS; making regulatory revisions to broaden the specified uses of Medicare Advantage (MA) risk adjustment data and to specify the conditions for release of such risk adjustment data to entities outside of CMS; and making changes to the enforcement procedures for organ transplant centers. We are aligning the reporting and submission timelines for clinical quality measures for the Medicare HER Incentive Program for eligible hospitals and critical access hospitals (CAHs) with the reporting and submission timelines for the Hospital IQR Program. In addition, we provide guidance and clarification of certain policies for eligible hospitals and CAHs such as our policy for reporting zero denominators on clinical quality measures and our policy for case threshold exemptions. In this document, we are finalizing two interim final rules with comment period relating to criteria for disproportionate share hospital uncompensated care payments and extensions of temporary changes to the payment adjustment for low-volume hospitals and of the Medicare-Dependent, Small Rural Hospital (MDH) Program.

Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores.

PubMed Central

Bajekal, M; Alves, B; Jarman, B; Hurwitz, B

2001-01-01

BACKGROUND: The Department of Health introduced a new deprivation payments system for general practitioners (GPs) on 1 April 1999. Following a three-year phasing-in process, registered patients will attract deprivation payments based on the underprivileged area (UPA) score of their enumeration district (ED) of residence, rather than their electoral ward, changing the pattern and distribution of payments throughout England. AIM: To assess the rationale behind the changed deprivation payments system for GPs in England and to examine its impact on GP and practice payments. DESIGN OF STUDY: A quantitative study modelling practice-based deprivation payments. SETTING: A total of 25,450 unrestricted principal GPs in 8919 practices in England. METHOD: The effect of three new components in the system were examined: changes in the ED score ranges attracting payment, the percentage increase in the size of successive payment bands, and the total budget. The relationship between consultation rates (used as a proxy for workload) and UPA score was examined, together with changes in GP payments calculated nationally and by geographical area. RESULTS: A total of 11.6% of the population of England live in wards with a UPA score of 30 or more, qualifying for deprivation payments, and a similar proportion (11.4%) live in EDs with a UPA score of 20 or more. The larger percentage increases in the size of payments in successive ED UPA bands is supported by the modelled relationship between consultation rate and UPA score. Financially, under the new deprivations payment system, entitlement widens with 88% of practices receiving a payment. Overall, 74% of GPs gain and 13% lose (3% losing more than 1500 Pounds), with 13% receiving no payment. CONCLUSION: The new ED system maps onto the previous system well. Moreover, it more finely discriminates between smaller areas of different relative deprivation and, thereby, targets payments more accurately. PMID:11407049

Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores.

PubMed

Bajekal, M; Alves, B; Jarman, B; Hurwitz, B

2001-06-01

The Department of Health introduced a new deprivation payments system for general practitioners (GPs) on 1 April 1999. Following a three-year phasing-in process, registered patients will attract deprivation payments based on the underprivileged area (UPA) score of their enumeration district (ED) of residence, rather than their electoral ward, changing the pattern and distribution of payments throughout England. To assess the rationale behind the changed deprivation payments system for GPs in England and to examine its impact on GP and practice payments. A quantitative study modelling practice-based deprivation payments. A total of 25,450 unrestricted principal GPs in 8919 practices in England. The effect of three new components in the system were examined: changes in the ED score ranges attracting payment, the percentage increase in the size of successive payment bands, and the total budget. The relationship between consultation rates (used as a proxy for workload) and UPA score was examined, together with changes in GP payments calculated nationally and by geographical area. A total of 11.6% of the population of England live in wards with a UPA score of 30 or more, qualifying for deprivation payments, and a similar proportion (11.4%) live in EDs with a UPA score of 20 or more. The larger percentage increases in the size of payments in successive ED UPA bands is supported by the modelled relationship between consultation rate and UPA score. Financially, under the new deprivations payment system, entitlement widens with 88% of practices receiving a payment. Overall, 74% of GPs gain and 13% lose (3% losing more than 1500 Pounds), with 13% receiving no payment. The new ED system maps onto the previous system well. Moreover, it more finely discriminates between smaller areas of different relative deprivation and, thereby, targets payments more accurately.

42 CFR 412.535 - Publication of the Federal prospective payment rates.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care Hospitals § 412.535 Publication of the Federal prospective... care hospital prospective payment system effective for each annual update in the Federal Register. (a...

31 CFR 50.54 - Payment of Federal share of compensation.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 31 Money and Finance: Treasury 1 2014-07-01 2014-07-01 false Payment of Federal share of compensation. 50.54 Section 50.54 Money and Finance: Treasury Office of the Secretary of the Treasury TERRORISM RISK INSURANCE PROGRAM Claims Procedures § 50.54 Payment of Federal share of compensation. (a) Timing...

31 CFR 50.54 - Payment of Federal share of compensation.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 31 Money and Finance: Treasury 1 2012-07-01 2012-07-01 false Payment of Federal share of compensation. 50.54 Section 50.54 Money and Finance: Treasury Office of the Secretary of the Treasury TERRORISM RISK INSURANCE PROGRAM Claims Procedures § 50.54 Payment of Federal share of compensation. (a) Timing...

31 CFR 50.54 - Payment of Federal share of compensation.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 31 Money and Finance: Treasury 1 2011-07-01 2011-07-01 false Payment of Federal share of compensation. 50.54 Section 50.54 Money and Finance: Treasury Office of the Secretary of the Treasury TERRORISM RISK INSURANCE PROGRAM Claims Procedures § 50.54 Payment of Federal share of compensation. (a) Timing...

14 CFR 198.13 - Premium insurance-payment of premiums.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 14 Aeronautics and Space 3 2010-01-01 2010-01-01 false Premium insurance-payment of premiums. 198... (CONTINUED) WAR RISK INSURANCE AVIATION INSURANCE § 198.13 Premium insurance—payment of premiums. The insured must pay the premium for insurance issued under this part within the stated period after receipt of...

14 CFR 198.13 - Premium insurance-payment of premiums.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 14 Aeronautics and Space 3 2011-01-01 2011-01-01 false Premium insurance-payment of premiums. 198... (CONTINUED) WAR RISK INSURANCE AVIATION INSURANCE § 198.13 Premium insurance—payment of premiums. The insured must pay the premium for insurance issued under this part within the stated period after receipt of...

20 CFR 411.515 - Can the EN change its elected payment system?

Code of Federal Regulations, 2012 CFR

2012-04-01

... 20 Employees' Benefits 2 2012-04-01 2012-04-01 false Can the EN change its elected payment system? 411.515 Section 411.515 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.515 Can the EN change its elected payment system...

20 CFR 411.515 - Can the EN change its elected payment system?

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Can the EN change its elected payment system? 411.515 Section 411.515 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.515 Can the EN change its elected payment system...

20 CFR 411.515 - Can the EN change its elected payment system?

Code of Federal Regulations, 2013 CFR

2013-04-01

... 20 Employees' Benefits 2 2013-04-01 2013-04-01 false Can the EN change its elected payment system? 411.515 Section 411.515 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.515 Can the EN change its elected payment system...

Value-Based Payment Reform and the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015: A Primer for Plastic Surgeons.

PubMed

Squitieri, Lee; Chung, Kevin C

2017-07-01

In 2015, the U.S. Congress passed the Medicare Access and Children's Health Insurance Program Reauthorization Act, which effectively repealed the Centers for Medicare and Medicaid Services sustainable growth rate formula and established the Centers for Medicare and Medicaid Services Quality Payment Program. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents an unparalleled acceleration toward value-based payment models and a departure from traditional volume-driven fee-for-service reimbursement. The Quality Payment Program includes two paths for provider participation: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. The Merit-Based Incentive Payment System pathway replaces existing quality reporting programs and adds several new measures to create a composite performance score for each provider (or provider group) that will be used to adjust reimbursed payment. The advanced alternative payment model pathway is available to providers who participate in qualifying Advanced Alternative Payment Models and is associated with an initial 5 percent payment incentive. The first performance period for the Merit-Based Incentive Payment System opens January 1, 2017, and closes on December 31, 2017, and is associated with payment adjustments in January of 2019. The Centers for Medicare and Medicaid Services estimates that the majority of providers will begin participation in 2017 through the Merit-Based Incentive Payment System pathway, but aims to have 50 percent of payments tied to quality or value through Advanced Alternative Payment Models by 2018. In this article, the authors describe key components of the Medicare Access and Children's Health Insurance Program Reauthorization Act to providers navigating through the Quality Payment Program and discuss how plastic surgeons may optimize their performance in this new value-based payment program.

[Outlier cases in surgical disciplines. Micro-economic and macro-economic problems].

PubMed

Tecklenburg, A; Liebeneiner, J; Schaefer, O

2009-09-01

Postoperative complications will always occur and the negative impact puts strain on patients, relatives and the attending physicians. The conversion to a remuneration system based on flat rates (diagnosis-related groups) presents additional economic problems for hospitals in some resource-intensive treatments. This particularly pertains to extremely cost-intensive cases in which costs succeed revenue by the factor of 2 and are often surgical procedures. Here the economic risk increases with the number of interventions performed. Despite improvements in the remuneration system this problem persists. An improved payment for these treatments is desirable. To achieve this it is necessary to systematically analyze the extremely cost-intensive cases by experts of different medical disciplines to create a data basis for a proposal of a cost-covering payment.

Pilot of a mobile money school fee payment system in rural Benin.

PubMed

Adida, Claire L; Chabi Bouko, Adam; Verink, Alex; Chockalingam, Ganz; Burney, Jennifer

2018-01-01

We present a rationale for, and results from, the pilot of a direct individual-to-institution remittance system in the context of school fee payment in rural Benin. Data confirm that school fees act as an impediment to educational attainment, and in very rural poor settings such as northern Benin, students often depend on extended family and kinship networks to pay fees. But existing remittance options are costly, in terms of fees, time, and risk. We pilot a new technology bundle in a single public high school in northeastern Benin, and evaluate its effectiveness. Here we describe the technical and institutional implementation of the project, as well as our findings from the first year of operation. We discuss takeaways and implications for scale-up.

Pilot of a mobile money school fee payment system in rural Benin

PubMed Central

Chabi Bouko, Adam; Verink, Alex; Chockalingam, Ganz; Burney, Jennifer

2018-01-01

We present a rationale for, and results from, the pilot of a direct individual-to-institution remittance system in the context of school fee payment in rural Benin. Data confirm that school fees act as an impediment to educational attainment, and in very rural poor settings such as northern Benin, students often depend on extended family and kinship networks to pay fees. But existing remittance options are costly, in terms of fees, time, and risk. We pilot a new technology bundle in a single public high school in northeastern Benin, and evaluate its effectiveness. Here we describe the technical and institutional implementation of the project, as well as our findings from the first year of operation. We discuss takeaways and implications for scale-up. PMID:29889839

Prior health expenditures and risk sharing with insurers competing on quality.

PubMed

Marchand, Maurice; Sato, Motohiro; Schokkaert, Erik

2003-01-01

Insurers can exploit the heterogeneity within risk-adjustment classes to select the good risks because they have more information than the regulator on the expected expenditures of individual insurees. To counteract this cream skimming, mixed systems combining capitation and cost-based payments have been adopted that do not, however, generally use the past expenditures of insurees as a risk adjuster. In this article, two symmetric insurers compete for clients by differentiating the quality of service offered to them according to some private information about their risk. In our setting it is always welfare improving to use prior expenditures as a risk adjuster.

Evolving provider payment models and patient access to innovative medical technology.

PubMed

Long, Genia; Mortimer, Richard; Sanzenbacher, Geoffrey

2014-12-01

Abstract Objective: To investigate the evolving use and expected impact of pay-for-performance (P4P) and risk-based provider reimbursement on patient access to innovative medical technology. Structured interviews with leading private payers representing over 110 million commercially-insured lives exploring current and planned use of P4P provider payment models, evidence requirements for technology assessment and new technology coverage, and the evolving relationship between the two topics. Respondents reported rapid increases in the use of P4P and risk-sharing programs, with roughly half of commercial lives affected 3 years ago, just under two-thirds today, and an expected three-quarters in 3 years. All reported well-established systems for evaluating new technology coverage. Five of nine reported becoming more selective in the past 3 years in approving new technologies; four anticipated that in the next 3 years there will be a higher evidence requirement for new technology access. Similarly, four expected it will become more difficult for clinically appropriate but costly technologies to gain coverage. All reported planning to rely more on these types of provider payment incentives to control costs, but didn't see them as a substitute for payer technology reviews and coverage limitations; they each have a role to play. Interviews limited to nine leading payers with models in place; self-reported data. Likely implications include a more uncertain payment environment for providers, and indirectly for innovative medical technology and future investment, greater reliance on quality and financial metrics, and increased evidence requirements for favorable coverage and utilization decisions. Increasing provider financial risk may challenge the traditional technology adoption paradigm, where payers assumed a 'gatekeeping' role and providers a countervailing patient advocacy role with regard to access to new technology. Increased provider financial risk may result in an additional hurdle to the adoption of new technology, rather than substitution of provider- for payer-based gatekeeping.

76 FR 32815 - Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-06

... Hospital IPPS Inpatient prospective payment system MS-DRG Diagnosis-related group NCA National coverage... based on the ``inpatient prospective payment system'' (IPPS) described in section 1886(d) of the Act... and procedures, and payment systems. We reviewed various articles, reports, summaries, and data bases...

The risk of upcoding in casemix systems: a comparative study.

PubMed

Steinbusch, Paul J M; Oostenbrink, Jan B; Zuurbier, Joost J; Schaepkens, Frans J M

2007-05-01

With the introduction of a diagnosis related group (DRG) classification system in the Netherlands in 2005 it has become relevant to investigate the risk of upcoding. The problem of upcoding in the US casemix system is substantial. In 2004, the US Centres for Medicare and Medicaid estimated that the total number of improper Medicare payments for the Prospective Payment system for acute inpatient care (both short term and long term) amounted to US$ 4.8 billion (5.2%). By comparing the casemix systems in the US, Australian and Dutch healthcare systems, this article illustrates why certain casemix systems are more open to the risk of upcoding than other systems. This study identifies various market, control and casemix characteristics determining the weaknesses of a casemix reimbursement system to upcoding. It can be concluded that fewer opportunities for upcoding occur in casemix systems that do not allow for-profit ownership and in which the coder's salary does not depend on the outcome of the classification process. In addition, casemix systems in which the first point in time of registration is at the beginning of the care process and in which there are a limited number of occasions to alter the registration are less vulnerable to the risk of upcoding. Finally, the risk of upcoding is smaller in casemix systems that use classification criteria that are medically meaningful and aligned with clinical practice. Comparing the US, Australian and Dutch systems the following conclusions can be drawn. Given the combined occurrences of for-profit hospitals and the use of the secondary diagnosis criterion to classify DRGs, the US casemix system tends to be more open to upcoding than the Australian system. The strength of the Dutch system is related to the detailed classification scheme, using medically meaningful classification criteria. Nevertheless, the detailed classification scheme also causes a weakness, because of its increased complexity compared with the US and Australian system. It is recommended that researchers and policy makers carefully consider all relevant market, control and casemix characteristics when developing and restructuring casemix reimbursement systems.

Impact of payment system change from per-case to per-diem on high severity patient's length of stay.

PubMed

Jang, Sung-In; Nam, Chung Mo; Lee, Sang Gyu; Kim, Tae Hyun; Park, Sohee; Park, Eun-Cheol

2016-09-01

A new payment system, the diagnosis-related group (DRG) system, and Korean diagnosis procedure combination (KDPC, per-diem) payment system were officially introduced in 2002 and in 2012, respectively. We evaluated the impact of payment system change from per-case to per-diem on high severity patient's length of stay (LOS).Claim data was used. A total of 36,240 case admissions and 72,480 control admissions were included in the analysis. Segmented regression analysis of interrupted time series between cases and controls was conducted. Hospitals that consistently participated in the DRG payment system and changed to the KDPC payment system were defined as case hospitals. Hospitals that consistently participated in the DRG payment system were defined as control hospitals.LOS increased by 0.025 days per month (P = 0.0055) for 3 surgical diagnosis-related admissions due to the bundled payment system change. LOS among emergency admissions also increased and showed an increasing tendency under the KDPC. The LOS increase was observed specifically for complex procedure admissions and high severity cases (CCI 0, 1: 0.022, P = 0.0142; CCI 2, 3: 0.026, P = 0.0288; CCI ≥ 4: 0.055, P = 0.0003).Although both payment systems are optimized to decrease LOS, incentives to reduce LOS are stronger under the DRG system than under the KDPC system. It is worth noting that too strong incentive for reducing LOS is suitable to high severity cases.

Risk-adjusted payment and performance assessment for primary care.

PubMed

Ash, Arlene S; Ellis, Randall P

2012-08-01

Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped. Using MarketScan's claims-based data on 17.4 million commercially insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multipayer medical home implementation with commercially insured, Medicare, and Medicaid patients. Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R(2)'s at patient and practice levels, and within policy-relevant subgroups. The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types, and provider specialties; it explains 72% of practice-level variation. In 9 performance measures, the outcome-specific models explain 17%-86% of variation at the practice level, often substantially outperforming a generic score like the one used for full capitation payments in Medicare: for example, with grouped R(2)'s of 47% versus 5% for predicting "prescriptions for antibiotics of concern." Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.

Solving Disparities Through Payment And Delivery System Reform: A Program To Achieve Health Equity.

PubMed

DeMeester, Rachel H; Xu, Lucy J; Nocon, Robert S; Cook, Scott C; Ducas, Andrea M; Chin, Marshall H

2017-06-01

Payment systems generally do not directly encourage or support the reduction of health disparities. In 2013 the Finding Answers: Solving Disparities through Payment and Delivery System Reform program of the Robert Wood Johnson Foundation sought to understand how alternative payment models might intentionally incorporate a disparities-reduction component to promote health equity. A qualitative analysis of forty proposals to the program revealed that applicants generally did not link payment reform tightly to disparities reduction. Most proposed general pay-for-performance, global payment, or shared savings plans, combined with multicomponent system interventions. None of the applicants proposed making any financial payments contingent on having successfully reduced disparities. Most applicants did not address how they would optimize providers' intrinsic and extrinsic motivation to reduce disparities. A better understanding of how payment and care delivery models might be designed and implemented to reduce health disparities is essential. Project HOPE—The People-to-People Health Foundation, Inc.

Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program.

PubMed

Cairns, Mark A; Ostrum, Robert F; Clement, R Carter

2018-02-21

The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p < 0.01). Younger age was also associated with higher payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p < 0.01). Most comorbidities were associated with higher reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p < 0.01). Twenty-two procedure codes are included in the bundle, and patients with the 3 most common codes accounted for 98% of the cases, with average reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p < 0.01). DRGs also showed significant differences in reimbursement (p < 0.01); e.g., DRG 480 was reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15). Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that patients retain access to care. At a minimum, payments should be adjusted for age, comorbidities, demographic factors, geographic location, and surgical procedure.

Physician Practice Audit Targets Now Become Hospital and Health System Compliance Risks.

PubMed

Hirsch, Ronald L

2015-01-01

In 2013, 22% of the federal budget was spent on Medicare and Medicaid. The Medicare Trust Fund is forecast to be depleted in 2030. More than 12% of Medicare fee-for-service payments in 2014 were made in error. These factors have led Congress to apply more pressure to reduce improper payments. Although hospitals were the initial targets because of their higher reimbursement, recent efforts have shifted to physician billing. Hospitals and health systems continue to acquire physician practices, making them liable for the billing activities of physicians. And for physicians who remain independent, the cost and effort required to respond to audits and denials can be financially devastating, further demonstrating the importance of prevention. This article addresses some of the common audit targets and mistakes made by physicians and provides strategies for physician practices and health systems to respond to and, ultimately, avoid these denials.

Inequalities in financial risk protection in Bangladesh: an assessment of universal health coverage.

PubMed

Islam, Md Rashedul; Rahman, Md Shafiur; Islam, Zobida; Nurs, Cherri Zhang B; Sultana, Papia; Rahman, Md Mizanur

2017-04-04

Financial risk protection and equity are major components of universal health coverage (UHC), which is defined as ensuring access to health services for all citizens without any undue financial burden. We investigated progress towards UHC financial risk indicators and assessed variability of inequalities in financial risk protection indicators by wealth quintile. We further examined the determinants of different financial hardship indicators related to healthcare costs. A cross-sectional, three-stage probability survey was conducted in Bangladesh, which collected information from 1600 households from August to November 2011. Catastrophic health payments, impoverishment, and distress financing (borrowing or selling assets) were treated as financial hardship indicators in UHC. Poisson regression models were used to identify the determinants of catastrophic payment, impoverishment and distress financing separately. Slope, relative and concentration indices of inequalities were used to assess wealth-based inequalities in financial hardship indicators. The study found that around 9% of households incurred catastrophic payments, 7% faced distress financing, and 6% experienced impoverishing health payments in Bangladesh. Slope index of inequality indicated that the incidence of catastrophic health payment and distress financing among the richest households were 12 and 9 percentage points lower than the poorest households respectively. Multivariable Poisson regression models revealed that all UHC financial hardship indicators were significantly higher among household that had members who received inpatient care or were in the poorest quintile. The presence of a member with chronic illness in a household increased the risk of impoverishment by nearly double. This study identified a greater inequality in UHC financial hardship indicators. Rich households in Bangladesh were facing disproportionately less financial hardship than the poor ones. Households can be protected from financial hardship associated with healthcare costs by implementing risk pooling mechanism, increasing GDP spending on health, and properly monitoring subsidized programs in public health facilities.

76 FR 51475 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-18

... Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment... Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective...-related costs of acute care hospitals to implement changes arising from our continuing experience with...

78 FR 27485 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-10

... Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment... [CMS-1599-P] RIN 0938-AR53 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute... capital-related costs of acute care hospitals to implement changes arising from our continuing experience...

42 CFR 412.130 - Retroactive adjustments for incorrectly excluded hospitals and units.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments to Hospitals Under the Prospective Payment Systems § 412.130 Retroactive adjustments for... hospital that was excluded from the prospective payment systems specified in § 412.1(a)(1) or paid under...

20 CFR 411.545 - How are the outcome payments calculated under the outcome-milestone payment system?

Code of Federal Regulations, 2010 CFR

2010-04-01

... the outcome-milestone payment system? 411.545 Section 411.545 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.545 How... of the Social Security Act for all beneficiaries for months during the preceding calendar year; and...

20 CFR 411.545 - How are the outcome payments calculated under the outcome-milestone payment system?

Code of Federal Regulations, 2012 CFR

2012-04-01

... the outcome-milestone payment system? 411.545 Section 411.545 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.545 How... of the Social Security Act for all beneficiaries for months during the preceding calendar year; and...

20 CFR 411.545 - How are the outcome payments calculated under the outcome-milestone payment system?

Code of Federal Regulations, 2011 CFR

2011-04-01

... the outcome-milestone payment system? 411.545 Section 411.545 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.545 How... of the Social Security Act for all beneficiaries for months during the preceding calendar year; and...

20 CFR 411.545 - How are the outcome payments calculated under the outcome-milestone payment system?

Code of Federal Regulations, 2013 CFR

2013-04-01

... the outcome-milestone payment system? 411.545 Section 411.545 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.545 How... of the Social Security Act for all beneficiaries for months during the preceding calendar year; and...

20 CFR 411.545 - How are the outcome payments calculated under the outcome-milestone payment system?

Code of Federal Regulations, 2014 CFR

2014-04-01

... the outcome-milestone payment system? 411.545 Section 411.545 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.545 How... of the Social Security Act for all beneficiaries for months during the preceding calendar year; and...

77 FR 63751 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-10-17

... [CMS-1588-F2] RIN 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for...

A new dental insurance scheme--effects on the treatment provided and costs.

PubMed

Andås, Charlotte Andrén; Ostberg, Anna-Lena; Berggren, Pontus; Hakeberg, Magnus

2014-01-01

The aim of this study was to investigate whether the revenues cover the costs in a pilot capitation plan, a dental insurance scheme, and to compare this capitation plan (CP) with the original fee-for-service system (FFS), in terms of the amount and type of dental care provided. Data was collected longitudinally over a period of three years from 1,650 CP patients in five risk groups at a test clinic, and from 1,609 (from the test clinic) and 3,434 (from a matched control clinic) FFS patients, in Göteborg, Sweden. The care investigated was the number of total treatments provided and the number of examinations by dentists and dental hygienists, together with preventive, restorative and emergency treatments. The economic outcome was positive from the administrator's perspective, in all risk groups for the three-year period. The amount and type of care provided differed between the payment models, as CP patients received more preventive treatments, less restorative treatments, and more examinations by dental hygienists than the FFS patients. Emergency treatment was performed more often on CP patients, and the difference was due to a higher frequency of such treatments among women in the CP group. The difference between clinics concerning certain treatment measures was sometimes greater than the difference between payment models. The results from this study indicate a net positive economic outcome for the pilot CP system over three years. The payment model and the clinic affiliation had impact on what type and amount of dental care the patients received. This might suggest that the risk of skewed selection and its consequences as well as the influence of clinic-specific practice need further investigation, to ensure economic sustainability in a longer perspective.

Financial incentives to increase Canadian organ donation: quick fix or fallacy?

PubMed

Gill, John S; Klarenbach, Scott; Barnieh, Lianne; Caulfield, Timothy; Knoll, Greg; Levin, Adeera; Cole, Edward H

2014-01-01

Unlike the United States, the potential to increase organ donation in Canada may be sufficient to meet the need for transplantation. However, there has been no national coordinated effort to increase organ donation. Strategies that do not involve payment for organs, such as investment in health care resources to support deceased donor organ donation and introduction of a remuneration framework for the work of deceased organ donation, should be prioritized for implementation. Financial incentives that may be permitted under existing legislation and that pose little risk to existing donation sources should be advanced, including the following: payment of funeral expenses for potential donors who register their decision on organ donation during life (irrespective of the decision to donate or actual organ donation) and removal of disincentives for directed and paired exchange living donation, such as payment of wages, payment for pain and suffering related to the donor surgery, and payment of directed living kidney donors for participation in Canada's paired exchange program. In contrast, it would be premature to contemplate a regulated system of organ sales that would require a paradigm shift in the current approach to organ donation and legislative change to implement. Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

The effect of health payment reforms on cost containment in Taiwan hospitals: the agency theory perspective.

PubMed

Chang, Li

2011-01-01

This study aims to determine whether the Taiwanese government's implementation of new health care payment reforms (the National Health Insurance with fee-for-service (NHI-FFS) and global budget (NHI-GB)) has resulted in better cost containment. Also, the question arises under the agency theory whether the monitoring system is effective in reducing the risk of information asymmetry. This study uses panel data analysis with fixed effects model to investigate changes in cost containment at Taipei municipal hospitals before and after adopting reforms from 1989 to 2004. The results show that the monitoring system does not reduce information asymmetry to improve cost containment under the NHI-FFS. In addition, after adopting the NHI-GB system, health care costs are controlled based on an improved monitoring system in the policymaker's point of view. This may suggest that the NHI's fee-for-services system actually causes health care resource waste. The GB may solve the problems of controlling health care costs only on the macro side.

When Changing from Merit Pay to Variable/Bonus Pay: What Do Employees Want?

ERIC Educational Resources Information Center

Fox, Jeremy B.; Donohue, Joan M.

2004-01-01

This study examines potential responses to a change in an employee reward system from permanent merit pay increases to one-time bonus payments. Removing long term risks associated with escalating pay is an increasingly common compensation strategy. Often overlooked, however, are employee perceptions of reward fairness under such conditions of…

12 CFR 327.12 - Prepayment of quarterly risk-based assessments.

Code of Federal Regulations, 2010 CFR

2010-01-01

... (b)(2) and (3) of this section shall be determined based upon data in the FDIC's computer systems as of December 24, 2009. Changes to data underlying an institution's adjusted total base assessment rate... data changes as provided in paragraph (b)(4) of this section. (d) Payment of prepaid assessment. Each...

31 CFR 256.53 - How does the submitting agency know when payment is made?

Code of Federal Regulations, 2010 CFR

2010-07-01

... form. Also, FMS maintains an on-line payment status system that the submitting agency can access to determine the status of a payment. The payment reporting system can be accessed from the Judgment Fund Web...

Why 'Optimal' Payment for Healthcare Providers Can Never be Optimal Under Community Rating.

PubMed

Zweifel, Peter; Frech, H E

2016-02-01

This article extends the existing literature on optimal provider payment by accounting for consumer heterogeneity in preferences for health insurance and healthcare. This heterogeneity breaks down the separation of the relationship between providers and the health insurer and the relationship between consumers and the insurer. Both experimental and market evidence for a high degree of heterogeneity are presented. Given heterogeneity, a uniform policy fails to effectively control moral hazard, while incentives for risk selection created by community rating cannot be neutralized through risk adjustment. Consumer heterogeneity spills over into relationships with providers, such that a uniform contract with providers also cannot be optimal. The decisive condition for ensuring optimality of provider payment is to replace community rating (which violates the principle of marginal cost pricing) with risk rating of contributions combined with subsidization targeted at high risks with low incomes.

15 CFR 14.22 - Payment.

Code of Federal Regulations, 2013 CFR

2013-01-01

... transfer of funds and disbursement by the recipient, and financial management systems that meet the... accounts shall be remitted annually to Department of Health and Human Services, Payment Management System... ORGANIZATIONS Post-Award Requirements Financial and Program Management § 14.22 Payment. (a) Payment methods...

15 CFR 14.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-01-01

... transfer of funds and disbursement by the recipient, and financial management systems that meet the... accounts shall be remitted annually to Department of Health and Human Services, Payment Management System... ORGANIZATIONS Post-Award Requirements Financial and Program Management § 14.22 Payment. (a) Payment methods...

45 CFR 2543.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... and disbursement by the recipient, and (2) Financial management systems that meet the standards for... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Requirements Financial and Program Management § 2543.22 Payment. (a) Payment methods shall minimize the time...

15 CFR 14.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-01-01

... transfer of funds and disbursement by the recipient, and financial management systems that meet the... accounts shall be remitted annually to Department of Health and Human Services, Payment Management System... ORGANIZATIONS Post-Award Requirements Financial and Program Management § 14.22 Payment. (a) Payment methods...

45 CFR 2543.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... and disbursement by the recipient, and (2) Financial management systems that meet the standards for... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Requirements Financial and Program Management § 2543.22 Payment. (a) Payment methods shall minimize the time...

20 CFR 435.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-04-01

..., and (ii) Financial management systems that meet the standards for fund control and accountability as..., Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may be retained by...-Award Requirements Financial and Program Management § 435.22 Payment. (a) Introduction. Payment methods...

45 CFR 2543.22 - Payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... and disbursement by the recipient, and (2) Financial management systems that meet the standards for... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Requirements Financial and Program Management § 2543.22 Payment. (a) Payment methods shall minimize the time...

Leap of Faith--Medicare's New Physician Payment System.

PubMed

Oberlander, Jonathan; Laugesen, Miriam J

2015-09-24

Medicare's new payment system reflects the movement toward value-based payment, which is built on the view that we can contain costs only by eliminating fee-for-service payment. But there are important problems with this belief and the reforms it inspires.

Effects of the per diem prospective payment system with DRG-like grouping system (DPC/PDPS) on resource usage and healthcare quality in Japan.

PubMed

Hamada, Hironori; Sekimoto, Miho; Imanaka, Yuichi

2012-10-01

In 2003, Japan introduced the prospective payment system (PPS) with diagnosis-related groups (DRG) rearranged grouping system called the diagnostic procedure combination/per-diem payment system (DPC/PDPS). Even after eight years, little is known about the effects of DPC/PDPS. The purpose of this study was to examine the effects of DPC/PDPS on resource usage and healthcare quality. Using 2001-2009 (fiscal year) administrative data of acute myocardial infarction patients, four indices, including inpatient total accumulated medical charges, length of stay (LOS), mortality rate, and readmission rate, were compared between patients reimbursed by DPC/PDPS or by fee-for-service. DPC/PDPS significantly reduced total accumulated medical charges by $1061 (95% confidence interval [CI], -2007, -116) and LOS by 2.29 days (95% CI, -3.71, -0.88) after risk adjustment. However, mortality rate (Odds ratio [OR], 0.94; 95% CI, 0.73, 1.21) was unchanged. Furthermore, DPC/PDPS increased the readmission rate (OR, 1.37; 95% CI, 1.03, 1.82). This study showed that DPC/PDPS was associated with reduced resource usage, but not improved healthcare quality, as with DRG/PPSs in other countries. To achieve successful healthcare reform, further discussion on additional motives will be required. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Will the "Fixes" Fall Flat? Prospects for Quality Measures and Payment Incentives to Control Healthcare Spending.

PubMed

Hauswald, Erik; Sklar, David

2017-04-01

Payment systems in the US healthcare system have rewarded physicians for services and attempted to control healthcare spending, with rewards and penalties based upon projected goals for future spending. The incorporation of quality goals and alternatives to fee-for-service was introduced to replace the previous system of rewards and penalties. We describe the history of the US healthcare payment system, focusing on Medicare and the efforts to control spending through the Sustainable Growth Rate. We describe the latest evolution of the payment system, which emphasizes quality measurement and alternative payment models. We conclude with suggestions for how to influence physician behavior through education and payment reform so that their behavior aligns with alternative care models to control spending in the future.

42 CFR 417.598 - Annual enrollment reconciliation.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH CARE PREPAYMENT PLANS Medicare Payment: Risk Basis § 417.598 Annual enrollment reconciliation. CMS... conducts this reconciliation as necessary to ensure that the payments made do not exceed or fall short of...

Existing and Emerging Payment and Delivery Reforms in Cardiology

PubMed Central

Farmer, Steven A.; Darling, Margaret L.; George, Meaghan; Casale, Paul N.; Hagan, Eileen; McClellan, Mark B.

2017-01-01

IMPORTANCE Recent health care reforms aim to increase patient access, reduce costs, and improve health care quality as payers turn to payment reform for greater value. Cardiologists need to understand emerging payment models to succeed in the evolving payment landscape. We review existing payment and delivery reforms that affect cardiologists, present 4 emerging examples, and consider their implications for clinical practice. OBSERVATIONS Public and commercial payers have recently implemented payment reforms and new models are evolving. Most cardiology models are modified fee-for-service or address procedural or episodic care, but population models are also emerging. Although there is widespread agreement that payment reform is needed, existing programs have significant limitations and the adoption ofnew programs has been slow. New payment reforms address some of these problems, but many details remain undefined. CONCLUSIONS AND RELEVANCE Early payment reforms were voluntary and cardiologists’ participation is variable. However, conventional fee-for-service will become less viable, and enrollment in new payment models will be unavoidable. Early participation in new payment models will allow clinicians to develop expertise in new care pathways during a period of relatively lower risk. PMID:27851858

Payment for whole blood donations in Lithuania: the risk for infectious disease markers.

PubMed

Kalibatas, V

2008-04-01

In Lithuania, remuneration for whole blood donations still prevails, with the government covering payment for the donors. The payment per donation in cash is equal to 40 litas (euro11.6); it is offered to all blood donors and accepted by the majority of them. Donors who gave blood and received the payment are treated as remunerated donors; those who gave blood and did not take the payment are treated as non-remunerated ones. The purpose of this study was to assess the risk of payment for whole blood donations and to analyse the prevalence of infectious diseases markers per 100 remunerated and non-remunerated, first-time and regular whole blood donations, and to compare the risk ratios of infectious disease markers of remunerated and non-remunerated whole blood donations in 2005 and 2006 at the National Blood Center in Lithuania. Whole blood donors were categorized as follows: (i) first-time donor, remunerated; (ii) first-time donor, non-remunerated; (iii) regular donor, remunerated; and (iv) regular donor, non-remunerated. The blood donations were analysed for the presence or absence of the following infectious disease markers: anti-hepatitis C virus (anti-HCV), hepatitis B surface antigen (HBsAg), anti-human immunodeficiency virus (anti-HIV (1)/(2)) and syphilis. Only confirmed infectious disease markers were classified. To assess the risk of payment for whole blood donations, the prevalence of infectious disease markers per 100 donations in the different donor groups and the risk ratios between the remunerated and non-remunerated donations were determined. The prevalence per 100 first-time remunerated donations was: for anti-HCV 1.84 (2005) and 2.98 (2006); for HBsAg 1.73 (2005) and 2.03 (2006); for syphilis 0.67 (2005) and 1.03 (2006). The prevalence per 100 first-time non-remunerated donations was: for anti-HCV 0.93 (2005) and 0.98 (2006); for HBsAg 1.57 (2005) and 1.33 (2006); for syphilis 0.29 (2005) and 0.47 (2006). The first-time donors who were remunerated for whole blood donations had a significantly higher prevalence of infectious disease markers per 100 donations and a higher risk ratio for at least three infectious disease markers (HBsAg, anti-HCV and syphilis) as compared to first-time donors who were non-remunerated. The regular donors who were non-remunerated for whole blood donations had the lowest prevalence of all infectious disease markers: anti-HCV -0.03 (2005) and 0.04 (2005); syphilis -0.06 (2005) and 0.02 (2006); and any positive cases of HBsAg and anti-HIV (1)/(2) were found both in 2005 and 2006. No statistically significance differences in incidence and risk ratio existed when comparing the regular donations who were remunerated and non-remunerated. The payment for whole blood donors provides a higher risk for infectious disease markers of first-time donations at the National Blood Center in Lithuania.

Econometric analysis of the impact of the relationship of GDP and the pension capital

NASA Astrophysics Data System (ADS)

Nepp, A. N.; Amiryan, A. A.

2016-12-01

The article demonstrates the impact of institutional risks on indicators of compulsory pension insurance and describes the results of a comparative analysis of investment risks faced by the pension systems of the Russian Federation and OECD countries. Efficiency of private companies managing pension funds in Russia and OECD countries is compared and analyzed to show the necessity to liberalize requirements placed on investments of pension savings funds. On the basis of the available statistical data, the article puts forward and discusses the hypothesis that increasing of the basic indicators of the pension system is possible by reducing its institutional risks. It is concluded that if the institutional risks are reduced and the level of trust increases, there will be enhance growth in the pension system key indicators, such as pension payments and the replacement rate.

42 CFR 412.332 - Payment based on the hospital-specific rate.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital Capital Costs Determination of Transition Period Payment Rates for... (f) is determined by multiplying the applicable hospital-specific rate by the DRG weighting factor...

34 CFR 74.22 - Payment.

Code of Federal Regulations, 2013 CFR

2013-07-01

... recipient; and (ii) Financial management systems that meet the standards for fund control and accountability... Human Services, Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may... Management § 74.22 Payment. (a) Payment methods shall minimize the time elapsing between the transfer of...

34 CFR 74.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-07-01

... recipient; and (ii) Financial management systems that meet the standards for fund control and accountability... Human Services, Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may... Management § 74.22 Payment. (a) Payment methods shall minimize the time elapsing between the transfer of...

42 CFR § 414.1465 - Physician-focused payment models.

Code of Federal Regulations, 2010 CFR

2017-10-01

... 42 Public Health 3 2017-10-01 2017-10-01 false Physician-focused payment models. § 414.1465... Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1465 Physician-focused payment models. (a) Definition. A physician-focused payment model (PFPM) is an Alternative Payment...

42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

Code of Federal Regulations, 2012 CFR

2012-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as inpatient rehabilitation...) Accelerated payments—(1) General rule. Upon request, an accelerated payment may be made to an inpatient.... (2) Approval of payment. An inpatient rehabilitation facility's request for an accelerated payment...

42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

Code of Federal Regulations, 2013 CFR

2013-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as inpatient rehabilitation...) Accelerated payments—(1) General rule. Upon request, an accelerated payment may be made to an inpatient.... (2) Approval of payment. An inpatient rehabilitation facility's request for an accelerated payment...

42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

Code of Federal Regulations, 2014 CFR

2014-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as inpatient rehabilitation...) Accelerated payments—(1) General rule. Upon request, an accelerated payment may be made to an inpatient.... (2) Approval of payment. An inpatient rehabilitation facility's request for an accelerated payment...

42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

Code of Federal Regulations, 2011 CFR

2011-10-01

...) Recovery of payment. Recovery of the accelerated payment is made by recoupment as inpatient rehabilitation...) Accelerated payments—(1) General rule. Upon request, an accelerated payment may be made to an inpatient.... (2) Approval of payment. An inpatient rehabilitation facility's request for an accelerated payment...

Equity in out-of-pocket payments for hospital care: evidence from India.

PubMed

Roy, Kakoli; Howard, David Hill

2007-02-01

The lack of formal health insurance and inadequate social safety nets cause families in most low-income countries to finance health spending through out-of-pocket (OOP) payments, leaving poor families unable to insure their consumption during periods of major illnesses. To examine how well the Indian healthcare system protects households of differing living standards against the financial consequences of unanticipated health shocks. The data are drawn from the 52nd round of National Sample Survey, a nationally representative socioeconomic and health survey conducted in 1995-1996. The sample comprises 24,379 (3.84%) households where a member was hospitalized during the 1-year reference period. We estimate, using ordinary least squares, the relationship between household consumption (proxy for ability to pay) and OOP payments for hospitalization. We also estimate the relationship between consumption and OOP share in consumption. Our results indicate that both utilization (payments) and the consequent financial burden (payment share) increases with increasing ability to pay (ATP). While this relationship is retained across the different subgroups (e.g., gender, social code, region, etc.), comparisons across groups indicate horizontal inequities including differences in both degrees of progressivity and the redistributive effect. The finding that OOP payments do not decline with ATP could be an indication of: (1) the lack of insurance which implies that the better-off must pay from OOP to secure quality health care and (2) the absence of risk-pooling or prepayments mechanisms which poses financial impediments to the consumption of health care by the poor.

Mortality, Hospital Costs, Payments, and Readmissions Associated With Clostridium difficile Infection Among Medicare Beneficiaries.

PubMed

Drozd, Edward M; Inocencio, Timothy J; Braithwaite, Shamonda; Jagun, Dayo; Shah, Hemal; Quon, Nicole C; Broderick, Kelly C; Kuti, Joseph L

2015-11-01

The management of Clostridium difficile infection (CDI) among hospitalized patients is costly, and ongoing payment reform is compelling hospitals to reduce its burden. To assess the impact of CDI on mortality, hospital costs, healthcare use, and Medicare payments for beneficiaries who were discharged with CDI listed as a secondary International Classification of Diseases , Ninth Revision , Clinical Modification claim diagnosis. Data were analyzed from the 2009 to 2010 5% random sample Medicare Standard Analytic Files of beneficiary claims. Patients with index hospitalizations with CDI as a secondary diagnosis and no previous hospitalization within 30 days were identified. Outcomes included inpatient and 30-day mortality, inpatient costs, index hospital payments, all-provider payments, net hospital losses, payment to cost ratio, length of stay (LOS), and 30-day readmission; outcomes were each risk adjusted using propensity score matching and regression modeling techniques. A total of 3262 patients with CDI were identified after matching to patients without a CDI diagnosis. After risk adjustment, secondary CDI was associated with statistically significantly (all P < 0.05) greater inpatient mortality (3.1% vs. 1.7%), 30-day mortality (4.1% vs. 2.2%), longer LOS (7.0 days vs. 3.8 days), higher rates of 30-day hospital readmissions (14.8% vs. 10.4%), and greater hospital costs ($16,184 vs. $13,954) compared with the non-CDI cohort. The risk-adjusted payment-to-cost ratio was shown to be lower for patients with CDI than those without (0.76 vs. 0.85). Secondary CDI is associated with greater adjusted mortality, costs, LOS, and hospital readmissions, while receiving similar hospital reimbursement compared with patients without CDI in a Medicare population.

Mortality, Hospital Costs, Payments, and Readmissions Associated With Clostridium difficile Infection Among Medicare Beneficiaries

PubMed Central

Drozd, Edward M.; Inocencio, Timothy J.; Braithwaite, Shamonda; Jagun, Dayo; Shah, Hemal; Quon, Nicole C.; Broderick, Kelly C.; Kuti, Joseph L.

2015-01-01

Background The management of Clostridium difficile infection (CDI) among hospitalized patients is costly, and ongoing payment reform is compelling hospitals to reduce its burden. To assess the impact of CDI on mortality, hospital costs, healthcare use, and Medicare payments for beneficiaries who were discharged with CDI listed as a secondary International Classification of Diseases, Ninth Revision, Clinical Modification claim diagnosis. Methods Data were analyzed from the 2009 to 2010 5% random sample Medicare Standard Analytic Files of beneficiary claims. Patients with index hospitalizations with CDI as a secondary diagnosis and no previous hospitalization within 30 days were identified. Outcomes included inpatient and 30-day mortality, inpatient costs, index hospital payments, all-provider payments, net hospital losses, payment to cost ratio, length of stay (LOS), and 30-day readmission; outcomes were each risk adjusted using propensity score matching and regression modeling techniques. Results A total of 3262 patients with CDI were identified after matching to patients without a CDI diagnosis. After risk adjustment, secondary CDI was associated with statistically significantly (all P < 0.05) greater inpatient mortality (3.1% vs. 1.7%), 30-day mortality (4.1% vs. 2.2%), longer LOS (7.0 days vs. 3.8 days), higher rates of 30-day hospital readmissions (14.8% vs. 10.4%), and greater hospital costs ($16,184 vs. $13,954) compared with the non-CDI cohort. The risk-adjusted payment-to-cost ratio was shown to be lower for patients with CDI than those without (0.76 vs. 0.85). Conclusions Secondary CDI is associated with greater adjusted mortality, costs, LOS, and hospital readmissions, while receiving similar hospital reimbursement compared with patients without CDI in a Medicare population. PMID:27885315

Interest rate swaps: financial tool of the '90s.

PubMed

Woodard, M A

1993-11-01

The implementation of prospective payment for capital costs makes it more necessary than ever for healthcare financial managers to be able to creatively balance capital costs with risk. A new financial management tool--the interest rate swap (a contractual agreement in which one party with a fixed interest rate payment liability and another party with a variable interest payment liability agree to trade those obligations)--is proving to be a solution for a growing number of hospital managers. This article describes the uses of interest rate swaps and discusses the variables to be considered when evaluating whether the benefits of an interest rate swap offset the additional risk.

Towards integrated care for chronic conditions: Dutch policy developments to overcome the (financial) barriers.

PubMed

Tsiachristas, Apostolos; Hipple-Walters, Bethany; Lemmens, Karin M M; Nieboer, Anna P; Rutten-van Mölken, Maureen P M H

2011-07-01

Chronic non-communicable diseases are a major threat to population health and have a major economic impact on health care systems. Worldwide, integrated chronic care delivery systems have been developed to tackle this challenge. In the Netherlands, the recently introduced integrated payment system--the chain-DTC--is seen as the cornerstone of a policy stimulating the development of a well-functioning integrated chronic care system. The purpose of this paper is to describe the recent attempts in the Netherlands to stimulate the delivery of integrated chronic care, focusing specifically on the new integrated payment scheme and the barriers to introducing this scheme. We also highlight possible threats and identify necessary conditions to the success of the system. This paper is based on a combination of methods and sources including literature, government documents, personal communications and site visits to disease management programs (DMPs). The most important conditions for the success of the new payment system are: complete care protocols describing both general (e.g. smoking cessation, physical activity) and disease-specific chronic care modules, coverage of all components of a DMP by basic health care insurance, adequate information systems that facilitate communication between caregivers, explicit links between the quality and the price of a DMP, expansion of the amount of specialized care included in the chain-DTC, inclusion of a multi-morbidity factor in the risk equalization formula of insurers, and thorough economic evaluation of DMPs. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

7 CFR 3019.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-01-01

... recipient, and financial management systems that meet the standards for fund control and accountability as... Department of Health and Human Services, Payment Management System, P.O. Box 6021, Rockville, MD 20852... HHS Payment Management System through an electronic medium such as the FEDWIRE Deposit system...

7 CFR 3019.22 - Payment.

Code of Federal Regulations, 2013 CFR

2013-01-01

... recipient, and financial management systems that meet the standards for fund control and accountability as... Department of Health and Human Services, Payment Management System, P.O. Box 6021, Rockville, MD 20852... HHS Payment Management System through an electronic medium such as the FEDWIRE Deposit system...

7 CFR 3019.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-01-01

... recipient, and financial management systems that meet the standards for fund control and accountability as... Department of Health and Human Services, Payment Management System, P.O. Box 6021, Rockville, MD 20852... HHS Payment Management System through an electronic medium such as the FEDWIRE Deposit system...

Oregon's experiment in health care delivery and payment reform: coordinated care organizations replacing managed care.

PubMed

Howard, Steven W; Bernell, Stephanie L; Yoon, Jangho; Luck, Jeff; Ranit, Claire M

2015-02-01

To control Medicaid costs, improve quality, and drive community engagement, the Oregon Health Authority introduced a new system of coordinated care organizations (CCOs). While CCOs resemble traditional Medicaid managed care, they have differences that have been deliberately designed to improve care coordination, increase accountability, and incorporate greater community governance. Reforms include global budgets integrating medical, behavioral, and oral health care and public health functions; risk-adjusted payments rewarding outcomes and evidence-based practice; increased transparency; and greater community engagement. The CCO model faces several implementation challenges. If successful, it will provide improved health care delivery, better health outcomes, and overall savings. Copyright © 2015 by Duke University Press.

Fee-for-service will remain a feature of major payment reforms, requiring more changes in Medicare physician payment.

PubMed

Ginsburg, Paul B

2012-09-01

Many health policy analysts envision provider payment reforms currently under development as replacements for the traditional fee-for-service payment system. Reforms include per episode bundled payment and elements of capitation, such as global payments or accountable care organizations. But even if these approaches succeed and are widely adopted, the core method of payment to many physicians for the services they provide is likely to remain fee-for-service. It is therefore critical to address the current shortcomings in the Medicare physician fee schedule, because it will affect physician incentives and will continue to play an important role in determining the payment amounts under payment reform. This article reviews how the current payment system developed and is applied, and it highlights areas that require careful review and modification to ensure the success of broader payment reform.

Bundled payment fails to gain a foothold In California: the experience of the IHA bundled payment demonstration.

PubMed

Ridgely, M Susan; de Vries, David; Bozic, Kevin J; Hussey, Peter S

2014-08-01

To determine whether bundled payment could be an effective payment model for California, the Integrated Healthcare Association convened a group of stakeholders (health plans, hospitals, ambulatory surgery centers, physician organizations, and vendors) to develop, through a consensus process, the methods and means of implementing bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed in its goal to implement bundled payment for orthopedic procedures across multiple payers and hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as administrative burden, state regulatory uncertainty, and disagreements about bundle definition and assumption of risk. Ultimately, few contracts were signed, which resulted in insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. Although bundled payment failed to gain a foothold in California, the evaluation provides lessons for future bundled payment initiatives. Project HOPE—The People-to-People Health Foundation, Inc.

12 CFR 233.3 - Designated payment systems.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 12 Banks and Banking 3 2010-01-01 2010-01-01 false Designated payment systems. 233.3 Section 233.3 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING (REGULATION GG) § 233.3 Designated payment systems. The...

12 CFR 233.3 - Designated payment systems.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 12 Banks and Banking 3 2011-01-01 2011-01-01 false Designated payment systems. 233.3 Section 233.3 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING (REGULATION GG) § 233.3 Designated payment systems. The...

12 CFR 226.10 - Payments.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 12 Banks and Banking 3 2011-01-01 2011-01-01 false Payments. 226.10 Section 226.10 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM TRUTH IN...) Specifying one particular address for receiving payments, such as a post office box. (3) In-person payments...

42 CFR 412.89 - Payment adjustment for certain replaced devices.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Payments for... implantation of the device determines the DRG assignment. (2) CMS lists the DRGs that qualify under paragraph (b)(1) of this section in the annual final rule for the hospital inpatient prospective payment system...

42 CFR 412.101 - Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Special Treatment of Certain Facilities Under the Prospective Payment System for... 42 Public Health 2 2010-10-01 2010-10-01 false Special treatment: Inpatient hospital payment...

48 CFR 847.306-70 - Transportation payment and audit.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 5 2010-10-01 2010-10-01 false Transportation payment and audit. 847.306-70 Section 847.306-70 Federal Acquisition Regulations System DEPARTMENT OF VETERANS AFFAIRS CONTRACT MANAGEMENT TRANSPORTATION Transportation in Supply Contracts 847.306-70 Transportation payment and audit. Transportation payments ar...

Alternative evaluation metrics for risk adjustment methods.

PubMed

Park, Sungchul; Basu, Anirban

2018-06-01

Risk adjustment is instituted to counter risk selection by accurately equating payments with expected expenditures. Traditional risk-adjustment methods are designed to estimate accurate payments at the group level. However, this generates residual risks at the individual level, especially for high-expenditure individuals, thereby inducing health plans to avoid those with high residual risks. To identify an optimal risk-adjustment method, we perform a comprehensive comparison of prediction accuracies at the group level, at the tail distributions, and at the individual level across 19 estimators: 9 parametric regression, 7 machine learning, and 3 distributional estimators. Using the 2013-2014 MarketScan database, we find that no one estimator performs best in all prediction accuracies. Generally, machine learning and distribution-based estimators achieve higher group-level prediction accuracy than parametric regression estimators. However, parametric regression estimators show higher tail distribution prediction accuracy and individual-level prediction accuracy, especially at the tails of the distribution. This suggests that there is a trade-off in selecting an appropriate risk-adjustment method between estimating accurate payments at the group level and lower residual risks at the individual level. Our results indicate that an optimal method cannot be determined solely on the basis of statistical metrics but rather needs to account for simulating plans' risk selective behaviors. Copyright © 2018 John Wiley & Sons, Ltd.

Wage Payment Systems. Supervising: Economic and Financial Aspects. The Choice Series #73. A Self Learning Opportunity.

ERIC Educational Resources Information Center

Carlisle, Ysanne

This student guide is intended to assist persons employed as supervisors in understanding various wage payment systems. Discussed in the first four sections are the following topics: the aims and determination of payment (aims of a payment system, the economy and wage levels, the government and wage levels, and method of pay and wage levels); main…

Comparative analysis of the current payment system for hospital services in Serbia and projected payments under diagnostic related groups system in urology.

PubMed

Babić, Uroš; Soldatović, Ivan; Vuković, Dejana; Milićević, Milena Šantrić; Stjepanović, Mihailo; Kojić, Dejan; Argirović, Aleksandar; Vukotić, Vinka

2015-03-01

Global budget per calendar year is a traditional method of funding hospitals in Serbia. Diagnose related groups (DGR) is a method of hospital payment based on classification of patients into groups with clinically similar problems and similar utilization of hospital resources. The aim of this study was to compare current methods of hospital services payment with the projected costs by DRG payment method in urology. The data were obtained from the information system used in the Clinical Hospital Center "Dr. Dragiša Mišović"--Dedinje in Belgrade, Serbia. The implemented hospital information system was the main criterion for selection of healthcare institutions. The study included 994 randomly selected patients treated surgically and conservatively in 2012. Average costs under the current payment method were slightly higher than those projected by DRG, however, the variability was twice as high (54,111 ± 69,789 compared to 53,434 ± 32,509, p < 0.001) respectively. The univariate analysis showed that the highest correlation with the current payment method as well as with the projected one by DRG was observed in relation to the number of days of hospitalization (ρ = 0.842, p < 0.001, and ρ = 0.637, p < 0.001, respectively). Multivariate regression models confirmed the influence of the number of hospitalization days to costs under the current payment system (β = 0.843, p < 0.001) as well as under the projected DRG payment system (β = 0.737, p < 0.001). The same predictor was crucial for the difference in the current payment method and the pro- jected DRG payment methods (β = 0.501, p < 0.001). Payment under the DRG system is administratively more complex because it requires detailed and standardized coding of diagnoses and procedures, as well as the information on the average consumption of resources (costs) per DRG. Given that aggregate costs of treatment under two hospital payment methods compared in the study are not significantly different, the focus on minor surgeries both under the current hospital payment method and under the introduced DRG system would be far more cost-effective for a hospital as great variations in treatment performance (reductions of days of hospitalization and complications), and consequently invoiced amounts would be reduced.

78 FR 74130 - Federal Reserve Policy on Payment System Risk; Procedures for Measuring Daylight Overdrafts

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-10

... Docket No. R-1473, the Board is also proposing necessary related changes to the Board's Regulation J... receive an electronic file and create substitute checks from check images in the file to present to paying... Regulation J. Elsewhere in the Federal Register, the Board is proposing necessary related changes to this and...

Nursing home costs, Medicaid rates, and profits under alternative Medicaid payment systems.

PubMed Central

Schlenker, R E

1991-01-01

This analysis compares nursing home costs, Medicaid payment rates, and profits under three Medicaid nursing home payment systems: case-mix, facility-specific, and class-rate systems. Data used were collected from 135 nursing homes in seven states. The association of case mix with costs, rates, and profits under the three payment systems was of particular interest. Case mix was more strongly associated (positively) with patient care cost and the Medicaid rate for the case-mix systems than for the other systems, particularly the class-rate systems. In contrast, case mix and profits were not associated in the case-mix or facility-specific systems, but were negatively associated in the class rate systems. Overall, the results suggest that case-mix systems have some important advantages over other payment systems, but further research is needed on larger samples and involving the newer case-mix systems. PMID:1743972

42 CFR 412.500 - Basis and scope of subpart.

Code of Federal Regulations, 2010 CFR

2010-10-01

... appropriate adjustments to that system, including adjustments to DRG weights, area wage adjustments... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long... payment system for long-term care hospitals described in section 1886(d)(1)(B)(iv) of the Act. (2) Section...

Medicare program; prospective payment system for hospital outpatient services--HCFA. Proposed rule.

PubMed

1998-09-08

As required by sections 4521, 4522, and 4523 of the Balanced Budget Act of 1997, this proposed rule would eliminate the formula-driven overpayment for certain outpatient hospital services, extend reductions in payment for costs of hospital outpatient services, and establish in regulations a prospective payment system for hospital outpatient services (and for Medicare Part B services furnished to inpatients who have no Part A coverage). The prospective payment system would simplify our current payment system and apply to all hospitals, including those that are excluded from the inpatient prospective payment system. The Balanced Budget Act provides for implementation of the prospective payment system effective January 1, 1999, but delays application of the system to cancer hospitals until January 1, 2000. The hospital outpatient prospective payment system would also apply to partial hospitalization services furnished by community mental health centers. Although the statutory effective date for the outpatient prospective payment system is January 1, 1999, implementation of the new system will have to be delayed because of year 2000 systems concerns. The demands on intermediary bill processing systems and HCFA internal systems to become compliant for the year 2000 preclude making the major systems changes that are required to implement the prospective payment system. The outpatient prospective payment system will be implemented for all hospitals and community mental health centers as soon as possible after January 1, 2000, and a notice of the anticipated implementation date will be published in the Federal Register at least 90 days in advance. This document also proposes new requirements for provider departments and provider-based entities. These proposed changes, as revised based on our consideration of public comments, will be effective 30 days after publication of a final rule. This proposed rule would also implement section 9343(c) of the Omnibus Budget Reconciliation Act of 1986, which prohibits Medicare payment for nonphysician services furnished to a hospital outpatient by a provider or supplier other than a hospital, unless the services are furnished under an arrangement with the hospital. This section also authorizes the Department of Health and Human Services' Office of Inspector General to impose a civil money penalty, not to exceed $10,000, against any individual or entity who knowingly and willfully presents a bill for nonphysician or other bundled services not provided directly or under such an arrangement. This proposed rule also addresses the requirements for designating certain entities as provider-based or as a department of a hospital.

78 FR 79058 - Proposed Information Collection Request; Notice of New Requirements and Procedures for Grant...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

...The DOT invites the public and other Federal agencies to comment on a revision to a previously approved information collection concerning new requirements and procedures for grant payment request submission. DOT will submit the proposed renewal of information collection request to the Office of Management and Budget (OMB) for review, as required by the Paperwork Reduction Act of 1995 (PRA) (44 U.S.C. 3506 (c)(2)(A)). This notice sets forth new requirements and procedures for grantees that submit and receive payments from DOT Operating Administrations (OAs).\\1\\ DOT is updating systems that support grant payments and there will be changes to the way grantees complete and submit payment requests. Simplifying the DOT grant payment process will save both the grantee and the Federal Government time and expense that come with paper-based grant application and payment administration. Note: At this time, this requirement is not applicable to DOT grant recipients requesting payment electronically through the National Highway Traffic Safety Administration's Grant Tracking System (GTS), the Federal Highway Administration's Rapid Approval State Payment System (RASPS), or Federal Transit Administration (FTA) grant recipients requesting payment through the Electronic Clearing House Operation System (ECHO-Web). ---------------------------------------------------------------------------

The LUGPA Alternative Payment Model for Initial Therapy of Newly Diagnosed Patients With Organ-confined Prostate Cancer: Rationale and Development.

PubMed

Kapoor, Deepak A; Shore, Neal D; Kirsh, Gary M; Henderson, Jonathan; Cohen, Todd D; Latino, Kathleen

2017-01-01

Over the past several decades, rapid expansion in healthcare expenditures has exposed the utilization incentives inherent in fee-for-service payment models. The passage of Medicare Access and CHIP Reauthorization Act of 2015 heralded a transition toward value-based care, creating incentives for practitioners to accept bidirectional risk linked to outcome and utilization metrics. At present, the limited availability of these vehicles excludes all but a handful of providers from participation in alternative payment models (APMs). The LUGPA APM supports the goals of the triple aim in improving the patient experience, enhancing population health and reducing expenditures. By requiring utilization of certified electronic health record technologies, tying payment to quality metrics, and requiring practices to bear more than nominal risk, the LUGPA APM qualifies as an advanced APM, thereby easing the reporting burden and creating opportunities for participating practices.

The LUGPA Alternative Payment Model for Initial Therapy of Newly Diagnosed Patients With Organ-confined Prostate Cancer: Rationale and Development

PubMed Central

Kapoor, Deepak A.; Shore, Neal D.; Kirsh, Gary M.; Henderson, Jonathan; Cohen, Todd D.; Latino, Kathleen

2017-01-01

Over the past several decades, rapid expansion in healthcare expenditures has exposed the utilization incentives inherent in fee-for-service payment models. The passage of Medicare Access and CHIP Reauthorization Act of 2015 heralded a transition toward value-based care, creating incentives for practitioners to accept bidirectional risk linked to outcome and utilization metrics. At present, the limited availability of these vehicles excludes all but a handful of providers from participation in alternative payment models (APMs). The LUGPA APM supports the goals of the triple aim in improving the patient experience, enhancing population health and reducing expenditures. By requiring utilization of certified electronic health record technologies, tying payment to quality metrics, and requiring practices to bear more than nominal risk, the LUGPA APM qualifies as an advanced APM, thereby easing the reporting burden and creating opportunities for participating practices. PMID:29726849

75 FR 30845 - Request Voucher for Grant Payment and Line of Credit Control System (LOCCS) Voice Response System...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-02

... request vouchers for distribution of grant funds using the automated Voice Response System (VRS). An... Payment and Line of Credit Control System (LOCCS) Voice Response System Access Authorization AGENCY... subject proposal. Payment request vouchers for distribution of grant funds using the automated Voice...

48 CFR 32.503-3 - Initiation of progress payments and review of accounting system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... payments and review of accounting system. 32.503-3 Section 32.503-3 Federal Acquisition Regulations System... on Costs 32.503-3 Initiation of progress payments and review of accounting system. (a) For..., (2) possessed of an adequate accounting system and controls, and (3) in sound financial condition...

Incentives and provider payment methods.

PubMed

Barnum, H; Kutzin, J; Saxenian, H

1995-01-01

The mode of payment creates powerful incentives affecting provider behavior and the efficiency, equity and quality outcomes of health finance reforms. This article examines provider incentives as well as administrative costs, and institutional conditions for successful implementation associated with provider payment alternatives. The alternatives considered are budget reforms, capitation, fee-for-service, and case-based reimbursement. We conclude that competition, whether through a regulated private sector or within a public system, has the potential to improve the performance of any payment method. All methods generate both adverse and beneficial incentives. Systems with mixed forms of provider payment can provide tradeoffs to offset the disadvantages of individual modes. Low-income countries should avoid complex payment systems requiring higher levels of institutional development.

Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform.

PubMed

Silva, Ezequiel; McGinty, Geraldine B; Hughes, Danny R; Duszak, Richard

2016-10-01

The Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on the Merit-Based Incentive Payment System and incentives for alternative payment model participation. It is important that radiologists understand the statutory requirements of MACRA. This includes the nature of the Merit-Based Incentive Payment System composite performance score and its impact on payments. The timeline for MACRA implementation is fairly aggressive and includes a robust effort to define episode groups, which include radiologic services. A number of organizations, including the ACR, are commenting on the structure of MACRA-directed initiatives. Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.

After the revolution: DRGs at age 30.

PubMed

Quinn, Kevin

2014-03-18

1 October 2013 marked 30 years since Medicare began paying hospitals by diagnosis-related group (DRG), arguably the most influential innovation in the history of health care financing. Initially developed as a tool for hospital management, DRGs became the basis of the inpatient prospective payment system that Medicare implemented in 1983. The strong incentives were revolutionary in their impact. Medicare spending growth slowed sharply, and, more remarkable, hospitals posted record profits. After the link between cost and payment was broken, hospitals moved quickly to cut costs. Nevertheless, a literature survey concluded that none of the worst fears about adverse effects on patients were realized. Diagnosis-related groups have also come to define "the product of a hospital" for purposes of benchmarking and risk adjustment. The acceptance of DRG algorithms owes much to their categorical approach, clinical focus, and transparency. The 2 most commonly used algorithms, Medicare DRGs and All Patient Refined (APR) DRGs, typically explain more than 40% of cost variance in inpatient stays, although with considerable range by care category. Because Medicare DRGs are unsuitable for obstetrics, pediatrics, and neonatology, some payers prefer APR DRGs. Diagnosis-related groups have proven to be a suitable basis for payment, as evidenced by widespread use. Common issues include mitigation of adverse incentives, appropriate payment for extremely costly stays, applicability to certain hospitals and care categories, and growing complexity. The DRG experience offers lessons about the effectiveness of financial incentives, the likelihood of adverse effects, the usefulness of case-mix measures, the risks of growing complexity, and the example that sensible policy need not be the domain of any one political party or other entity.

12 CFR 233.3 - Designated payment systems.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 12 Banks and Banking 4 2013-01-01 2013-01-01 false Designated payment systems. 233.3 Section 233.3 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING (REGULATION GG) § 233.3 Designated payment...

12 CFR 233.3 - Designated payment systems.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 12 Banks and Banking 4 2014-01-01 2014-01-01 false Designated payment systems. 233.3 Section 233.3 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING (REGULATION GG) § 233.3 Designated payment...

12 CFR 233.3 - Designated payment systems.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 12 Banks and Banking 4 2012-01-01 2012-01-01 false Designated payment systems. 233.3 Section 233.3 Banks and Banking FEDERAL RESERVE SYSTEM (CONTINUED) BOARD OF GOVERNORS OF THE FEDERAL RESERVE SYSTEM (CONTINUED) PROHIBITION ON FUNDING OF UNLAWFUL INTERNET GAMBLING (REGULATION GG) § 233.3 Designated payment...

12 CFR 234.3 - Standards for payment systems.

Code of Federal Regulations, 2014 CFR

2014-01-01

... SYSTEM (CONTINUED) DESIGNATED FINANCIAL MARKET UTILITIES (REGULATION HH) § 234.3 Standards for payment systems. (a) A designated financial market utility that is designated on the basis of its role as the... arrangements for timely completion of daily processing. (8) The payment system provides a means of making...

12 CFR 234.3 - Standards for payment systems.

Code of Federal Regulations, 2013 CFR

2013-01-01

... SYSTEM (CONTINUED) DESIGNATED FINANCIAL MARKET UTILITIES (REGULATION HH) § 234.3 Standards for payment systems. (a) A designated financial market utility that is designated on the basis of its role as the... arrangements for timely completion of daily processing. (8) The payment system provides a means of making...

75 FR 78707 - Medicare Program; First Semi-Annual Meeting of the Advisory Panel on Ambulatory Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-16

... hospital payment systems; hospital medical care delivery systems; provider billing and accounting systems; APC groups; Current Procedural Terminology codes; Health Care Common Procedure Coding System (HCPCS) codes; the use of, and payment for, drugs, medical devices, and other services in the outpatient setting...

20 CFR 411.595 - What oversight procedures are planned for the EN payment systems?

Code of Federal Regulations, 2013 CFR

2013-04-01

... EN payment systems? 411.595 Section 411.595 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.595 What oversight... activities to identify areas for improvement. Internal reviews of our systems security controls are regularly...

20 CFR 411.595 - What oversight procedures are planned for the EN payment systems?

Code of Federal Regulations, 2012 CFR

2012-04-01

... EN payment systems? 411.595 Section 411.595 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.595 What oversight... activities to identify areas for improvement. Internal reviews of our systems security controls are regularly...

20 CFR 411.595 - What oversight procedures are planned for the EN payment systems?

Code of Federal Regulations, 2014 CFR

2014-04-01

... EN payment systems? 411.595 Section 411.595 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.595 What oversight... activities to identify areas for improvement. Internal reviews of our systems security controls are regularly...

20 CFR 411.595 - What oversight procedures are planned for the EN payment systems?

Code of Federal Regulations, 2010 CFR

2010-04-01

... EN payment systems? 411.595 Section 411.595 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.595 What oversight... activities to identify areas for improvement. Internal reviews of our systems security controls are regularly...

20 CFR 411.595 - What oversight procedures are planned for the EN payment systems?

Code of Federal Regulations, 2011 CFR

2011-04-01

... EN payment systems? 411.595 Section 411.595 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.595 What oversight... activities to identify areas for improvement. Internal reviews of our systems security controls are regularly...

42 CFR 412.76 - Recovery of excess transition period payment amounts resulting from unlawful claims.

Code of Federal Regulations, 2010 CFR

2010-10-01

... & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR... 42 Public Health 2 2010-10-01 2010-10-01 false Recovery of excess transition period payment... System for Inpatient Operating Costs § 412.76 Recovery of excess transition period payment amounts...

DRG-based hospital payment systems and technological innovation in 12 European countries.

PubMed

Scheller-Kreinsen, David; Quentin, Wilm; Busse, Reinhard

2011-12-01

To assess how diagnosis-related group-based (DRG-based) hospital payment systems in 12 European countries participating in the EuroDRG project pay and incorporate technological innovation. A standardized questionnaire was used to guide comprehensive DRG system descriptions. Researchers from each country reviewed relevant materials to complete the questionnaire and drafted standardized country reports. Two characteristics of DRG-based hospital payment systems were identified as particularly important: the existence of short-term payment instruments encouraging technological innovation in different countries, and the characteristics of long-term updating mechanisms that assure technological innovation is ultimately incorporated into DRG-based hospital payment systems. Short-term payment instruments and long-term updating mechanisms differ greatly among the 12 European countries included in this study. Some countries operate generous short-term payment instruments that provide additional payments to hospitals for making use of technological innovation (e.g., France). Other countries update their DRG-based hospital payment systems very frequently and use more recent data for updates. Generous short-term payment instruments to promote technological innovation should be applied carefully as they may imply rapidly increasing health-care expenditures. In general, they should be granted only if rigorous analyses have demonstrated their benefits. If the evidence remains uncertain, coverage with evidence development frameworks or frequent updates of the DRG-based hospital systems may provide policy alternatives. Once the data and evidence base is substantially improved, future research should empirically investigate how different policy arrangements affect the adoption and use of technological innovation and health-care expenditures. Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.

5 CFR 9701.361 - Special skills payments.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 5 Administrative Personnel 3 2011-01-01 2011-01-01 false Special skills payments. 9701.361 Section... RESOURCES MANAGEMENT SYSTEM Pay and Pay Administration Special Payments § 9701.361 Special skills payments... at the same time as basic pay or in periodic lump-sum payments. Special skills payments are not basic...

42 CFR 413.350 - Periodic interim payments for skilled nursing facilities receiving payment under the skilled...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A...-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING...

42 CFR 413.350 - Periodic interim payments for skilled nursing facilities receiving payment under the skilled...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A...-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING...

42 CFR 413.350 - Periodic interim payments for skilled nursing facilities receiving payment under the skilled...

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A...-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING...

42 CFR 413.350 - Periodic interim payments for skilled nursing facilities receiving payment under the skilled...

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A...-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING...

42 CFR 413.350 - Periodic interim payments for skilled nursing facilities receiving payment under the skilled...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Periodic interim payments for skilled nursing facilities receiving payment under the skilled nursing facility prospective payment system for Part A...-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING...

42 CFR 412.200 - General provisions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Operating... the prospective payment system for inpatient operating costs. Except as provided in this subpart, the... for § 412.60, which deals with DRG classification and weighting factors, the provisions of subparts D...

42 CFR 412.4 - Discharges and transfers.

Code of Federal Regulations, 2014 CFR

2014-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES General Provisions § 412.4 Discharges... hospital inpatient is considered discharged from a hospital paid under the prospective payment system when... the initial discharge) to another hospital that is— (1) Paid under the prospective payment system...

42 CFR 412.4 - Discharges and transfers.

Code of Federal Regulations, 2011 CFR

2011-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES General Provisions § 412.4 Discharges... hospital inpatient is considered discharged from a hospital paid under the prospective payment system when... the initial discharge) to another hospital that is— (1) Paid under the prospective payment system...

42 CFR 412.4 - Discharges and transfers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES General Provisions § 412.4 Discharges... hospital inpatient is considered discharged from a hospital paid under the prospective payment system when... the initial discharge) to another hospital that is— (1) Paid under the prospective payment system...

42 CFR 412.4 - Discharges and transfers.

Code of Federal Regulations, 2013 CFR

2013-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES General Provisions § 412.4 Discharges... hospital inpatient is considered discharged from a hospital paid under the prospective payment system when... the initial discharge) to another hospital that is— (1) Paid under the prospective payment system...

42 CFR 412.4 - Discharges and transfers.

Code of Federal Regulations, 2012 CFR

2012-10-01

... PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES General Provisions § 412.4 Discharges... hospital inpatient is considered discharged from a hospital paid under the prospective payment system when... the initial discharge) to another hospital that is— (1) Paid under the prospective payment system...

Twenty-five years of professional liability in pediatric ophthalmology and strabismus: the OMIC experience.

PubMed

Wiggins, Robert E; Gold, Robert S; Menke, Anne M

2015-12-01

To summarize the claims statistics of the Ophthalmic Mutual Insurance Company (OMIC) in the field of pediatric ophthalmology and strabismus (POS). Internal OMIC case summaries and defense counsel case evaluations of all claims in the field of POS closed between December 1, 1988, and February 19, 2013 were retrospectively analyzed. A total of 140 claims were closed over the 25-year study period, of which 44 were closed with an indemnity payment. Claims related to strabismus and retinopathy of prematurity (ROP) were most common, and claims related to ROP resulted in the highest indemnity and expense payments. Issues related to follow-up represented the most significant risk factor among system-related claims. Claims in pediatric ophthalmology and strabismus were infrequent but associated with three times higher average indemnity payments relative to all claims paid by OMIC during the course of the study. Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.

77 FR 73117 - Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014

Federal Register 2010, 2011, 2012, 2013, 2014

2012-12-07

...This proposed rule provides further detail and parameters related to: the risk adjustment, reinsurance, and risk corridors programs; cost-sharing reductions; user fees for a Federally- facilitated Exchange; advance payments of the premium tax credit; a Federally-facilitated Small Business Health Option Program; and the medical loss ratio program. The cost-sharing reductions and advanced payments of the premium tax credit, combined with new insurance market reforms, will significantly increase the number of individuals with health insurance coverage, particularly in the individual market. The premium stabilization programs--risk adjustment, reinsurance, and risk corridors--will protect against adverse selection in the newly enrolled population. These programs, in combination with the medical loss ratio program and market reforms extending guaranteed availability (also known as guaranteed issue) protections and prohibiting the use of factors such as health status, medical history, gender, and industry of employment to set premium rates, will help to ensure that every American has access to high-quality, affordable health insurance.

78 FR 15409 - Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2014

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-11

...This final rule provides detail and parameters related to: the risk adjustment, reinsurance, and risk corridors programs; cost-sharing reductions; user fees for Federally-facilitated Exchanges; advance payments of the premium tax credit; the Federally-facilitated Small Business Health Option Program; and the medical loss ratio program. Cost-sharing reductions and advance payments of the premium tax credit, combined with new insurance market reforms, are expected to significantly increase the number of individuals with health insurance coverage, particularly in the individual market. In addition, we expect the premium stabilization programs--risk adjustment, reinsurance, and risk corridors--to protect against the effects of adverse selection. These programs, in combination with the medical loss ratio program and market reforms extending guaranteed availability (also known as guaranteed issue) and prohibiting the use of factors such as health status, medical history, gender, and industry of employment to set premium rates, will help to ensure that every American has access to high-quality, affordable health insurance.

The patient-centered medical home in oncology: from concept to reality.

PubMed

Page, Ray D; Newcomer, Lee N; Sprandio, John D; McAneny, Barbara L

2015-01-01

In recent years, the cost of providing quality cancer care has been subject to an epic escalation causing concerns on the verge of a health care crisis. Innovative patient-management models in oncology based on patient-centered medical home (PCMH) principles, coupled with alternative payments to traditional fee for service (FFS), such as bundled and episodes payment are now showing evidence of effectiveness. These efforts have the potential to bend the cost curve while also improving quality of care and patient satisfaction. However, going forward with FFS alternatives, there are several performance-based payment options with an array of financial risks and rewards. Most novel payment options convey a greater financial risk and accountability on the provider. Therefore, the oncology medical home (OMH) can be a way to mitigate some financial risks by sharing savings with the payer through better global care of the patient, proactively preventing complications, emergency department (ED) visits, and hospitalizations. However, much of the medical home infrastructure that is required to reduced total costs of cancer care comes as an added expense to the provider. As best-of-practice quality standards are being elucidated and refined, we are now at a juncture where payers, providers, policymakers, and other stakeholders should work in concert to expand and implement the OMH framework into the variety of oncology practice environments to better equip them to assimilate into the new payment reform configurations of the future.

48 CFR 49.112 - Payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Payment. 49.112 Section 49.112 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION CONTRACT MANAGEMENT TERMINATION OF CONTRACTS General Principles 49.112 Payment. ...

10 CFR 600.122 - Payment.

Code of Federal Regulations, 2013 CFR

2013-01-01

... transfer of funds and disbursement by the recipient, and (2) Financial management systems that meet the... accounts shall be remitted annually to the HHS Payment Management System through an electronic medium such... address is the Department of Health and Human Services, Payment Management System, P.O. Box 6021...

49 CFR 19.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-10-01

..., and (ii) Financial management systems that meet the standards for fund control and accountability as... accounts shall be remitted annually to Department of Health and Human Services, Payment Management System...), interest should be remitted to the HHS Payment Management System through an electric medium such as the...

49 CFR 19.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-10-01

..., and (ii) Financial management systems that meet the standards for fund control and accountability as... accounts shall be remitted annually to Department of Health and Human Services, Payment Management System...), interest should be remitted to the HHS Payment Management System through an electric medium such as the...

75 FR 51465 - Medicare Program; Announcement of Five New Members to the Advisory Panel on Ambulatory Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-20

... Panel. This expertise encompasses hospital payment systems; hospital medical-care delivery systems; provider billing systems; APC groups, Current Procedural Terminology codes, and alpha-numeric Healthcare Common Procedure Coding System codes; and the use of, and payment for, drugs and medical devices in the...

48 CFR 32.1107 - Payment information.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 1 2013-10-01 2013-10-01 false Payment information. 32... CONTRACTING REQUIREMENTS CONTRACT FINANCING Electronic Funds Transfer 32.1107 Payment information. The payment or disbursing office shall forward to the contractor available payment information that is suitable...

US hospital payment adjustments for innovative technology lag behind those in Germany, France, and Japan.

PubMed

Hernandez, John; Machacz, Susanne F; Robinson, James C

2015-02-01

Medicare pioneered add-on payments to facilitate the adoption of innovative technologies under its hospital prospective payment system. US policy makers are now experimenting with broader value-based payment initiatives, but these have not been adjusted for innovation. This article examines the structure, processes, and experience with Medicare's hospital new technology add-on payment program since its inception in 2001 and compares it with analogous payment systems in Germany, France, and Japan. Between 2001 and 2015 CMS approved nineteen of fifty-three applications for the new technology add-on payment program. We found that the program resulted in $201.7 million in Medicare payments in fiscal years 2002-13-less than half the level anticipated by Congress and only 34 percent of the amount projected by CMS. The US program approved considerably fewer innovative technologies, compared to analogous technology payment mechanisms in Germany, France and Japan. We conclude that it is important to adjust payments for new medical innovations within prospective and value-based payment systems explicitly as well as implicitly. The most straightforward method to use in adjusting value-based payments is for the insurer to retrospectively adjust spending targets to account for the cost of new technologies. If CMS made such retrospective adjustments, it would not financially penalize hospitals for adopting beneficial innovations. Project HOPE—The People-to-People Health Foundation, Inc.

Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.

PubMed

2015-11-13

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.

[Concept for Planning the Nurse-Patient Ratio and Nursing Fee Payment Linkage System].

PubMed

Lu, Meei-Shiow; Tseng, Hsiu-Yi; Liang, Shu-Yuan; Lin, Chiou-Fen

2017-02-01

This article describes the current situation in Taiwan with regard to the nurse-patient ratio and nursing fee payments, reviews the related policies and results in developed countries, and then proposes a plan for improving the domestic situation. Direct relationships exist between patient nursing quality and patient safety and the nurse-patient ratio as well as between nursing fee payments and the nurse-patient ratio. Therefore, in order to enhance the quality and safety of nursing care, it will be necessary to develop and institute a payment linkage system that links nursing fee payments to the nurse-patient ratio. This process requires public consensus and planning in order to institute an equitable and effective payment linkage system in the future.

48 CFR 28.102 - Performance and payment bonds and alternative payment protections for construction contracts.

Code of Federal Regulations, 2010 CFR

2010-10-01

... INSURANCE Bonds and Other Financial Protections 28.102 Performance and payment bonds and alternative payment... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Performance and payment bonds and alternative payment protections for construction contracts. 28.102 Section 28.102 Federal...

42 CFR 412.507 - Limitation on charges to beneficiaries.

Code of Federal Regulations, 2010 CFR

2010-10-01

... prospective payment system. If Medicare has paid the full LTC-DRG payment, that payment applies to the... than the full LTC-DRG payment, that payment only applies to the hospital's costs for those costs or... receives a full LTC-DRG payment under this subpart for covered days in a hospital stay may charge the...

42 CFR § 414.1450 - APM incentive payment.

Code of Federal Regulations, 2010 CFR

2017-10-01

... (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1450 APM incentive payment. (a) In... 42 Public Health 3 2017-10-01 2017-10-01 false APM incentive payment. § 414.1450 Section § 414...

42 CFR § 414.1405 - Payment.

Code of Federal Regulations, 2010 CFR

2017-10-01

...) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1405 Payment. (a) General. Each MIPS eligible... 42 Public Health 3 2017-10-01 2017-10-01 false Payment. § 414.1405 Section § 414.1405 Public...

The effects of patient cost sharing on inpatient utilization, cost, and outcome.

PubMed

Xu, Yuan; Li, Ning; Lu, Mingshan; Dixon, Elijah; Myers, Robert P; Jelley, Rachel J; Quan, Hude

2017-01-01

Health insurance and provider payment reforms all over the world beg a key empirical question: what are the potential impacts of patient cost-sharing on health care utilization, cost and outcomes? The unique health insurance system and rich electronic medical record (EMR) data in China provides us a unique opportunity to study this topic. Four years (2010 to 2014) of EMR data from one medical center in China were utilized, including 10,858 adult patients with liver diseases. We measured patient cost-sharing using actual reimbursement ratio (RR) which is allowed us to better capture financial incentive than using type of health insurance. A rigorous risk adjustment method was employed with both comorbidities and disease severity measures acting as risk adjustors. Associations between RR and health use, costs and outcome were analyzed by multivariate analyses. After risk adjustment, patients with more generous health insurance coverage (higher RR) were found to have longer hospital stay, higher total cost, higher medication cost, and higher ratio of medication to total cost, as well as higher number and likelihood that specific procedures were performed. Our study implied that patient cost-sharing affects health care services use and cost. This reflects how patients and physicians respond to financial incentives in the current healthcare system in China, and the responses could be a joint effect of both demand and supply side moral hazard. In order to contain cost and improve efficiency in the system, reforming provide payment and insurance scheme is urgently needed.

Using chronic disease risk factors to adjust Medicare capitation payments

PubMed Central

Schauffler, Helen Halpin; Howland, Jonathan; Cobb, Janet

1992-01-01

This study evaluates the use of risk factors for chronic disease as health status adjusters for Medicare's capitation formula, the average adjusted per capita costs (AAPCC). Risk factor data for the surviving members of the Framingham Study cohort who were examined in 1982-83 were merged with 100 percent Medicare payment data for 1984 and 1985, matching on Social Security number and sex. Seven different AAPCC models were estimated to assess the independent contributions of risk factors and measures of prior utilization and disability in increasing the explanatory power of AAPCC. The findings suggest that inclusion of risk factors for chronic disease as health status adjusters can improve substantially the predictive accuracy of AAPCC. PMID:10124441

Assessing the validity and reliability of three indicators self-reported on the pregnancy risk assessment monitoring system survey.

PubMed

Ahluwalia, Indu B; Helms, Kristen; Morrow, Brian

2013-01-01

We investigated the reliability and validity of three self-reported indicators from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey. We used 2008 PRAMS (n=15,646) data from 12 states that had implemented the 2003 revised U.S. Certificate of Live Birth. We estimated reliability by kappa coefficient and validity by sensitivity and specificity using the birth certificate data as the reference for the following: prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); Medicaid payment for delivery; and breastfeeding initiation. These indicators were examined across several demographic subgroups. The reliability was high for all three measures: 0.81 for WIC participation, 0.67 for Medicaid payment of delivery, and 0.72 for breastfeeding initiation. The validity of PRAMS indicators was also high: WIC participation (sensitivity = 90.8%, specificity = 90.6%), Medicaid payment for delivery (sensitivity = 82.4%, specificity = 85.6%), and breastfeeding initiation (sensitivity = 94.3%, specificity = 76.0%). The prevalence estimates were higher on PRAMS than the birth certificate for each of the indicators except Medicaid-paid delivery among non-Hispanic black women. Kappa values within most subgroups remained in the moderate range (0.40-0.80). Sensitivity and specificity values were lower for Hispanic women who responded to the PRAMS survey in Spanish and for breastfeeding initiation among women who delivered very low birthweight and very preterm infants. The validity and reliability of the PRAMS data for measures assessed were high. Our findings support the use of PRAMS data for epidemiological surveillance, research, and planning.

Strategic responses by hospitals to increased financial risk in the 1980s.

PubMed Central

Friedman, B.; Farley, D.

1995-01-01

OBJECTIVE. This research addresses the following types of responses by hospitals to increased financial risk: (a) increases in prices to privately insured patients (testing separately the effects of risk from the effects of "cost-shifting" that depends on level of Medicare payment in relation to case mix-adjusted cost); (b) changes in service mix offered and selectivity in acceptance of patients to reduce risk; and (c) efforts to reduce variation in resource use for those patients admitted. DATA SOURCES. The database includes a national panel of over 400 hospitals providing information from patient discharge abstracts, hospital financial reports, and county level information over the period 1980-1987. STUDY DESIGN. Econometric methods suitable to panel data are implemented, with tests for pooling, hospital-specific fixed effects, and possible problems of selection bias. PRINCIPAL FINDINGS. The prices paid by private insurers to a particular hospital were affected by the changes in risk imposed by Medicare prospective payment, the generosity of Medicare payment, state rate regulation, and ability of the hospital to bear risk. The risk-weighted measure of case mix did not respond to changes in payment policy, but other variables reflecting the management of care after admission to reduce risk did change in the predicted directions. CONCLUSIONS. Some of the findings in this article are relevant to current Medicare policies that involve risk-sharing, for instance, special allowances for "outlier" patients with unusually high cost, and for sole community hospitals. The first type of allowance appears successful in preserving access to care, while the second type is not well justified by the findings. State rate regulation programs were associated not only with lower hospital prices but also with less risk reduction behavior by hospitals. The design of regulation as a sort of risk-pooling arrangement across payers and hospitals may be attractive to hospitals and help explain their support for regulation is some states. PMID:7649752

42 CFR 412.108 - Special treatment: Medicare-dependent, small rural hospitals.

Code of Federal Regulations, 2010 CFR

2010-10-01

... HEALTH AND HUMAN SERVICES MEDICARE PROGRAM PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Special Treatment of Certain Facilities Under the Prospective Payment System for Inpatient Operating Costs... including days and discharges from units excluded from the prospective payment system under §§ 412.25...

42 CFR 413.171 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... outpatient maintenance dialysis for the treatment of ESRD and included in the composite payment system established under section 1881(b)(7) and the basic case-mix adjusted composite payment system established... dialysis services,” and paid under the ESRD prospective payment system under section 1881(b)(14) of the Act...

42 CFR 413.171 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... outpatient maintenance dialysis for the treatment of ESRD and included in the composite payment system established under section 1881(b)(7) and the basic case-mix adjusted composite payment system established... dialysis services,” and paid under the ESRD prospective payment system under section 1881(b)(14) of the Act...

42 CFR 413.171 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... outpatient maintenance dialysis for the treatment of ESRD and included in the composite payment system established under section 1881(b)(7) and the basic case-mix adjusted composite payment system established... dialysis services,” and paid under the ESRD prospective payment system under section 1881(b)(14) of the Act...

42 CFR 412.529 - Special payment provision for short-stay outliers.

Code of Federal Regulations, 2010 CFR

2010-10-01

... system DRG weighting factors. (B) Is adjusted for different area wage levels based on the geographic...-related share, using the applicable hospital inpatient prospective payment system wage index value for... share of low-income patients. (iii) Hospital inpatient prospective payment system capital Federal rate...

Effect of prospective reimbursement on nursing home costs.

PubMed Central

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-01-01

OBJECTIVE. This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems. PMID:8463109

Effect of prospective reimbursement on nursing home costs.

PubMed

Coburn, A F; Fortinsky, R; McGuire, C; McDonald, T P

1993-04-01

This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

20 CFR 411.580 - Can an EN receive payments for milestones or outcome payment months that occur before the...

Code of Federal Regulations, 2012 CFR

2012-04-01

....580 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.580 Can an EN receive payments for milestones or outcome payment...

20 CFR 411.580 - Can an EN receive payments for milestones or outcome payment months that occur before the...

Code of Federal Regulations, 2014 CFR

2014-04-01

....580 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.580 Can an EN receive payments for milestones or outcome payment...

20 CFR 411.580 - Can an EN receive payments for milestones or outcome payment months that occur before the...

Code of Federal Regulations, 2013 CFR

2013-04-01

....580 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment Systems § 411.580 Can an EN receive payments for milestones or outcome payment...

On the renewal risk model under a threshold strategy

NASA Astrophysics Data System (ADS)

Dong, Yinghui; Wang, Guojing; Yuen, Kam C.

2009-08-01

In this paper, we consider the renewal risk process under a threshold dividend payment strategy. For this model, the expected discounted dividend payments and the Gerber-Shiu expected discounted penalty function are investigated. Integral equations, integro-differential equations and some closed form expressions for them are derived. When the claims are exponentially distributed, it is verified that the expected penalty of the deficit at ruin is proportional to the ruin probability.

Strategic behavior and marriage payments: theory and evidence from Senegal.

PubMed

Gaspart, Frederic; Platteau, Jean-Philippe

2010-01-01

This article proposes an original theory of marriage payments based on insights gained from firsthand information collected in the Senegal River valley. This theory postulates that decisions about the bride-price, which are made by the bride's father, take into account the likely effects of the amount set on the risk of ill-treatment of the wife and the risk of marriage failure. Based on a sequential game with three players (the bride's father, the husband, and the wife) and a matching process, it leads to a number of important predictions that are tested against Senegalese data relating to bride-prices and various characteristics of women. The empirical results confirm that parents behave strategically by keeping bride-prices down so as to reduce the risk of marriage failure for their daughters. Other interesting effects on marriage payments and the probability of separation are also highlighted, stressing the role of the bride's bargaining power in her own family.

Disposition at Discharge and 60-Day Mortality among Elderly People Following Shorter Hospital Stays: A Population-Based Comparison.

ERIC Educational Resources Information Center

Leibson, Cynthia; And Others

1990-01-01

Examination of hospitalizations for 5,854 elderly adults for 1980, 1985, and 1987 revealed significant increases in 60-day mortality and nursing home transfers after Medicare's Prospective Payment System began and hospital stays were shortened. Increases were largely explained by differences in risk factors other than length of stay (age, gender,…

MACRA: A New Age for Physician Payments.

PubMed

Huston, Kent Kwasind

2017-04-01

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced a new system of physician payments in the United States. This legislation and the complex rules written to enact the law intend to force a shift away from volume-based payments and into so called value-based payments. Physicians and other clinicians will be graded via quality and cost metrics and payments will be adjusted based on performance. Robust use of certified electronic health records is required under MACRA. Physicians will follow one of two payment reform tracks known as the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) pathways. Although there are rheumatology and other specialty specific quality measures in the MIPS program, there are no rheumatology specific APMs to date. A thorough understating of MACRA is required for medical practices to survive the new era of payment reform.

Reforming the Portuguese mental health system: an incentive-based approach.

PubMed

Perelman, Julian; Chaves, Pedro; de Almeida, José Miguel Caldas; Matias, Maria Ana

2018-01-01

To promote an effective mental health system, the World Health Organization recommends the involvement of primary care in prevention and treatment of mild diseases and community-based care for serious mental illnesses. Despite a prevalence of lifetime mental health disorders above 30%, Portugal is failing to achieve such recommendations. It was argued that this failure is partly due to inadequate financing mechanisms of mental health care providers. This study proposes an innovative payment model for mental health providers oriented toward incentivising best practices. We performed a comprehensive review of healthcare providers' payment schemes and their related incentives, and a narrative review of best practices in mental health prevention and care. We designed an alternative payment model, on the basis of the literature, and then we presented it individually, through face-to-face interviews, to a panel of 22 experts with different backgrounds and experience, and from southern and northern Portuguese regions, asking them to comment on the model and provide suggestions. Then, after a first round of interviews, we revised our model, which we presented to experts again for their approval, and provide new suggestions and comments, if deemed necessary. This approach is close to what is generally known as the Delphi technique, although it was not applied in a rigid way. We designed a four-dimension model that focused on (i) the prevention of mental disorders early in life; (ii) the detection of mental disorders in childhood and adolescence; (iii) the implementation of a collaborative stepped care model for depression; and (iv) the integrated community-based care for patients with serious mental illnesses. First, we recommend a bundled payment to primary care practices for the follow-up of children with special needs or at risk under 2 years of age. Second, we propose a pay-for-performance scheme for all primary care practices, based on the number of users under 18 years old who are provided with check-up consultations. Third, we propose a pay-for-performance scheme for all primary care practices, based on the implementation of collaborative stepped care for depression. Finally, we propose a value-based risk-adjusted bundled payment for patients with serious mental illness. The implementation of evidence-based best practices in mental health needs to be supported by adequate payment mechanisms. Our study shows that mental health experts, including decision makers, agree with using economic tools to support best practices, which were also consensual.

A Third-Party E-Payment Protocol Based on Quantum Group Blind Signature

NASA Astrophysics Data System (ADS)

Zhang, Jian-Zhong; Yang, Yuan-Yuan; Xie, Shu-Cui

2017-09-01

A third-party E-payment protocol based on quantum group blind signature is proposed in this paper. Our E-payment protocol could protect user's anonymity as the traditional E-payment systems do, and also have unconditional security which the classical E-payment systems can not provide. To achieve that, quantum key distribution, one-time pad and quantum group blind signature are adopted in our scheme. Furthermore, if there were a dispute, the manager Trent can identify who tells a lie.

Model Adoption Exchange Payment System: Executive Summary.

ERIC Educational Resources Information Center

Ambrosino, Robert J.

This executive summary provides a brief description of the Model Adoption Exchange Payment System (MAEPS), a unique payment system aimed at improving the delivery of adoption exchange services throughout the United States. Following a brief introductory overview, MAEPS is described in terms of (1) its six components (registration, listing,…

41 CFR 301-73.300 - What is a travel payment system?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 41 Public Contracts and Property Management 4 2010-07-01 2010-07-01 false What is a travel payment system? 301-73.300 Section 301-73.300 Public Contracts and Property Management Federal Travel Regulation System TEMPORARY DUTY (TDY) TRAVEL ALLOWANCES AGENCY RESPONSIBILITIES 73-TRAVEL PROGRAMS Travel Payment...

42 CFR 412.405 - Preadmission services as inpatient operating costs under the inpatient psychiatric facility...

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system. 412.405 Section 412.405 Public... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

42 CFR 412.405 - Preadmission services as inpatient operating costs under the inpatient psychiatric facility...

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system. 412.405 Section 412.405 Public... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

42 CFR 412.405 - Preadmission services as inpatient operating costs under the inpatient psychiatric facility...

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system. 412.405 Section 412.405 Public... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

42 CFR 412.405 - Preadmission services as inpatient operating costs under the inpatient psychiatric facility...

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system. 412.405 Section 412.405 Public... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

42 CFR 412.405 - Preadmission services as inpatient operating costs under the inpatient psychiatric facility...

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system. 412.405 Section 412.405 Public... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Inpatient Hospital...

Hospital non-price competition under the Global Budget Payment and Prospective Payment Systems.

PubMed

Chen, Wen-Yi; Lin, Yu-Hui

2008-06-01

This paper provides theoretical analyses of two alternative hospital payment systems for controlling medical cost: the Global Budget Payment System (GBPS) and the Prospective Payment System (PPS). The former method assigns a fixed total budget for all healthcare services over a given period with hospitals being paid on a fee-for-service basis. The latter method is usually connected with a fixed payment to hospitals within a Diagnosis-Related Group. Our results demonstrate that, given the same expenditure, the GBPS would approach optimal levels of quality and efficiency as well as the level of social welfare provided by the PPS, as long as market competition is sufficiently high; our results also demonstrate that the treadmill effect, modeling an inverse relationship between price and quantity under the GBPS, would be a quality-enhancing and efficiency-improving outcome due to market competition.

Payment reform will shift home health agency valuation parameters.

PubMed

Hahn, A D

1998-12-01

Changes authorized by the Balanced Budget Act of 1997 have removed many of the payment benefits that motivated past home health agency acquisition activity and temporarily have slowed the rapid pace of acquisitions of home health agencies. The act required that Medicare's cost-based payment system be replaced with a prospective payment system (PPS) and established an interim payment system to provide a framework for home health agencies to make the transition to the PPS. As a consequence, realistic valuations of home health agencies will be determined primarily by cash flows, with consideration given to operational factors, such as quality of patient care, service territory, and information systems capabilities. The limitations imposed by the change in payment mechanism will cause acquisition interest to shift away from home health agencies with higher utilization and revenue expansion to agencies able to control costs and achieve operating leverage.

42 CFR § 414.1300 - Basis and scope.

Code of Federal Regulations, 2010 CFR

2017-10-01

... Incentive Payment System and Alternative Payment Model Incentive § 414.1300 Basis and scope. (a) Basis. This... Participation in Eligible Alternative Payment Models. (2) Section 1848(a)—Payment for Physicians' Services Based... to QPs. (10) Criteria for Physician-Focused Payment Models (PFPMs). ...

48 CFR 847.306-70 - Transportation payment and audit.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 5 2013-10-01 2013-10-01 false Transportation payment and... AFFAIRS CONTRACT MANAGEMENT TRANSPORTATION Transportation in Supply Contracts 847.306-70 Transportation payment and audit. Transportation payments are audited by the Traffic Manager to ensure that payment and...

48 CFR 847.306-70 - Transportation payment and audit.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 5 2011-10-01 2011-10-01 false Transportation payment and... AFFAIRS CONTRACT MANAGEMENT TRANSPORTATION Transportation in Supply Contracts 847.306-70 Transportation payment and audit. Transportation payments are audited by the Traffic Manager to ensure that payment and...

Calculating five types of typical underpayments.

PubMed

Welter, T; Stevenson, P

2001-10-01

Underpayments to providers under their payer agreements are a cause of many thousands of dollars in lost revenue. Providers should devise a plan to make certain that payments made to them are accurate, on time, and adhere to other contractual obligations. The importance of developing and implementing such a plan is substantiated by the fact that nearly 100 percent of a provider's commercial business is under contract. As a starting point, providers may wish to focus on five common types of underpayments: underfunding due to late payments; fee-schedule changes that are contractually disallowed; miscalculation of performance-based bonuses and errors in risk-payment reconciliations; inappropriate denials or inappropriate downcoding of claims; and non-payments. The successful execution of a plan to identify and resolve problems and recover payments owed relies on the provider's ability to document and prove that payment is due.

48 CFR 52.228-13 - Alternative Payment Protections.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 2 2010-10-01 2010-10-01 false Alternative Payment....228-13 Alternative Payment Protections. As prescribed in 28.102-3(b), insert the following clause: Alternative Payment Protections (JUL 2000) (a) The Contractor shall submit one of the following payment...

42 CFR § 414.1460 - Monitoring and program integrity.

Code of Federal Regulations, 2010 CFR

2017-10-01

... SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1460 Monitoring and program integrity. (a) Vetting eligible clinicians prior to payment of the APM Incentive Payment. Prior to...

42 CFR § 414.1305 - Definitions.

Code of Federal Regulations, 2010 CFR

2017-10-01

... Payment System and Alternative Payment Model Incentive § 414.1305 Definitions. As used in this section... additional MIPS payment adjustment factors for exceptional performance. Advanced Alternative Payment Model.... Alternative Payment Model (APM) means any of the following: (1) A model under section 1115A of the Act (other...

42 CFR 412.2 - Basis of payment.

Code of Federal Regulations, 2011 CFR

2011-10-01

... services furnished to Medicare beneficiaries. The prospective payment rate for each discharge (as defined... the election in § 405.521 of this chapter. (4) The acquisition costs of hearts, kidneys, livers, lungs... payments to hospitals. In addition to payments based on the prospective payment system rates for inpatient...

42 CFR 412.2 - Basis of payment.

Code of Federal Regulations, 2014 CFR

2014-10-01

... services furnished to Medicare beneficiaries. The prospective payment rate for each discharge (as defined... the election in § 405.521 of this chapter. (4) The acquisition costs of hearts, kidneys, livers, lungs... payments to hospitals. In addition to payments based on the prospective payment system rates for inpatient...

42 CFR 412.2 - Basis of payment.

Code of Federal Regulations, 2013 CFR

2013-10-01

... services furnished to Medicare beneficiaries. The prospective payment rate for each discharge (as defined... the election in § 405.521 of this chapter. (4) The acquisition costs of hearts, kidneys, livers, lungs... payments to hospitals. In addition to payments based on the prospective payment system rates for inpatient...

42 CFR 412.2 - Basis of payment.

Code of Federal Regulations, 2012 CFR

2012-10-01

... services furnished to Medicare beneficiaries. The prospective payment rate for each discharge (as defined... the election in § 405.521 of this chapter. (4) The acquisition costs of hearts, kidneys, livers, lungs... payments to hospitals. In addition to payments based on the prospective payment system rates for inpatient...

42 CFR 412.2 - Basis of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... services furnished to Medicare beneficiaries. The prospective payment rate for each discharge (as defined... the election in § 405.521 of this chapter. (4) The acquisition costs of hearts, kidneys, livers, lungs... payments to hospitals. In addition to payments based on the prospective payment system rates for inpatient...

Do financial incentives in a globally budgeted healthcare payment system produce changes in the way patients are categorized? A five-year study.

PubMed

Petersen, Laura A; Urech, Tracy H; Byrne, Margaret M; Pietz, Kenneth

2007-09-01

To assess the responses to financial incentives after a change in the payment system in a capitation-style healthcare payment system over a 5-year period. Cross-sectional and longitudinal examination of cost, utilization, and diagnostic data. Using Veterans Health Administration (VHA) administrative data on healthcare users between fiscal years 1998 and 2002, we calculated the proportion of new patients entering each of the payment classes, the illness burden of patients entering the payment classes, and the profitability index (a ratio of payment to costs) for each class suspected of gaming and each control class. Our main dependent variables of interest were the differences in the measures between each utilization-based class and each diagnosis-based class. We used 2 different analytic approaches to assess whether these differences increased or decreased over time. No clear evidence of gaming behavior was present in our results. A few comparisons were significant, but they did not show a consistent pattern of responses to incentives. For example, 6 of 16 comparisons of profitability index were significant, but (contrary to the hypothesis) 4 of these had a negative value for the time parameter, indicating decreasing profitability in the utilization-based classes versus the diagnosis-based classes. Although the payment system could be manipulated to increase payment to VHA networks, no such consistent gaming behavior was observed. More research is needed to better understand the effects of financial incentives in other healthcare payment systems.

Payment Reform Pilot In Beijing Hospitals Reduced Expenditures And Out-Of-Pocket Payments Per Admission.

PubMed

Jian, Weiyan; Lu, Ming; Chan, Kit Yee; Poon, Adrienne N; Han, Wei; Hu, Mu; Yip, Winnie

2015-10-01

In 2009 China announced plans to reform provider payment methods at public hospitals by moving from fee-for-service (FFS) to prospective and aggregated payment methods that included the use of diagnosis-related groups (DRGs) to control health expenditures. In October 2011 health policy makers selected six Beijing hospitals to pioneer the first DRG payment system in China. We used hospital discharge data from the six pilot hospitals and eight other hospitals, which continued to use FFS and served as controls, from the period 2010-12 to evaluate the pilot's impact on cost containment through a difference-in-differences methods design. Our study found that DRG payment led to reductions of 6.2 percent and 10.5 percent, respectively, in health expenditures and out-of-pocket payments by patients per hospital admission. We did not find evidence of any increase in hospital readmission rates or cost shifting from cases eligible for DRG payment to ineligible cases. However, hospitals continued to use FFS payments for patients who were older and had more complications than other patients, which reduced the effectiveness of payment reform. Continuous evidence-based monitoring and evaluation linked with adequate management systems are necessary to enable China and other low- and middle-income countries to broadly implement DRGs and refine payment systems. Project HOPE—The People-to-People Health Foundation, Inc.

5 CFR 9701.361 - Special skills payments.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 9701.361 Administrative Personnel DEPARTMENT OF HOMELAND SECURITY HUMAN RESOURCES MANAGEMENT SYSTEM (DEPARTMENT OF HOMELAND SECURITY-OFFICE OF PERSONNEL MANAGEMENT) DEPARTMENT OF HOMELAND SECURITY HUMAN RESOURCES MANAGEMENT SYSTEM Pay and Pay Administration Special Payments § 9701.361 Special skills payments...

48 CFR 32.009 - Providing accelerated payments to small business subcontractors.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 1 2014-10-01 2014-10-01 false Providing accelerated payments to small business subcontractors. 32.009 Section 32.009 Federal Acquisition Regulations System... accelerated payments to small business subcontractors. ...

Do falls and falls-injuries in hospital indicate negligent care -- and how big is the risk? A retrospective analysis of the NHS Litigation Authority Database of clinical negligence claims, resulting from falls in hospitals in England 1995 to 2006.

PubMed

Oliver, D; Killick, S; Even, T; Willmott, M

2008-12-01

Accidental falls are very common in older hospital patients -- accounting for 32% of reported adult patient safety incidents in UK National Health Service (NHS) hospitals and occurring with similar frequency in settings internationally. In countries where the population is ageing, and care is provided in inpatient settings, falls prevention is therefore a significant and growing risk-management issue. Falls may lead to a variety of harms and costs, are cited in formal complaints and can lead to claims of clinical negligence. The NHS Litigation Authority (NHSLA) negligence claims database provides a novel opportunity to systematically analyse such (falls-related) claims made against NHS organisations in England and to learn lessons for risk-management systems and claims recording. To describe the circumstances and injuries most frequently cited in falls-related claims; to investigate any association between the financial impact (total cost), and the circumstances of or injuries resulting from falls in "closed" claims; to draw lessons for falls risk management and for future data capture on falls incidents and resulting claims analysis; to identify priorities for future research. A keyword search was run on the NHSLA claims database for April 1995 to February 2006, to identify all claims apparently relating to falls. Claims were excluded from further analysis if, on scrutiny, they had not resulted from falls, or if they were still "open" (ie, unresolved). From the narrative descriptions of closed claims (ie, those for which the financial outcome was known), we developed categories of "principal" and "secondary" injury/harm and "principal" and "contributory" circumstance of falls. For each category, it was determined whether cases had resulted in payment and what total payments (damages and costs) were awarded. The proportions of contribution-specific injuries or circumstances to the number of cases and to the overall costs incurred were compared in order to identify circumstances that tend to be more costly. Means were compared and tested through analysis of variance (ANOVA). The association between categorical variables was tested using the chi-square test. Of 668 claims identified by word search, 646 met inclusion criteria. The results presented are for the 479 of these that were "closed" at the time of the census. Of these, 290 (60.5%) had resulted in payment of costs or damages, with the overall total payment being 6,200,737 pound (mean payment 12,945 pound). All claims were settled out of court, so no legal rulings on establishing liability or causation of injury are available. "Falls whilst walking;" "from beds or trolleys" ("with and without bedrails applied") or "transferring/from a chair" were the most frequent source of these claims (n = 308, 64.2%). Clear secondary contributory circumstances were identified in 190 (39.7%) of closed claims. The most common circumstances cited were "perioperative/procedural incidents" (60, 12.5%) and "requests for bedrails being ignored" (54, 11.3%). For primary injuries, "hip/femoral/pelvic fracture" accounted for 203 (42.4%) of closed claims with total payments of 3,228,781 pound (52.1% of all payments), with a mean payment 15,905 pound per closed case. A "secondary" contributory circumstance could be attributed in 133 (27.8%) of cases. Of these, "delay in diagnosis of injury," "recurrent falls during admission" and "fatalities relating to falls" were the commonest circumstances (n = 59, 12.2%). Although falls are the highest volume patient safety incident reported in hospital trusts in England, they result in a relatively small number of negligence claims and receive a relatively low total payment (0.019% in both cases). The mean payment in closed claims is also relatively small. This may reflect the high average age of the people who fall and difficulty in establishing causation, especially where individuals are already frail when they fall. The patterns of claims and the narrative descriptions provide wider lessons for improving risk-management strategies. However, the inherent limitations and biases in the data routinely recorded for legal purposes suggest that for more informative research or actuarial claims analysis, more comprehensive and systematic data to be recorded for each incident claim are needed.

The role of hospital payments in the adoption of new medical technologies: an international survey of current practice.

PubMed

Sorenson, Corinna; Drummond, Michael; Torbica, Aleksandra; Callea, Giuditta; Mateus, Ceu

2015-04-01

This study examined the role of prospective payment systems in the adoption of new medical technologies across different countries. A literature review was conducted to provide background for the study and guide development of a survey instrument. The survey was disseminated to hospital payment systems experts in 15 jurisdictions. Fifty-one surveys were disseminated, with 34 returned. The surveys returned covered 14 of the 15 jurisdictions invited to participate. The majority (71%) of countries update the patient classification system and/or payment tariffs on an annual basis to try to account for new technologies. Use of short-term separate or supplementary payments for new technologies occurs in 79% of countries to ensure adequate funding and facilitate adoption. A minority (43%) of countries use evidence of therapeutic benefit and/or costs to determine or update payment tariffs, although it is somewhat more common in establishing short-term payments. The main barrier to using evidence is uncertain or unavailable clinical evidence. Almost three-fourths of respondents believed diagnosis-related group systems incentivize or deter technology adoption, depending on the particular circumstances. Improvements are needed, such as enhanced strategies for evidence generation and linking evidence of value to payments, national and international collaboration and training to improve existing practice, and flexible timelines for short-term payments. Importantly, additional research is needed to understand how different payment policies impact technology uptake as well as quality of care and costs.

Participation determinants in the DRG payment system of obstetrics and gynecology clinics in South Korea.

PubMed

Song, Jung-Kook; Kim, Chang-yup

2010-03-01

The Diagnosis Related Group (DRG) payment system, which has been implemented in Korea since 1997, is based on voluntary participation. Hence, the positive impact of this system depends on the participation of physicians. This study examined the factors determining participation of Korean obstetrics & gynecology (OBGYN) clinics in the DRG-based payment system. The demographic information, practice-related variables of OBGYN clinics and participation information in the DRG-based payment system were acquired from the nationwide data from 2002 to 2007 produced by the National Health Insurance Corporation and the Health Insurance Review & Assessment Service. The subjects were 336 OBGYN clinics consisting of 43 DRG clinics that had maintained their participation in 2003-2007 and 293 no-DRG (fee-for-service) clinics that had never been a DRG clinic during the same period. Logistic regression analysis was carried out to determine the factors associated with the participation of OBGYN clinics in the DRG-based payment system. The factors affecting participation of OBGYN clinics in the DRG-based payment system were as follows (p<0.05): (1) a larger number of caesarian section (c/sec) claims, (2) higher cost of a c/sec, (3) less variation in the price of a c/sec, (4) fewer days of admission for a c/sec, and (5) younger pregnant women undergoing a c/sec. These results suggest that OBGYN clinics with an economic practice pattern under a fee-for-service system are more likely to participate in the DRG-based payment system. Therefore, to ensure adequate participation of physicians, a payment system with a stronger financial incentive might be more suitable in Korea.

Impact of the Japanese Diagnosis Procedure Combination-based Payment System on cardiovascular medicine-related costs.

PubMed

Yasunaga, Hideo; Ide, Hiroo; Imamura, Tomoaki; Ohe, Kazuhiko

2005-09-01

In 2003, a lump-sum payment system based on Diagnosis Procedure Combinations (DPC) was introduced to 82 specific function hospitals in Japan. While the US DRG/PPS system is a "per case payment" system, the DPC based payment system adopts a "per day payment." It is generally believed that the Japanese system provides as much of an incentive as the DRG/PPS system to shorten the average length of stay (LOS). We performed an empirical analysis of the effect of LOS shortening on hospital revenue and expenditure under the DPC-based payment system, particularly in cardiovascular diseases. We also point out fundamentally controversial aspects of the current system. A total 109 cases were selected from patients hospitalized at the University of Tokyo Hospital from May to July, 2003 and classified into one of three categories: (1) cardiac catheter interventions, (2) cardiac catheter examinations, and (3) other conservative treatments. We analyzed the changes in profit per day in cases of a reduction in average LOS and an increase in the number of cases. In category (1) profit increased significantly in conjunction with reduced LOS. In category (2) profit increased only minimally. In category (3), profit increased rarely and sometimes decreased. In cases of conservative treatment, profits sometimes decreased because an increase in material costs exceeded the increase in revenue. It therefore became clear that the DPC-based payment system does not decisively provide an economic incentive to reduce LOS in cardiovascular medicine.

76 FR 40497 - Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for CY 2012...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-08

...] RIN 0938-AQ27 Medicare Program; Changes to the End-Stage Renal Disease Prospective Payment System for... through Federal Digital System (FDsys), a service of the U.S. Government Printing Office. This database... Internet on the CMS Web site. The Addenda to the End-Stage Renal Disease (ESRD) Prospective Payment System...

75 FR 81138 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-27

... [CMS-1510-CN2] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices AGENCY... ``Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in...

76 FR 37121 - Medicare Program; Second Semi-Annual Meeting of the Advisory Panel on Ambulatory Payment...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-06-24

... participate fully in the Panel's work. The expertise encompasses hospital payment systems; hospital medical care delivery systems; provider billing systems; APC groups; Current Procedural Terminology (CPT) codes... payment for, drugs, medical devices, and other services in the outpatient setting, as well as other forms...

75 FR 78246 - Medicare Program; Re-Chartering of the Advisory Panel on Ambulatory Payment Classification (APC...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-12-15

... Administrator among the fields of hospital payment systems; hospital medical care delivery systems; provider billing and accounting systems; APC groups; Current Procedural Terminology codes; HCPCS codes; the use of, and payment for, drugs, medical devices, and other services in the outpatient setting; and other forms...

48 CFR 52.232-16 - Progress Payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 2 2011-10-01 2011-10-01 false Progress Payments. 52.232... Progress Payments. As prescribed in 32.502-4(a), insert the following clause: Progress Payments (AUG 2010) The Government will make progress payments to the Contractor when requested as work progresses, but...

42 CFR § 414.1375 - Advancing care information performance category.

Code of Federal Regulations, 2010 CFR

2017-10-01

... HEALTH AND HUMAN SERVICES (CONTINUED) MEDICARE PROGRAM (CONTINUED) PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES Merit-Based Incentive Payment System and Alternative Payment Model Incentive § 414.1375... final score for MIPS payment year 2019 and each MIPS payment year thereafter. (b) Reporting for the...

Cost of practice in a tertiary/quaternary referral center: is it sustainable?

PubMed

Cologne, K G; Hwang, G S; Senagore, A J

2014-11-01

Third-party payers are moving toward a bundled care payment system. This means that there will need to be a warranty cost of care-where the cost of complexity and complication rates is built into the bundled payment. The theoretical benefit of this system is that providers with lower complication rates will be able to provide care with lower warranty costs and lower overall costs. This may also result in referring riskier patients to tertiary or quaternary referral centers. Unless the payment model truly covers the higher cost of managing such referred cases, the economic risk may be unsustainable for these centers. We took the last seven patients that were referred by other surgeons as "too high risk" for colectomy at other centers. A contribution margin was calculated using standard Medicare reimbursement rates at our institution and cost of care based on our administrative database. We then recalculated a contribution margin assuming a 3 % reduction in payment for a higher than average readmission rate, like that which will take effect in 2014. Finally, we took into account the cost of any readmissions. Seven patients with diagnosis related group (DRG) 330 were reviewed with an average age of 66.8 ± 16 years, American Society of Anesthesiologists score 2.3 ± 1.0, body mass index 31.6 ± 9.8 kg/m(2) (range 22-51 kg/m(2)). There was a 57 % readmission rate, 29 % reoperation rate, 10.8 ± 7.7 day average initial length of stay with 14 ± 8.6 day average readmission length of stay. Forty-two percent were discharged to a location other than home. Seventy-one percent of these patients had Medicare insurance. The case mix index was 2.45. Average reimbursement for DRG 330 was $17,084 (based on Medicare data) for our facility in 2012, with the national average being $12,520. The total contribution margin among all cases collectively was -$19,122 ± 13,285 (average per patient -$2,731, range -$21,905-$12,029). Assuming a 3 % reimbursement reduction made the overall contribution margin -$22,122 ± 13,285 (average -$3,244). Including the cost of readmission in the variable cost made the contribution margin -$115,741 ± 16,023 (average -$16,534). Care of high-risk patients at tertiary and quaternary referral centers is a very expensive proposition and can lead to financial ruin under the current reimbursement system.

42 CFR 413.335 - Basis of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Facilities § 413.335 Basis of payment. (a) Method of payment. Under the prospective payment system, SNFs... and, during a transition period, on the basis of a blend of the Federal rate and the facility-specific...

42 CFR 412.503 - Definitions.

Code of Federal Regulations, 2014 CFR

2014-10-01

... from a long-term care hospital based on clinical characteristics and average resource use, for... hospital based on clinical characteristics and average resource use, for prospective payment purposes for... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care...

42 CFR 412.503 - Definitions.

Code of Federal Regulations, 2013 CFR

2013-10-01

... from a long-term care hospital based on clinical characteristics and average resource use, for... hospital based on clinical characteristics and average resource use, for prospective payment purposes for... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care...

42 CFR 412.503 - Definitions.

Code of Federal Regulations, 2011 CFR

2011-10-01

... from a long-term care hospital based on clinical characteristics and average resource use, for... hospital based on clinical characteristics and average resource use, for prospective payment purposes for... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care...

42 CFR 412.503 - Definitions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... from a long-term care hospital based on clinical characteristics and average resource use, for... hospital based on clinical characteristics and average resource use, for prospective payment purposes for... PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES Prospective Payment System for Long-Term Care...

48 CFR 252.217-7007 - Payments.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Section 252.217-7007 Federal Acquisition Regulations System DEFENSE ACQUISITION REGULATIONS SYSTEM, DEPARTMENT OF DEFENSE CLAUSES AND FORMS SOLICITATION PROVISIONS AND CONTRACT CLAUSES Text of Provisions And...) (a) Progress payments, as used in this clause, means payments made before completion of work in...

48 CFR 252.217-7007 - Payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Section 252.217-7007 Federal Acquisition Regulations System DEFENSE ACQUISITION REGULATIONS SYSTEM, DEPARTMENT OF DEFENSE CLAUSES AND FORMS SOLICITATION PROVISIONS AND CONTRACT CLAUSES Text of Provisions And...) (a) Progress payments, as used in this clause, means payments made before completion of work in...

48 CFR 252.217-7007 - Payments.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Section 252.217-7007 Federal Acquisition Regulations System DEFENSE ACQUISITION REGULATIONS SYSTEM, DEPARTMENT OF DEFENSE CLAUSES AND FORMS SOLICITATION PROVISIONS AND CONTRACT CLAUSES Text of Provisions And...) (a) Progress payments, as used in this clause, means payments made before completion of work in...

48 CFR 252.217-7007 - Payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Section 252.217-7007 Federal Acquisition Regulations System DEFENSE ACQUISITION REGULATIONS SYSTEM, DEPARTMENT OF DEFENSE CLAUSES AND FORMS SOLICITATION PROVISIONS AND CONTRACT CLAUSES Text of Provisions And...) (a) Progress payments, as used in this clause, means payments made before completion of work in...

48 CFR 252.217-7007 - Payments.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Section 252.217-7007 Federal Acquisition Regulations System DEFENSE ACQUISITION REGULATIONS SYSTEM, DEPARTMENT OF DEFENSE CLAUSES AND FORMS SOLICITATION PROVISIONS AND CONTRACT CLAUSES Text of Provisions And...) (a) Progress payments, as used in this clause, means payments made before completion of work in...

48 CFR 3432.170 - Method of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 7 2010-10-01 2010-10-01 false Method of payment. 3432.170 Section 3432.170 Federal Acquisition Regulations System DEPARTMENT OF EDUCATION ACQUISITION REGULATION GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING General 3432.170 Method of payment. The...

48 CFR 2432.906 - Contract financing payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Contract financing payments. 2432.906 Section 2432.906 Federal Acquisition Regulations System DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING Prompt Payment 2432.906 Contract financing...

Bundling Post-Acute Care Services into MS-DRG Payments

PubMed Central

Vertrees, James C.; Averill, Richard F.; Eisenhandler, Jon; Quain, Anthony; Switalski, James

2013-01-01

Objective A bundled hospital payment system that encompasses both acute and post-acute care has been proposed as a means of creating financial incentives in the Medicare fee-for-service system to foster care coordination and to improve the current disorganized system of post care. The objective of this study was to evaluate the statistical stability of alternative designs of a hospital payment system that includes post-acute care services to determine the feasibility of using a combined hospital and post-acute care bundle as a unit of payment. Methods The Medicare Severity-Diagnosis Related Groups (MS-DRGs) were subdivided into clinical subclasses that measured a patient's chronic illness burden to test whether a patient's chronic illness burden had a substantial impact on post-acute care expenditures. Using Medicare data the statistical performance of the MS-DRGs with and without the chronic illness subclasses was evaluated across a wide range of post-acute care windows and combinations of post-acute care service bundles using both submitted charges and Medicare payments. Results The statistical performance of the MS-DRGs as measured by R2 was consistently better when the chronic illness subclasses are included indicating that MS-DRGs by themselves are an inadequate unit of payment for post-acute care payment bundles. In general, R2 values increased as the post-acute care window length increased and decreased as more services were added to the post-acute care bundle. Discussion The study results suggest that it is feasible to develop a payment system that incorporates significant post-acute care services into the MS-DRG inpatient payment bundle. This expansion of the basic DRG payment approach can provide a strong financial incentive for providers to better coordinate care potentially leading to improved efficiency and outcome quality. PMID:24753970

Medicare Program; End-Stage Renal Disease Prospective Payment System, Payment for Renal Dialysis Services Furnished to Individuals With Acute Kidney Injury, and End-Stage Renal Disease Quality Incentive Program. Final rule.

PubMed

2017-11-01

This rule updates and makes revisions to the end-stage renal disease (ESRD) prospective payment system (PPS) for calendar year (CY) 2018. It also updates the payment rate for renal dialysis services furnished by an ESRD facility to individuals with acute kidney injury (AKI). This rule also sets forth requirements for the ESRD Quality Incentive Program (QIP), including for payment years (PYs) 2019 through 2021.

Medicare program; additional extension of the payment adjustment for low-volume hospitals and the Medicare-dependent hospital (MDH) program under the hospital Inpatient Prospective Payment Systems (IPPS) for acute care hospitals for fiscal year 2014. Extension of a payment adjustment and a program.

PubMed

2014-06-17

This document announces changes to the payment adjustment for low-volume hospitals and to the Medicare-dependent hospital (MDH) program under the hospital inpatient prospective payment systems (IPPS) for the second half of FY 2014 (April 1, 2014 through September 30, 2014) in accordance with sections 105 and 106, respectively, of the Protecting Access to Medicare Act of 2014 (PAMA).

Implications of global budget payment system on nursing home costs.

PubMed

Di Giorgio, Laura; Filippini, Massimo; Masiero, Giuliano

2014-04-01

Pressure on health care systems due to the increasing expenditures of the elderly population is pushing policy makers to adopt new regulation and payment schemes for nursing home services. We consider the behavior of nonprofit nursing homes under different payment schemes and empirically investigate the implications of prospective payments on nursing home costs under tightly regulated quality aspects. To evaluate the impact of the policy change introduced in 2006 in Southern Switzerland - from retrospective to prospective payment - we use a panel of 41 homes observed over a 10-years period (2001-2010). We employ a fixed effects model with a time trend that is allowed to change after the policy reform. There is evidence that the new payment system slightly reduces costs without impacting quality. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

48 CFR 342.7003 - Withholding of contract payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 4 2010-10-01 2010-10-01 false Withholding of contract payments. 342.7003 Section 342.7003 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT CONTRACT ADMINISTRATION Contract Monitoring 342.7003 Withholding of contract payments. ...

48 CFR 342.7003 - Withholding of contract payments.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 4 2013-10-01 2013-10-01 false Withholding of contract payments. 342.7003 Section 342.7003 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT CONTRACT ADMINISTRATION Contract Monitoring 342.7003 Withholding of contract payments. ...

48 CFR 342.7003 - Withholding of contract payments.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 4 2014-10-01 2014-10-01 false Withholding of contract payments. 342.7003 Section 342.7003 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT CONTRACT ADMINISTRATION Contract Monitoring 342.7003 Withholding of contract payments. ...

48 CFR 342.7003 - Withholding of contract payments.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 48 Federal Acquisition Regulations System 4 2012-10-01 2012-10-01 false Withholding of contract payments. 342.7003 Section 342.7003 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT CONTRACT ADMINISTRATION Contract Monitoring 342.7003 Withholding of contract payments. ...

48 CFR 342.7003 - Withholding of contract payments.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 48 Federal Acquisition Regulations System 4 2011-10-01 2011-10-01 false Withholding of contract payments. 342.7003 Section 342.7003 Federal Acquisition Regulations System HEALTH AND HUMAN SERVICES CONTRACT MANAGEMENT CONTRACT ADMINISTRATION Contract Monitoring 342.7003 Withholding of contract payments. ...

48 CFR 232.007 - Contract financing payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 3 2010-10-01 2010-10-01 false Contract financing... SYSTEM, DEPARTMENT OF DEFENSE GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING 232.007 Contract financing payments. (a) DoD policy is to make contract financing payments as quickly as possible. Generally...

42 CFR § 512.320 - Treatment of incentive programs or add-on payments under existing Medicare payment systems.

Code of Federal Regulations, 2010 CFR

2017-10-01

... INFRASTRUCTURE AND MODEL PROGRAMS EPISODE PAYMENT MODEL Pricing and Payment § 512.320 Treatment of incentive... under such models are independent of, and do not affect, any incentive programs or add-on payments under... 42 Public Health 5 2017-10-01 2017-10-01 false Treatment of incentive programs or add-on payments...

Forecasting the Future Reimbursement System of Korean National Health Insurance: A Contemplation Focusing on Global Budget and Neo-KDRG-Based Payment Systems

PubMed Central

2012-01-01

With the adoption of national health insurance in 1977, Korea has been utilizing fee-for-service payment with contract-based healthcare reimbursement system in 2000. Under the system, fee-for-service reimbursement has been accused of augmenting national healthcare expenditure by excessively increasing service volume. The researcher examined in this paper two major alternatives including diagnosis related group-based payment and global budget to contemplate the future of reimbursement system of Korean national health insurance. Various literature and preceding studies on pilot project and actual implementation of Neo-KDRG were reviewed. As a result, DRG-based payment was effective for healthcare cost control but low in administrative efficiency. Global budget may be adequate for cost control and improving the quality of healthcare and administrative efficiency. However, many healthcare providers disagree that excess care arising from fee-for-service payment alone has led to financial deterioration of national health insurance and healthcare institutions should take responsibility with global budget payment as an appropriate solution. Dissimilar payment systems may be applied to different types of institutions to reflect their unique attributes, and this process can be achieved step-by-step. Developing public sphere among the stakeholders and striving for consensus shall be kept as collateral to attain the desirable reimbursement system in the future. PMID:22661867

Forecasting the future reimbursement system of Korean National Health Insurance: a contemplation focusing on global budget and Neo-KDRG-based payment systems.

PubMed

Kim, Yang-Kyun

2012-05-01

With the adoption of national health insurance in 1977, Korea has been utilizing fee-for-service payment with contract-based healthcare reimbursement system in 2000. Under the system, fee-for-service reimbursement has been accused of augmenting national healthcare expenditure by excessively increasing service volume. The researcher examined in this paper two major alternatives including diagnosis related group-based payment and global budget to contemplate the future of reimbursement system of Korean national health insurance. Various literature and preceding studies on pilot project and actual implementation of Neo-KDRG were reviewed. As a result, DRG-based payment was effective for healthcare cost control but low in administrative efficiency. Global budget may be adequate for cost control and improving the quality of healthcare and administrative efficiency. However, many healthcare providers disagree that excess care arising from fee-for-service payment alone has led to financial deterioration of national health insurance and healthcare institutions should take responsibility with global budget payment as an appropriate solution. Dissimilar payment systems may be applied to different types of institutions to reflect their unique attributes, and this process can be achieved step-by-step. Developing public sphere among the stakeholders and striving for consensus shall be kept as collateral to attain the desirable reimbursement system in the future.

75 FR 46169 - Medicare Program; Proposed Changes to the Hospital Outpatient Prospective Payment System and CY...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-08-03

...This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act). In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain provisions of the Affordable Care Act. In this proposed rule, we set forth the proposed applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other pertinent ratesetting information for the CY 2011 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2011. This proposed rule also includes proposals to implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest.

Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period.

PubMed

2011-11-30

This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.

42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 2 2013-10-01 2013-10-01 false Payments to hospitals located in Puerto Rico. 412... Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for capital-related...

42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 2 2011-10-01 2011-10-01 false Payments to hospitals located in Puerto Rico. 412... Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for capital-related...

42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 2 2014-10-01 2014-10-01 false Payments to hospitals located in Puerto Rico. 412... Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for capital-related...

42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Payments to hospitals located in Puerto Rico. 412... Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for capital-related...

42 CFR 412.374 - Payments to hospitals located in Puerto Rico.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 2 2012-10-01 2012-10-01 false Payments to hospitals located in Puerto Rico. 412... Payment System for Inpatient Hospital Capital Costs Special Rules for Puerto Rico Hospitals § 412.374 Payments to hospitals located in Puerto Rico. (a) FY 1998 through FY 2004. Payments for capital-related...

42 CFR 412.116 - Method of payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Method of payment. 412.116 Section 412.116 Public... Payment Systems § 412.116 Method of payment. (a) General rules. (1) Unless the provisions of paragraphs (b... section is removed from that method of payment at its own request, it may reelect to receive periodic...

The Effects of Goal-Contingent Payment on the Performance of a Complex Task.

ERIC Educational Resources Information Center

Campbell, Donald J.

1984-01-01

Using a complex, computerized decision-making task, 56 university students participated in a six-week, repeated measures, goal-setting project, involving different payment systems. Results indicated that goal-contingent payment is superior to hourly payment in influencing performance, even though the perceived valence of payment and the actual…

Does an activity based remuneration system attract young doctors to general practice?

PubMed Central

2012-01-01

Background The use of increasingly complex payment schemes in primary care may represent a barrier to recruiting general practitioners (GP). The existing Norwegian remuneration system is fully activity based - 2/3 fee-for-service and 1/3 capitation. Given that the system has been designed and revised in close collaborations with the medical association, it is likely to correspond - at least to some degree - with the preferences of current GPs (men in majority). The objective of this paper was to study which preferences that young doctors (women in majority), who are the potential entrants to general practice have for activity based vs. salary based payment systems. Methods In November-December 2010 all last year medical students and all interns in Norway (n = 1.562) were invited to participate in an online survey. The respondents were asked their opinion on systems of remuneration for GPs; inclination to work as a GP; risk attitude; income preferences; work pace tolerance. The data was analysed using one-way ANOVA and multinomial logistic regression analysis. Results A total of 831 (53%) responded. Nearly half the sample (47%) did not consider the remuneration system to be important for their inclination to work as GP; 36% considered the current system to make general practice more attractive, while 17% considered it to make general practice less attractive. Those who are attracted by the existing system were men and those who think high income is important, while those who are deterred by the system are risk averse and less happy with a high work pace. On the question of preferred remuneration system, half the sample preferred a mix of salary and activity based remuneration (the median respondent would prefer a 50/50 mix). Only 20% preferred a fully activity based system like the existing one. A salary system was preferred by women, and those less concerned with high income, while a fully activity based system was preferred by men, and those happy with a high work pace. Conclusions Given a concern about low recruitment to general practice in Norway, and the fact that an increasing share of medical students is women, we were interested in the extent to which the current Norwegian remuneration system correspond with the preferences of potential GPs. This study suggests that an existing remuneration mechanism has a selection effect on who would like to become a GP. Those most attracted are income motivated men. Those deterred are risk averse, and less happy with a high work pace. More research is needed on the extent to which experienced GPs differ along the questions we asked potential GPs, as well as studying the relative importance of other attributes than payment schemes. PMID:22433750

78 FR 41013 - Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-09

... [CMS-1450-CN] RIN 0938-AR52 Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY 2014, Home Health Quality Reporting Requirements, and Cost Allocation of Home Health Survey... period titled ``Medicare and Medicaid Programs; Home Health Prospective Payment System Rate Update for CY...

76 FR 9502 - Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-18

... [CMS-1510-F2] RIN 0938-AP88 Medicare Program; Home Health Prospective Payment System Rate Update for Calendar Year 2011; Changes in Certification Requirements for Home Health Agencies and Hospices; Correction... set forth an update to the Home Health Prospective Payment System (HH PPS) rates, including: The...

31 CFR 205.17 - Are funds transfers delayed by automated payment systems restrictions based on the size and...

Code of Federal Regulations, 2010 CFR

2010-07-01

... automated payment systems restrictions based on the size and timing of the drawdown request subject to this... EFFICIENT FEDERAL-STATE FUNDS TRANSFERS Rules Applicable to Federal Assistance Programs Included in a Treasury-State Agreement § 205.17 Are funds transfers delayed by automated payment systems restrictions...

The transition to emerging revenue models.

PubMed

Harris, John M; Hemnani, Rashi

2013-04-01

A financial assessment aimed at gauging the true impact of the healthcare industry's new value-based payment models for a health system should begin with separate analyses of the following: The direct contract results, The impact of volume changes on net income, The impact of operational improvements, Net income at risk from competitor actions. The results of these four analyses then should be evaluated in combination to identify the ultimate impact of the new revenue models on the health system's bottom line.

Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models. Final rule with comment period.

PubMed

2016-11-04

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new approach to payment called the Quality Payment Program that rewards the delivery of high-quality patient care through two avenues: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS) for eligible clinicians or groups under the PFS. This final rule with comment period establishes incentives for participation in certain alternative payment models (APMs) and includes the criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models (PFPMs). Alternative Payment Models are payment approaches, developed in partnership with the clinician community, that provide added incentives to deliver high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. This final rule with comment period also establishes the MIPS, a new program for certain Medicare-enrolled practitioners. MIPS will consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs), and will continue the focus on quality, cost, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies. In this final rule with comment period we have rebranded key terminology based on feedback from stakeholders, with the goal of selecting terms that will be more easily identified and understood by our stakeholders.

42 CFR 403.310 - Reduction in payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS SPECIAL PROGRAMS AND PROJECTS Recognition of State Reimbursement Control Systems § 403.310... amount by which the Medicare payments under the system exceed the amount of Medicare payments to such...

48 CFR 49.112-2 - Final payment.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Final payment. 49.112-2 Section 49.112-2 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION CONTRACT MANAGEMENT TERMINATION OF CONTRACTS General Principles 49.112-2 Final payment. (a) Negotiated settlement. After execution...

38 CFR 49.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-07-01

... elapsing between the transfer of funds and disbursement by the recipient, and financial management systems..., Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may be retained by... NON-PROFIT ORGANIZATIONS Post-Award Requirements Financial and Program Management § 49.22 Payment. (a...

38 CFR 49.22 - Payment.

Code of Federal Regulations, 2013 CFR

2013-07-01

... elapsing between the transfer of funds and disbursement by the recipient, and financial management systems..., Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may be retained by... NON-PROFIT ORGANIZATIONS Post-Award Requirements Financial and Program Management § 49.22 Payment. (a...

38 CFR 49.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-07-01

... elapsing between the transfer of funds and disbursement by the recipient, and financial management systems..., Payment Management System, Rockville, MD 20852. Interest amounts up to $250 per year may be retained by... NON-PROFIT ORGANIZATIONS Post-Award Requirements Financial and Program Management § 49.22 Payment. (a...

48 CFR 1332.1108 - Payment by Governmentwide commercial purchase card.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 5 2010-10-01 2010-10-01 false Payment by Governmentwide commercial purchase card. 1332.1108 Section 1332.1108 Federal Acquisition Regulations System DEPARTMENT OF COMMERCE GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING Electronic Funds Transfer 1332.1108 Payment by...

Financial catastrophe and poverty impacts of out-of-pocket health payments in Turkey.

PubMed

Özgen Narcı, Hacer; Şahin, İsmet; Yıldırım, Hasan Hüseyin

2015-04-01

To determine the prevalence of catastrophic health payments, examine the determinants of catastrophic expenditures, and assess the poverty impact of out-of-pocket (OOP) payments. Data came from the 2004 to 2010 Household Budget Survey. Catastrophic health spending was defined by health payments as percentage of household consumption expenditures and capacity to pay at a set of thresholds. The poverty impact was evaluated by poverty head counts and poverty gaps before and after OOP health payments. The percentage of households that catastrophically spent their consumption expenditure and capacity to pay increased from 2004 to 2010, regardless of the threshold used. Households with a share of more than 40% health spending in both consumption expenditure and capacity to pay accounted for less than 1% across years. However, when a series of potential confounders were taken into account, the study found statistically significantly increased risk for the lowest threshold and decreased risk for the highest threshold in 2010 relative to the base year. Household income, size, education, senior and under 5-year-old members, health insurance, disabled members, payment for inpatient care and settlement were also statistically significant predictors of catastrophic health spending. Overall, poverty head counts were below 1%. Poverty gaps reached a maximum of 0.098%, with an overall increase in 2010 compared to 2004. Catastrophe and poverty increased from 2004 to 2010. However, given that the realization of some recent policies will affect the financial burden of OOP payments on households, the findings of this study need to be replicated.

Equity in out-of-pocket payment in Chile

PubMed Central

Mondaca, Alicia Lorena Núñez; Chi, Chunhuei

2017-01-01

ABSTRACT OBJECTIVE To assess the distribution of financial burden in Chile, with a focus on the burden and progressivity of out-of-pocket payment. METHODS Based on the principle of ability to pay, we explore factors that contribute to inequities in the health system finance and issues about the burden of out-of-pocket payment, as well as the progressivity and redistributive effect of out-of-pocket payment in Chile. Our analysis is based on data from the 2006 National Survey on Satisfaction and Out-of-Pocket Payments. RESULTS Results from this study indicate evidence of inequity, in spite of the progressivity of the healthcare system. Our analysis also identifies relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. CONCLUSIONS In order to reduce the detected disparities among income groups, healthcare priorities should target low-income groups. Furthermore, policies should explore changes in the access to education and its impact on equity. PMID:28492762

Equity in out-of-pocket payment in Chile.

PubMed

Mondaca, Alicia Lorena Núñez; Chi, Chunhuei

2017-05-04

To assess the distribution of financial burden in Chile, with a focus on the burden and progressivity of out-of-pocket payment. Based on the principle of ability to pay, we explore factors that contribute to inequities in the health system finance and issues about the burden of out-of-pocket payment, as well as the progressivity and redistributive effect of out-of-pocket payment in Chile. Our analysis is based on data from the 2006 National Survey on Satisfaction and Out-of-Pocket Payments. Results from this study indicate evidence of inequity, in spite of the progressivity of the healthcare system. Our analysis also identifies relevant policy variables such as education, insurance system, and method of payment that should be taken into consideration in the ongoing debates and research in improving the Chilean system. In order to reduce the detected disparities among income groups, healthcare priorities should target low-income groups. Furthermore, policies should explore changes in the access to education and its impact on equity.

Effects of payment changes on trends in post-acute care.

PubMed

Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J

2009-08-01

To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.

Sorting Out the Health Risk in California's State-Based Marketplace.

PubMed

Bindman, Andrew B; Hulett, Denis; Gilmer, Todd P; Bertko, John

2016-02-01

To characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan. 2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases. Chronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00. Among the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average. Providing health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums. © Health Research and Educational Trust.

Strategic interaction among hospitals and nursing facilities: the efficiency effects of payment systems and vertical integration.

PubMed

Banks, D; Parker, E; Wendel, J

2001-03-01

Rising post-acute care expenditures for Medicare transfer patients and increasing vertical integration between hospitals and nursing facilities raise questions about the links between payment system structure, the incentive for vertical integration and the impact on efficiency. In the United States, policy-makers are responding to these concerns by initiating prospective payments to nursing facilities, and are exploring the bundling of payments to hospitals. This paper develops a static profit-maximization model of the strategic interaction between the transferring hospital and a receiving nursing facility. This model suggests that the post-1984 system of prospective payment for hospital care, coupled with nursing facility payments that reimburse for services performed, induces inefficient under-provision of hospital services and encourages vertical integration. It further indicates that the extension of prospective payment to nursing facilities will not eliminate the incentive to vertically integrate, and will not result in efficient production unless such integration takes place. Bundling prospective payments for hospitals and nursing facilities will neither remove the incentive for vertical integration nor induce production efficiency without such vertical integration. However, bundled payment will induce efficient production, with or without vertical integration, if nursing facilities are reimbursed for services performed. Copyright 2001 John Wiley & Sons, Ltd.

Why do we pay? A national survey of investigators and IRB chairpersons

PubMed Central

Ripley, Elizabeth; Macrina, Francis; Markowitz, Monika; Gennings, Chris

2011-01-01

The principle that payment to participants should not be undue or coercive is the consensus of international and national guidelines and ethical debates; however, what this means in practice is unclear. This study determined the attitudes and practices of IRB chairpersons and investigators regarding participant payment. One thousand six hundred investigators and 1900 IRB chairpersons received an invitation to participate in a web-based survey. Four hundred and fifty-five investigators (28.3%) and 395 IRB chairpersons (18.6%) responded. The survey was designed to gather considerations that govern payment determination and practical application of these considerations in hypothetical case studies. The survey asked best answer, multiple choice, and open text questions. Short hypothetical case scenarios where presented, and participants were asked to rate factors in the study that might impact payment and then determine their recommended payment. A predictive model was developed for each case to determine factors which affected payment. Although compensation was the primary reason given to justify payment by both investigators and IRB chairpersons, the cases suggested that, in practice, payment is often guided by incentive, as shown by the impact of anticipated difficulty recruiting, inconvenience, and risk in determining payment. Payment models varied by type of study. Ranges for recommended payments by both groups for different types of procedures and studies are presented. PMID:20831420

Risk Adjustment, Reinsurance Improved Financial Outcomes For Individual Market Insurers With The Highest Claims.

PubMed

Jacobs, Paul D; Cohen, Michael L; Keenan, Patricia

2017-04-01

The Affordable Care Act (ACA) reformed the individual health insurance market. Because insurers can no longer vary their offers of coverage based on applicants' health status, the ACA established a risk adjustment program to equalize health-related cost differences across plans. The ACA also established a temporary reinsurance program to subsidize high-cost claims. To assess the impact of these programs, we compared revenues to claims costs for insurers in the individual market during the first two years of ACA implementation (2014 and 2015), before and after the inclusion of risk adjustment and reinsurance payments. Before these payments were included, for the 30 percent of insurers with the highest claims costs, claims (not including administrative expenses) exceeded premium revenues by $90-$397 per enrollee per month. The effect was reversed after these payments were included, with revenues exceeding claims costs by $0-$49 per month. The risk adjustment and reinsurance programs were relatively well targeted in the first two years. While there is ongoing discussion regarding the future of the ACA, our findings can shed light on how risk-sharing programs can address risk selection among insurers-a pervasive issue in all health insurance markets. Project HOPE—The People-to-People Health Foundation, Inc.

Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and FY 2012 rates; hospitals' FTE resident caps for graduate medical education payment. Final rules.

PubMed

2011-08-18

We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. We also are setting forth the update to the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. We are updating the payment policy and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes made by the Affordable Care Act. In addition, we are finalizing an interim final rule with comment period that implements section 203 of the Medicare and Medicaid Extenders Act of 2010 relating to the treatment of teaching hospitals that are members of the same Medicare graduate medical education affiliated groups for the purpose of determining possible full-time equivalent (FTE) resident cap reductions.

Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017. Final rule.

PubMed

2016-03-08

This final rule sets forth payment parameters and provisions related to the risk adjustment, reinsurance, and risk corridors programs; cost-sharing parameters and cost-sharing reductions; and user fees for Federally-facilitated Exchanges. It also provides additional amendments regarding the annual open enrollment period for the individual market for the 2017 and 2018 benefit years; essential health benefits; cost sharing; qualified health plans; Exchange consumer assistance programs; network adequacy; patient safety; the Small Business Health Options Program; stand-alone dental plans; third-party payments to qualified health plans; the definitions of large employer and small employer; fair health insurance premiums; student health insurance coverage; the rate review program; the medical loss ratio program; eligibility and enrollment; exemptions and appeals; and other related topics.

48 CFR 32.1007 - Administration and payment of performance-based payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... contractor's experience, performance record, reliability, financial strength, and the adequacy of controls... of performance-based payments. 32.1007 Section 32.1007 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING Performance-Based Payments 32.1007...

42 CFR 412.632 - Method of payment under the inpatient rehabilitation facility prospective payment system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... and for costs of an approved education program and other costs paid outside the prospective payment... must be approved by the intermediary and us. (3) Amount of payment. The amount of the accelerated...

48 CFR 832.7002 - Electronic payment requests.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 48 Federal Acquisition Regulations System 5 2014-10-01 2014-10-01 false Electronic payment... GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING Electronic Invoicing Requirements 832.7002 Electronic payment requests. (a) The contractor shall submit payment requests in electronic form unless directed by...

48 CFR 832.7002 - Electronic payment requests.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 48 Federal Acquisition Regulations System 5 2013-10-01 2013-10-01 false Electronic payment... GENERAL CONTRACTING REQUIREMENTS CONTRACT FINANCING Electronic Invoicing Requirements 832.7002 Electronic payment requests. (a) The contractor shall submit payment requests in electronic form unless directed by...

22 CFR 226.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-04-01

... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Relations AGENCY FOR INTERNATIONAL DEVELOPMENT ADMINISTRATION OF ASSISTANCE AWARDS TO U.S. NON-GOVERNMENTAL ORGANIZATIONS Post-award Requirements Financial and Program Management § 226.22 Payment. (a) Payment methods...

22 CFR 226.22 - Payment.

Code of Federal Regulations, 2012 CFR

2012-04-01

... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Relations AGENCY FOR INTERNATIONAL DEVELOPMENT ADMINISTRATION OF ASSISTANCE AWARDS TO U.S. NON-GOVERNMENTAL ORGANIZATIONS Post-award Requirements Financial and Program Management § 226.22 Payment. (a) Payment methods...

22 CFR 226.22 - Payment.

Code of Federal Regulations, 2013 CFR

2013-04-01

... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Relations AGENCY FOR INTERNATIONAL DEVELOPMENT ADMINISTRATION OF ASSISTANCE AWARDS TO U.S. NON-GOVERNMENTAL ORGANIZATIONS Post-award Requirements Financial and Program Management § 226.22 Payment. (a) Payment methods...

22 CFR 226.22 - Payment.

Code of Federal Regulations, 2011 CFR

2011-04-01

... remitted annually to Department of Health and Human Services, Payment Management System, Rockville, MD... Relations AGENCY FOR INTERNATIONAL DEVELOPMENT ADMINISTRATION OF ASSISTANCE AWARDS TO U.S. NON-GOVERNMENTAL ORGANIZATIONS Post-award Requirements Financial and Program Management § 226.22 Payment. (a) Payment methods...

29 CFR 95.22 - Payment.

Code of Federal Regulations, 2014 CFR

2014-07-01

... and Human Services, Payment Management System, P.O. Box 6021, Rockville, MD 20852. Interest amounts up... FOREIGN GOVERNMENTS, AND INTERNATIONAL ORGANIZATIONS Post-Award Requirements Financial and Program Management § 95.22 Payment. (a) Payment methods shall minimize the time elapsing between the transfer of...

42 CFR 413.170 - Scope.

Code of Federal Regulations, 2010 CFR

2010-10-01

... PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; OPTIONAL PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES Payment for End-Stage Renal Disease (ESRD... the principles and authorities under which CMS is authorized to establish a prospective payment system...

48 CFR 49.112-1 - Partial payments.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 48 Federal Acquisition Regulations System 1 2010-10-01 2010-10-01 false Partial payments. 49.112-1 Section 49.112-1 Federal Acquisition Regulations System FEDERAL ACQUISITION REGULATION CONTRACT MANAGEMENT TERMINATION OF CONTRACTS General Principles 49.112-1 Partial payments. (a) General. If the contract authorizes...

Casemix--an AMA perspective.

PubMed

Nelson, B

1994-09-05

The introduction of casemix payment systems into Australia's public hospitals is an inevitability which the Australian Medical Association has now begun to address. A greater involvement of clinicians in the design and implementation of casemix can add substantial quality to these systems. However, there is concern that a proliferation of separate casemix systems may be contrary to overall health policy developments and that governments will not understand the limits of casemix. Recent attempts to include medical payments within a casemix payment system in the private sector faced our united opposition. Finally, special care needs to be taken to ensure that the introduction of a casemix payment system does not further disadvantage access to high quality health care for Aborigines.

14 CFR 198.15 - Non-premium insurance-payment of registration binders.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 14 Aeronautics and Space 3 2012-01-01 2012-01-01 false Non-premium insurance-payment of registration binders. 198.15 Section 198.15 Aeronautics and Space FEDERAL AVIATION ADMINISTRATION, DEPARTMENT OF TRANSPORTATION (CONTINUED) WAR RISK INSURANCE AVIATION INSURANCE § 198.15 Non-premium insurance...

42 CFR 417.585 - Special rules: Hospice care.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Special rules: Hospice care. 417.585 Section 417... (CONTINUED) MEDICARE PROGRAM HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS Medicare Payment: Risk Basis § 417.585 Special rules: Hospice care. (a) No payment is made...

Minnesota's Nursing Facility Performance-Based Incentive Payment Program: An Innovative Model for Promoting Care Quality

ERIC Educational Resources Information Center

Cooke, Valerie; Arling, Greg; Lewis, Teresa; Abrahamson, Kathleen A.; Mueller, Christine; Edstrom, Lisa

2010-01-01

Purpose: Minnesota's Nursing Facility Performance-Based Incentive Payment Program (PIPP) supports provider-initiated projects aimed at improving care quality and efficiency. PIPP moves beyond conventional pay for performance. It seeks to promote implementation of evidence-based practices, encourage innovation and risk taking, foster collaboration…

Contract Audits: Role in Helping Ensure Effective Oversight and Reducing Improper Payments

DTIC Science & Technology

2011-02-01

this testimony. 18 GAO, Hanford Waste Treatment Plant: Department of Energy Needs to Strengthen Controls over Contractor Payments and Project Assets...Government Interests at Risk, GAO-07-839, Washington, D.C.: July 31, 2007. Hanford Waste Treatment Plant: Department of Energy Needs to Strengthen

20 CFR 411.536 - Under what circumstances can we make a reconciliation payment under the outcome-milestone payment...

Code of Federal Regulations, 2014 CFR

2014-04-01

... 20 Employees' Benefits 2 2014-04-01 2014-04-01 false Under what circumstances can we make a reconciliation payment under the outcome-milestone payment system? 411.536 Section 411.536 Employees' Benefits SOCIAL SECURITY ADMINISTRATION THE TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM Employment Network Payment...