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PubMed2005

[Changes for rheumatology in the G-DRG system 2005].

The German prospective payment system G-DRG has been recently adapted and recalculated. Apart from the adjustments of the G-DRG classification system itself changes in the legal framework like the extension of the "convergence period" or the limitation of budget loss due to DRG introduction have to be considered. Especially the introduction of new procedure codes (OPS) describing the specialized and complex rheumatologic treatment of inpatients might be of significant importance. Even though these procedures will not yet develop influence on the grouping process in 2005, it will enable a more accurate description of the efforts of acute-rheumatologic treatment which can be used for further adaptations of the DRG algorithm. Numerous newly introduced additive payment components (ZE) result in a more adequate description of the "DRG-products". Although not increasing the individual hospital budget, these additive payments contribute to more transparency of high cost services and can be addressed separately from the DRG-budget. Furthermore a lot of other relevant changes to the G-DRG catalogue, the classification systems ICD-10-GM and OPS-301 and the German Coding Standards (DKR) are presented.

Diagnosis-Related Groups↗

PubMed1991

Outpatient prospective payment.

In September of this year, the Health Care Financing Administration (HCFA) will present Congress with its recommendations for developing a prospective payment system for all Medicare outpatient services. Whichever plan is ultimately adopted, this system of payment will greatly impact the structure and management of outpatient services and, in particular, reimbursement for radiology services and use of technologies. While a system is perhaps at least two years away from full-scale implementation, providers are already witnessing diminishing reimbursement as a result of incremental payment changes since the early 1980's. With the across-the-board cuts of six percent for all hospital outpatient services, authorized for the first time last year by Congress, some providers are experiencing an escalation of payment short-falls. Further, if current experience with implementation of the inpatient prospective payment system is replicated in the outpatient arena, payments will not only be less but they will be dramatically different for various providers. Since implementation of DRGs, Medicare has achieved savings of $18 billion for inpatient care. While some hospitals have reported their best years financially, others are consolidating or closing. A prospective payment system for outpatients will also have such "winners and losers," but as a single policy initiative it will probably have a greater impact than both DRGs and the resource-based relative value scale (RBRVS) combined. Because fixed payments for inpatients have proliferated the push to outpatient care, a DRG-like system for outpatients will result in capping payments for the entire continuum of services provided in hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗

PubMed1984

Task force, staff education ease transition to prospective payment.

Columbus-Cuneo-Cabrini Medical Center prepared extensively for the Medicare prospective payment system (PPS), which went into effect there Jan. 1, 1984. Administrators believe the planning effected a smooth transition from the retrospective reimbursement system. Preparation took two froms: educational sessions for all staff and trustees and establishment of a Prospective Payment System Implementation Task Force to develop ways to deal with new problems. All staff and trustees attended educational sessions, which were tailored to address each group's specific concerns. The sessions compared the old and new systems and emphasized PPS's effects on the institution over three years. The financial staff also provided weekly written updates to administrators and physicians on financial issues, including PPS, regulations, and reimbursement. The medical center's task force consisted of eight "in-house experts" on PPS. Because they had to act quickly, they operated under unique ground rules: Communicate with each other. Ignore the chain of command. Believe any problem can be resolved. Believe conflict is good. As chairman, the vice-president of finance had the task of estimating PPS's impact on the institution. The medical records director was responsible for the case-mix management system. The utilization review director ranked physicians and DRGs according to their profitability. The data processing director was responsible for installation of the DRG information system. The controller, reimbursement director, and cost accounting manager developed ways to maintain accurate financial records. The director of patient care services developed and scheduled PPS education programs. As a result of the preparation, the medical center staff realizes the importance of cost control if the institution is to remain viable.

Administrative Personnel↗

PubMed2004

Identifying and accommodating statistical outliers when setting prospective payment rates for inpatient rehabilitation facilities.

OBJECTIVE: To demonstrate how a Bayesian outlier accommodation model identifies and accommodates statistical outlier hospitals when developing facility payment adjustments for Medicare's prospective payment system for inpatient rehabilitation care. DATA SOURCES/STUDY SETTING: Administrative data on costs and facility characteristics of inpatient rehabilitation facilities (IRFs) for calendar years 1998 and 1999. STUDY DESIGN: Compare standard linear regression and the Bayesian outlier accommodation model for developing facility payment adjustors for a prospective payment system. DATA COLLECTION: Variables describing facility average cost per case and facility characteristics were derived from several administrative data sources. PRINCIPAL FINDINGS: Evidence was found of non-normality of regression errors in the data used to develop facility payment adjustments for the inpatient rehabilitation facilities prospective payment system (IRF PPS). The Bayesian outlier accommodation model is shown to be appropriate for these data, but the model is largely consistent with the standard linear regression used in the development of the IRF PPS payment adjustors. CONCLUSIONS: The Bayesian outlier accommodation model is more robust to statistical outlier IRFs than standard linear regression for developing facility payment adjustments. It also allows for easy interpretation of model parameters, making it a viable policy alternative to standard regression in setting payment rates.

Bayes Theorem↗

PubMed2003

[Prospective payment in medical rehabilitation].

After introducing DRGs (Diagnosis-Related Groups) in the prospective payment system for German hospitals, the use of per-case reimbursement for medical rehabilitation as well is being discussed. In particular two systems have already been tested internationally. FIM-FRG were especially developed for a prospective payment system for inpatient rehabilitation facilities. RUG-III are used for reimbursing long-term care in nursing homes and are based on a per-day payment. It is recommended to test the FIM-FRG or one of the refined systems in Germany in a pilot project.

Activities of Daily Living↗

PubMed1983

Medicare program; prospective payments for Medicare inpatient hospital services--HCFA. Interim final rule with comment period.

This interim final rule sets forth the revised conditions and procedures for making Medicare payments to hospitals for inpatient services, effective with cost reporting periods that begin on or after October 1, 1983. It also contains certain provisions effective on October 1, 1983 for all providers. This rule is needed to implement the Social Security Amendments of 1983 (Pub. L. 98-21), which change the method of payment for inpatient hospital services from a cost-based, retrospective reimbursement system to a diagnosis specific prospective payment system. The new system will be phased in over a three-year period and is primarily intended to provide incentives to hospitals to manage their operations in a more cost-effective manner. The attached addendum sets forth the schedule of standardized amounts and relative weights applicable for cost reporting periods beginning on or after October 1, 1983 and before October 1, 1984.

Centers for Medicare and Medicaid Services, U.S.↗

PubMed1993

Design of a prospective payment patient classification system for ambulatory care.

The Ambulatory Patient Group (APGs) are a patient classification system that was developed to be used as the basis of a prospective payment system (PPS) for the facility costs of outpatient care. This article will review the key characteristics of a patient classification system for ambulatory care, describe the APG development process, and describe a payment model based on the APGs. We present the results of simulating the use of APGs in a prospective payment system, and conclude with a discussion of the implementation issues associated with an outpatient PPS.

Ambulatory Care↗

PubMed1988

Medicare: short-stay hospital services, by leading diagnosis-related groups, 1983 and 1985.

Assigning a code from any of the diagnosis-related groups to a short-stay hospital discharge covered by Medicare is tantamount to the Medicare payment to the hospital, subject to certain statutory adjustments. Therefore, diagnosis-related groups are the backbone of the prospective payment system implemented October 1, 1983. However, methods employed in the assignment of diagnosis-related groups have changed since the prospective payment system was introduced. The focus of this article is to note some of these changes in methods of assigning diagnosis-related groups, which may have caused some of the migrations, or shifts, from one diagnosis-related group to another during the period 1983-85.

Diagnosis-Related Groups↗

PubMed1987

Prospective payment based on case mix: will it work in nursing homes?

This article evaluates the potential efficacy of implementing a prospective payment system based on case mix in the nursing home industry. The analysis of structural differences between the nursing home and hospital industries suggests that the mechanism of compensating long-term care facilities should be based on functional health status rather than on diagnosis and that incentives to improve quality and access should be strengthened. The article assesses several systems of classifying patients that have been proposed as the basis for implementing a prospective payment system in the nursing home industry. The article concludes with a discussion of policy issues related to the appropriate unit of payment and the scope of regulatory authority.

Costs and Cost Analysis↗

PubMed1986

AVGs: framework for ambulatory care payment.

In preparation for an ambulatory care prospective payment system, the Health Care Financing Administration (HCFA), Office of Research and Demonstration, supported a two-year grant project at Yale University for further development of an ambulatory patient classification system based on Ambulatory Visit Groups (AVGs). This article explains the premises of the study and gives us insight into what we may ultimately expect in an ambulatory care prospective payment system.

Ambulatory Care↗

PubMed1986

The impact of capital payment options under Medicare prospective payment. An ECRI technology management assessment.

In view of the upcoming legislative deadline for inclusion of capital costs within the Medicare prospective payment system, both public and private-sector entities have scrutinized various capital payment options and debated key issues relating to appropriate overall payments for capital costs, the nature of the mechanism for allocating payments to hospitals, and the method for transition from the present to the new capital payment system. The new capital payment policy will play an important role in future hospital capital decisions and technology levels. This report describes the nature and magnitude of hospital capital costs, examines alternative proposals for reflecting capital costs in the Medicare prospective payment system, and details each alternative's impact, incentives, and disincentives.

Capital Expenditures↗

PubMedDate not supplied

The five most frequently asked questions about private duty home care.

Where are the growth opportunities in home care? How can I reduce my dependency on Medicare? What can I do to improve the bottom line? These are some of the questions being asked by successful home care leaders as they work to recover from the effects of the Balanced Budget Act and the Interim Payment System and prepare for the Prospective Payment System.

Community Health Nursing↗

PubMedDate not supplied

Prospective payment and its impact on radiologic technology.

The prospective payment system is affecting the management and delivery of health care, and will have a large impact on the radiology department. This article describes the prospective payment system and explains how the role of the radiologic technologist may be altered.

Aged↗

PubMedDate not supplied

How nurses can survive under DRGs.

In an attempt to arrest spiralling health care costs, the US in April 1983 took the bold step of changing the method of payment for government-paid inpatient services from a cost-based retrospective reimbursement system to a prospective payment system (PPS) based on diagnosis related groups (DRGs). Since then Medicare payments to hospitals have been based on a fixed predetermined payment per case, discharge or per diem, or an overall revenue limitation, regardless of costs actually incurred. Naturally, this method has fostered fundamental changes throughout the US health care system, particularly for nursing: among them, the reduction of nursing staff and nurses resuming some functions previously taken over by ancillary staff. While the pros and cons of DRGs continue to create controversy, their use in planning and management of hospitals is being seriously explored in at least seven other countries, including Australia. "Should Australia adopt DRGs, what will be the effects on the health care services?" asks Vera F. Irurita, the author of the following article. But in the meantime, she places a call to nurses to start now to prepare for the future challenge...for their own survival.

Australia↗

PubMed1985

Growth, renewal, and challenge: an important era for occupational therapy.

Occupational therapy is facing some important decisions as it approaches a changing health care system. By understanding the prospective payment system it is possible to promote occupational therapy services to a changing marketplace while avoiding major problems. Specific opportunities and strategies are defined to promote occupational therapy to new markets.

Delivery of Health Care↗

PubMed1989

The effect of prospective payment on Medicare expenditures.

Medicare's prospective payment system was introduced in 1983 to slow the growth of expenditures for hospital care, which from the bulk of Medicare costs. Instead of reimbursing hospitals for the actual costs of patient care, the system pays them at fixed rates for each admission. In this study, we estimated the savings to Medicare from the use of prospective payment. We analyzed the expenditure projections published in 10 successive annual reports (1979 to 1988) by the trustees of the federal Hospital Insurance Trust Fund, which pays hospital bills for Medicare beneficiaries. To show the effect of prospective payment, these projections were adjusted to correct for the different assumptions about inflation and admissions made in each report. We also examined trends in expenditures from the Supplementary Medical Insurance Trust Fund, which pays for outpatient services, to see whether the savings in hospital expenses were offset by higher spending for out-of-hospital services. We found that prospective payment has reduced Medicare's hospital costs substantially. Expenditures from the Hospital Insurance Trust Fund for 1990 are expected to be +12 billion less in 1980 dollars, and +18 billion in 1990 dollars, than was expected shortly before prospective payment went into effect--the equivalent of a savings of approximately 20 percent. By contrast, the effect of prospective payment on the supplementary fund has not been great. We conclude that the prospective payment system is having a major impact on Medicare's hospital expenditures and that the savings is not offset by an increase in outpatient expenditures.

Ambulatory Care↗

PubMed1986

Prospective payment for Medicare skilled nursing facilities: background and issues.

Strong interest by Congress in a Medicare prospective payment system for skilled nursing facilities (SNF's) resulted in a major study by the Health Care Financing Administration on the Medicare SNF benefit. This article highlights findings from that study, which addressed the following: the Medicare SNF benefit, utilization and expenditures, the Medicare SNF industry, problems with the current Medicare SNF reimbursement system, efforts to develop a Medicare SNF case-mix measure, and case-mix differences between hospital-based and freestanding SNF's. In addition, we discuss the implications of the study findings for the design of a Medicare SNF prospective payment system (PPS).

Costs and Cost Analysis↗

PubMed2005

Toward a new payment system for inpatient rehabilitation. Part II: Reimbursing providers.

BACKGROUND: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment. OBJECTIVES: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855). RESEARCH DESIGN: We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis. RESULTS: We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions. CONCLUSION: For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Diagnosis-Related Groups↗