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Results for “Prospective Payment System”

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PubMed1991

Changes in psychiatric inpatient treatment of children and youth in general hospitals: 1980-1985.

Changes in the prevalence of inpatient psychiatric treatment of children and youth in short-term general hospitals between 1980 and 1985 were investigated. During that period, the locus of treatment of mental illness among children and youth shifted dramatically away from specialized facilities to general hospitals without psychiatric units. Among general hospitals without psychiatric units, the number of inpatient psychiatric episodes treated increased dramatically, patients' average length of stay almost doubled, and the total days of care provided more than tripled. The increased care was paid for primarily by Medicaid and commercial insurance. Total days of care for drug and alcohol problems among children and youth in general hospitals decreased substantially. The results suggest that general hospitals may be relying on psychiatric treatment to supplement revenues that were limited by Medicare's prospective payment system, which became effective during the period under study.

Adolescent↗

PubMed1988

The observable patient in the DRG era.

We examined financial differences of observing patients in the acute care hospital versus an emergency department observation unit. We identified 193 patients who could have been treated in either the acute care hospital or observation unit. Under a cost reimbursement system, the charge per patient was +197 greater, the reimbursement per patient was +254 greater, and the profit per patient was +140 greater for observing patients in the hospital rather than in the observation unit (p less than 0.001). Under a prospective payment system, the charge per patient was +1187 greater, the reimbursement per patient was +1137 greater, and the profit per patient was +1063 greater for observing patients in the hospital rather than in the observation unit (p less than 0.001). This difference in reimbursement can be a great financial incentive for hospitals to admit patients rather than to observe them in the emergency department. Significant savings might be realized for the health care payer by optimal use of observation units under a prospective payment or cost reimbursement system.

Connecticut↗

PubMed1992

Home care PPS holds promise of profits.

Home healthcare agencies might be able to make money under a Medicare prospective payment system, according to preliminary results from the first year of a three-year HCFA demonstration project. After a year, most of the 26 agencies in the project made a profit under the per-visit reimbursement system HCFA is testing. A per-episode of care system will be tested later next year.

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

PubMedDate not supplied

A new payment system for outpatient services? The implications for radiology.

Congress is now contemplating the most significant change in outpatient payment methodology in Medicare's 31-year history. It may approve a proposal by the Health Care Financing Administration (HCFA) to establish a Medicare prospective payment system for hospital outpatient departments. In March 1955, five years after a Congressional directive to develop a new outpatient payment system, HCFA delivered its proposal recommending use of the ambulatory patient groups (APG) classification system for determining payment of hospital outpatient services. The APG system, which uses outpatient procedures as its primary variable, divides all such procedures into one of three categories: 1) significant procedures or therapies (including therapeutic and other significant radiological procedures); 2) ancillary test and procedures (including 11 radiology ancillary service APGs); or 3) medical visits. Outpatients can be assigned to one or more of the 290 APGs, each comprising a number of clinically and resource intensity-similar procedures, medical visits or ancillary tests. Any new payment methodology for outpatient procedures would broadly impact the radiology community. How radiology providers will fare under the system being proposed will depend on several issues that have not yet been resolved, such as how the basic unit of payment is defined (e.g., a service, a visit, or an episode of care) and whether payment rates will be adequate to compensate for the costs of providing services. One key issue will be whether contrast media and radiopharmaceuticals will continue to be paid as pass-through costs, giving providers the flexibility to choose the specific agent that is most appropriate for their patients.

Ambulatory Care↗

PubMed1988

Use of specialty psychiatric settings in constructing DRGs.

Characteristics of a psychiatric setting, such as staffing intensity and scope of services, are examined to see if they contribute to explaining variation in length of stay over that explained by commonly available patient descriptors. For short-stay admissions (less than 31 days), only a small improvement in predictive ability was found. Implications for prospective payment systems are discussed.

Adult↗

PubMedDate not supplied

The effects of a low-cost intervention program on hospital costs.

OBJECTIVE: To assess the impact of a low-cost education and feedback intervention designed to change physicians' utilization behavior on general medicine services. DESIGN: Prospective, nonequivalent control group study of 1,432 admissions on four general medicine services over 12 months. Two services were randomly selected to receive the intervention. The other two served as controls. Admissions alternated between control and intervention services each day. Results were casemix-adjusted using diagnosis-related groups (DRGs). Three internists blinded to patient study group assignment assessed quality of care using a structured implicit instrument. SETTING: Four general medicine services at a university hospital. INTERVENTIONS: A brief orientation, a pamphlet of cost strategies and common charges, detailed interim bills, and information about projected length of stay and usual hospital reimbursement for each patient. PATIENTS/PARTICIPANTS: Each service was staffed by a full-time internal medicine faculty member, one third-year and two first-year internal medicine houseofficers, three medical students, and a clinical pharmacist. Physicians were assigned to services for one-month periods by a physician unaware of the study design. To prevent crossover, houseofficers assigned to a service returned to the same service for all subsequent general medical inpatient assignments. MEASUREMENTS AND MAIN RESULTS: Geometric mean length of stay was 0.44 days (7.8%) shorter for the intervention services than for the control services (p less than 0.01), and geometric mean charges were $341 (7.1%) less (p less than 0.01). Effects persisted despite using a more precise cost estimate or casemix adjustment. Intervention houseofficers demonstrated superior cost-related attitudes but no difference in knowledge of charges. Audits of quality of care detected no significant difference between groups. CONCLUSION: This low-intensity intervention reduced length of stay and charges, even under the cost-constrained context of the prospective payment system.

Cost Control↗

PubMed1992

HB/SNFs feasible, despite looming prospective payments.

Hospital-based skilled nursing facilities provide hospitals with favourable reimbursement levels because patient care is reimbursed according to costs rather than under a prospective payment system. The promise of case-mix Medicare reimbursements has not dampened the growth in the number of HB/SNFs.

Bed Conversion↗

PubMedDate not supplied

Costs and benefits of prosthetic vascular surgery.

For a variety of reasons, primary amputation is often advised in the elderly individual with a severely ischemic leg. Reinforcing this recommendation is the perception that reconstructive arterial surgery in this group is far more expensive than the primary amputation. Living more than only one more year after amputation, professional nursing care cost approaches $100,000. In two recent studies, the cost for patients undergoing primary below the knee amputations plus rehabilitation was almost identical to the mean patient cost for arterial reconstruction. In addition, under the prospective payment systems, substantial financial loss accrues to hospitals caring for these patients.

Actuarial Analysis↗

PubMed1995

Pediatric mortality and hospital use in Canada and the United States, 1971 through 1987.

Since 1971 pediatric mortality rates have decreased markedly but differently in Canada and the United States. These trends were examined in light of changes in hospital use and health care financing. Annual mortality and hospital use rates for children aged 14 years and younger were calculated. Between 1971 and 1987, all-cause mortality in Canada fell from 165 to 74 per 100,000; the American rate fell from 172 to 96 per 100,000. American hospitalization rates remained essentially constant until 1983 and then fell by 27.5%, while Canadian hospitalization rates declined throughout. In 1987 Canadian children had higher hospitalization rates, while American children had higher mortality rates. These differences may be associated with differences in health financing; the adoption of US prospective payment systems was temporally coincident with sharp declines in hospitalization rates for American children.

Adolescent↗

PubMed2002

Rolling back Medicare home health.

The Balanced Budget Act (BBA) of 1997 included major changes to Medicare's home health benefit designed to control spending and promote efficient delivery of services. Using national data from Medicare home health claims, this study finds the initial effect of the BBA was to steeply reduce use of the home health benefit and intensify its focus on post-acute skilled nursing and therapy services. The striking responsiveness of home health agencies (HHAs) to altered financial incentives suggests that we may again see large shifts in patterns of care under the new incentives of Medicare's prospective payment system (PPS) for home health.

Aged↗

PubMed1993

Development of a resource-based patient classification scheme for rehabilitation.

Efforts are currently underway to develop a prospective payment system for inpatient medical rehabilitation. In this study, a clinically based, condition-specific patient classification scheme was developed that includes 33 patient groupings, referred to as Functional Related Groups (FRGs). Each FRG is comprised of patients with similar clinical characteristics and resource use, as measured by length of stay. From a policy perspective, the FRGs minimize the adverse incentives that may develop in the selection of patients for admission to the rehabilitation facility. The FRGs, therefore, may be used as a basis in the development of a prospective reimbursement system for rehabilitation services.

Adult↗

PubMed2000

APCs: reimbursement implications.

A transition to a new Medicare outpatient prospective payment system (PPS) will begin in July 2000, affecting many of the outpatient services provided by hospitals that participate in the Medicare program. The outpatient PPS will rely on ambulatory payment classifications (APCs) to classify outpatient services. Hospitals should anticipate that discounts and other factors will affect APC payments and take into account the impact that the new system will have on their revenue.

Ambulatory Care↗

PubMed2003

Payment system reform for health care providers in Korea.

Since its introduction in 1977, the national health insurance programme in Korea has paid health care providers on a fee-for-service basis. Regulated fee-for-service payment has resulted in an increased volume and intensity of medical care. It has also distorted the input mix of treatment because physicians have substituted more profitable and uninsured (no coverage) medical services for those with lower margins, as is evidenced by the sharp increase in the caesarean delivery rate. This paper examines two recent supply-side reforms in Korea: Diagnosis Related Group (DRG) and Resource-based Relative Value (RBRV). Since 1997, through a pilot programme covering a selected group of diseases for voluntarily participating health care institutions, the DRG-based prospective payment system has proven to be effective in containing cost with little negative effect on quality. RBRV-based payment was implemented in 2001, but led to an almost uniform increase in fees for physician services without a mechanism to control the volume and expenditure. Challenges and future issues in the reform of the payment system in Korea include the expansion of benefit coverage, quality monitoring and improvement, strategic plans to overcome the strong opposition of providers and the introduction of global budgeting.

Budgets↗

PubMed2002

Medical necessity under OPPS: a look at the challenges.

The outpatient prospective payment system (OPPS) has dramatically changed claims processing by introducing an automated system. Medical necessity validation has also been automated as a result, leaving hospitals with increased rejections. This article explores how OPPS impacts tile medical necessity process.

Ambulatory Care↗

PubMed2000

New PPS brings mixed blessings.

With the start-up of the new outpatient prospective payment system a little more than a month away, hospitals are busy trying to determine how the PPS will affect their bottom lines. Joanne Tucker (left), a vice president at a California hospital, is among those who expect a revenue loss. But others say the changeover looks like a positive development. The biggest burden could be preparing for the system's implementation.

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

PubMed1991

Medicare program; Medicare Geographic Classification Review Board--procedures and criteria--HCFA. Final rule with comment period.

This final rule with comment period responds to public comments on the September 6, 1990 interim final rule with comment period that established the Medicare Geographic Classification Review Board (MGCRB) and sets forth the criteria for the MGCRB to use in issuing its decisions concerning the geographic reclassification of hospitals for purposes of payment under the prospective payment system. In addition, this final rule with comment period implements provisions of the Omnibus Budget Reconciliation Act of 1990 concerning the MGCRB.

Catchment Area, Health↗

PubMed1986

Case mix reimbursement for nursing homes.

Nursing home care is growing in importance as the population ages and as Medicare's prospective payment system encourages earlier discharges from acute care settings to nursing homes. Nursing home reimbursement policy is primarily a Medicaid issue, since Medicaid pays for about half the nation's nursing home care. The research reviewed in this article suggests a strong association between case mix and cost, and a weaker but still positive association between quality and cost. The research also implies that traditional nursing home reimbursement methodologies may impede access and may lower quality for Medicaid (and Medicare) recipients. To offset these problems, several states have recently begun to incorporate case mix directly into the reimbursement process. These systems deserve careful policy consideration.

Costs and Cost Analysis↗

PubMed2001

Preparing for the inpatient rehabilitation PPS.

To assess the financial impact of the inpatient rehabilitation prospective payment system (PPS) on its future revenues, the MetroHealth Center for Rehabilitation (MHCR), Cleveland, Ohio, undertook a three-phase process using data from calendar year 2000 to estimate its potential profit or loss for each case-mix group (CMG) identified in the final rule. This process entailed developing a database to facilitate the combination and comparison of patient-charge and clinical data by CMG, using the combined data to estimate costs by cost center, and using payment information included in the final rule to estimate revenues by CMG. Following the assessment, the MHCR decided to expand the database to assist clinicians in making informed decisions in their patient-assessment and care-delivery processes that would account for cost and revenue considerations under the PPS.

Aged↗