IPE 350 - Spring 2012 Reimbursement

IPE 350 - Spring 2012 Reimbursement - Health Care...

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Health Care Reimbursement Anthony Breitbach PhD, ATC IPE 350
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What is the impact of rising health care costs on employers? Greater portion of operating budget devoted to health care.
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What has been done by employers to deal with the problem? Increase cost of premium – pass portion of premium cost on to beneficiary (Medicare recipient or employee) Increase amount of deductibles and co-payments Reduce benefits Increase taxes of cost of product or service to consumer
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What is the impact of rising health care costs on the federal and state governments? Increased % GDP Increase deficit spending Decrease amount to spend on other necessities (defense, transportation, education)
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What has been done by the government to deal with the problem? Changed payment mechanism from fee-for-service to prospective pricing system Health became recognized as personal responsibility – promoting of healthy living Focus on self management of health condition (i.e. disease management) What are some legislative/regulative actions to promote health?
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What is the impact that Medicaid and Medicare has on the health care system? Made health care more accessible to many who were not financially able to obtain care Increase demand for health care professionals and hospitals and other types of health care settings (ex. home health agencies, rehab and extended care facilities, ambulatory care) Insurance coverage now available out-of-hospital – more health professionals needed to provide services in variety of settings
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What has be done to improve the situation? Look for least expensive setting and personnel to provide safe and efficient care Systematically move patients to the least complex setting that can provided care Development of PT assistants, OT assistants, physician assistants, nurse practitioner How care is reimbursed has a very strong influence on how we health practitioners practice
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DRG’s, RBRVS, APC’s, RUG’s Prospective “pricing” established by the government for payment for federally funded care.
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Diagnostic Related Groups (DRG’s) In-patients (Medicare) Method of classifying patients who have similar patterns of resource consumption CMS assigned a weight to each DRG based on that resource consumption Each hospital is assigned a rate based on the case mix of their patient population These are adjusted based on region, type of facility, urban v. rural, whether they provide resident education, and other characteristics
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Resource Based Relative Value Scale (RBRVS) Used for physician reimbursement Covers basic services, diagnostic tests, radiology services, PT/OT Payments for PA, nurse practitioners and midwives are tied to RBRVS Based on geographic index (GI), practice expense, malpractice, and work activity RVU’s: Relative Value Units
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Ambulatory Payment Categories (APC’s) A prospective system for the facility component of ambulatory care rendered in
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IPE 350 - Spring 2012 Reimbursement - Health Care...

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