Health Care Financing Administration Research Articles

Inequalities in Out-of-Pocket Health Expenditure Measured Using Financing Incidence Analysis (FIA): A Systematic Review

Government efforts and reforms in health financing systems in various countries are aimed at achieving universal health coverage. Household spending on healthcare plays a very important role in achieving this goal. The aim of this systematic review was to assess out-of-pocket health expenditure inequalities measured by the FIA across different territories, in the context of achieving UHC by 2030. A comprehensive systematic search was conducted in the PubMed, Scopus, and Web of Science databases to identify original quantitative and mixed-method studies published in the English language between 2016 and 2022. A total of 336 articles were initially identified, and after the screening process, 15 articles were included in the systematic review, following the removal of duplicates and articles not meeting the inclusion criteria. Despite the overall regressivity, insurance systems have generally improved population coverage and reduced inequality in out-of-pocket health expenditures among the employed population, but regional studies highlight the importance of examining the situation at a micro level. The results of the study provide further evidence supporting the notion that healthcare financing systems relying less on public funding and direct tax financing and more on private payments are associated with a higher prevalence of catastrophic health expenditures and demonstrate a more regressive pattern in terms of healthcare financing, highlighting the need for policy interventions to address these inequities. Governments face significant challenges in achieving universal health coverage due to inequalities experienced by financially vulnerable populations, including high out-of-pocket payments for pharmaceutical goods, informal charges, and regional disparities in healthcare financing administration.

ACHIEVING QUALITY PATIENT-CENTERED CARE IN THE NURSING HOME SETTING

Abstract In 1987, The Nursing Home Reform Act was enacted as part of the Omnibus Reconciliation Act of 1987 (OBRA 87). At that time, the Health Care Finance Administration (now Centers for Medicare and Medicaid Services) issued comprehensive regulations and survey processes to “ensure that residents of nursing homes receive quality care that will result in their highest practicable physical, mental, and social well-being.” Despite this landmark legislation, nursing homes struggle to provide quality care, and are additionally challenged by natural disasters and pandemics. This presentation will report on recommendations that examine, structures, policies, and care models that promote change and innovation, with a focus on safety, environmental modifications, patient centered approaches, and quality care. Dr. Colleen Galambos, a professor at University of Wisconsin-Milwaukee, with expertise in nursing home care delivery and quality improvement will present the care delivery recommendations from the NASEM report.

Facts About DSM-5-TR

Facts About <i>DSM-5-TR</i>

A congener-specific and mixtures analysis of plasma polychlorinated biphenyl (PCB) levels and incident breast cancer in the Carolina Breast Cancer Study

Background: Polychlorinated biphenyls (PCBs), which are carcinogens and endocrine disrupting chemicals with innate heterogeneity, are hypothesized to influence risk of breast cancer. However, studies assessing PCB mixtures and breast cancer are lacking. Herein, we examined plasma levels of 17 PCBs as individual congeners and as mixtures in association with breast cancer. Methods: This study included 845 White and 562 Black women who participated in the case-control Carolina Breast Cancer Study Phase I. Cases (n=748) were women with a first diagnosis of histologically confirmed invasive breast cancer identified from the North Carolina (NC) Central Cancer Registry. Population-based controls (n=659) were identified from NC Department of Motor Vehicles or Health Care Financing Administration lists. PCBs were measured in plasma samples obtained at the time of the case-control interview. We used logistic regression to estimate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between individual lipid-adjusted PCB congeners and breast cancer. We used quantile g-computation (qgComp) to assess PCB mixtures, and in sensitivity analyses compared results to those from generalized weighted quantile sum regression (WQS). We examined effect measure modification by race (white vs. black). Results: The highest (vs. lowest) tertiles of PCBs 74, 99, 194, and 201 were associated with breast cancer ORs of 1.30 (95%CI=0.95-1.79), 1.39 (95%CI=1.02-1.89), 1.27 (95%CI=0.91-1.77), and 1.24 (95%CI=0.90-1.72), respectively. These PCBs also showed dose-response relationships is models using ln-transformed continuous PCB levels. Using qgComp, among all women a one-unit change in all PCB quantiles was associated with an OR of 1.29 (95%CI=1.00-1.67). In stratified analyses, associations of PCB mixtures were stronger among black women (ORqgComp=1.55, 95%CI=1.05-2.30), than among white women (ORqgComp=1.13, 95%CI=0.80-1.60). Conclusion: Exposure to PCBs may increase the risk of breast cancer. Additional studies are needed that consider mixtures of PCB congeners in association with breast cancer.

Assessing medical student documentation using simulated charts in emergency medicine

BackgroundThe 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students’ documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines.MethodsWe conducted a prospective study of fourth-year medical students’ simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students’ simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics.ResultsWe found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams.ConclusionNew curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.

Abstract 217: Prediction Outcomes Using Other People’s Models

Introduction: Predictive models of adverse outcomes are developed to identify combinations of variables that can be used to identify at-risk patients. Prediction accuracy of the model is assessed by discrimination - how well the model discriminates those experiencing the outcome vs. those who don’t, and calibration - how well the predicted probabilities of the model correspond to the observed probabilities of the outcome. The ultimate test of a model is applying it to a different cohort. Typically, models developed from the same cohort tend to be overfit, that is, they apply well to the cohort on which they were developed, but less well to a different cohort. We show that re-calibration can result in a valid and useful model. Methods: The Society of Thoracic Surgeons (STS) established the National Adult Cardiac Surgery Database (NCD) in response to inadequately risk-adjusted hospital mortality released by the former Health Care Financing Administration (now the Centers for Medicare and Medicaid Services). Subsequently, the STS published models of several adverse outcomes including in-hospital mortality for patients undergoing coronary artery bypass grafting surgery (CABG). We applied the regression coefficients of the risk factors from their model to a different cohort of CABG patients (patients who underwent CABG at Christiana Care Health System) and assessed discrimination and calibration with the c-index and correlation of observed probabilities to predicted probabilities of in-hospital death. As the model resulted in poor calibration, we then re-estimated the regression coefficients for our cohort by applying penalized logistic regression and calculated discrimination and calibration statistics for the re-calibrated model. Results: While discrimination was good (0.827), the STS model was not well-calibrated (Figure 1A) when applied to our cohort. When the model was re-calibrated, discrimination and calibration statistics indicated good discrimination (0.835) and calibration (Figure 1B). Conclusion: When predictive models of adverse outcomes developed on one cohort of patients are applied to a different cohort of patients, the model needs to be re-calibrated to obtain a useful model.

Quality Measurement and Accountability in Cardiovascular Medicine: An Incomplete Revolution.

The rise of quality measurement and the proliferation of programs that require accountability for quality are among the most dramatic developments in cardiovascular medicine in the past 2 decades. The quality revolution now affects the daily practice of virtually every cardiovascular clinician and has influenced national health policy. Over time, however, both the successes and limitations of the quality movement have become apparent. As is often the case with revolutionary changes, quality measurement and the uses of these measures merit reflection and consideration of further change. For years, quality measurement played an insignificant role in medicine. This changed with a growing appreciation of substantial unexplained variation in healthcare practice in parallel with seemingly unrestrained increases in care costs. The actions of the Health Care Financing Administration, now the Centers for Medicare & Medicaid Services, are illustrative of this evolution. Having employed the ineffectual approach of performing individual case review (quality assurance) of negative outliers, the Health Care Financing Administration adopted the relatively radical approach of measuring quality nationally in the hopes of stimulating improvement for all institutions and providers in the early 1990s.1 The Health Care Financing Administration’s Cooperative Cardiovascular Project measured the quality of care for acute myocardial infarction; subsequent efforts expanded to other high-impact conditions, including heart failure. Although these programs focused entirely on measuring processes of care (eg, rates of use of evidence-based therapies for acute myocardial infarction and heart failure) and did not address strategies for quality improvement, they introduced clinicians and hospitals to formal …

Can the US minimum data set be used for predicting admissions to acute care facilities?

This paper is intended to give an overview of Knowledge Discovery in Large Datasets (KDD) and data mining applications in healthcare particularly as related to the Minimum Data Set, a resident assessment tool which is used in US long-term care facilities. The US Health Care Finance Administration, which mandates the use of this tool, has accumulated massive warehouses of MDS data. The pressure in healthcare to increase efficiency and effectiveness while improving patient outcomes requires that we find new ways to harness these vast resources. The intent of this preliminary study design paper is to discuss the development of an approach which utilizes the MDS, in conjunction with KDD and classification algorithms, in an attempt to predict admission from a long-term care facility to an acute care facility. The use of acute care services by long term care residents is a negative outcome, potentially avoidable, and expensive. The value of the MDS warehouse can be realized by the use of the stored data in ways that can improve patient outcomes and avoid the use of expensive acute care services. This study, when completed, will test whether the MDS warehouse can be used to describe patient outcomes and possibly be of predictive value.

50th Anniversary Landmark Commentary on Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12–9

50th Anniversary Landmark Commentary on Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons National Database experience. Ann Thorac Surg 1994;57:12–9

Commentary - Payment Policy Disruption and Policy Drift.

Commentary - Payment Policy Disruption and Policy Drift.

The CMS Innovation Center: Delivering on the Promise of Payment and Delivery Reform

The CMS Innovation Center: Delivering on the Promise of Payment and Delivery Reform

The STS National Database

he initial stimulus for developing The Society of TThoracic Surgeons (STS) National Database came in 1986 when the Health Care Financing Administration (HCFA) publicly reported hospital mortality using minimally adjusted, non-clinical data. Because of the lack of adequate risk adjustment and questions regarding the accuracy of diagnoses and procedures, cardiothoracic surgeons became very concerned that such data could be misleading. The STS Standards and Ethics Committee released a “Statement of Concern” in 1986, followed by the Society appointing an Ad Hoc Committee on Risk Factors for Coronary Bypass Surgery, which issued a report in 1988 stating:

RVUs and DRGs: Do They Fairly Reimburse Physicians and Hospitals and Incentivize Improved Care?

* Abbreviations: BAS — : balloon atrial septostomy BW — : birth weight CPAP — : continuous airway pressure CPT — : current procedural terminology DRG — : diagnosis-related group ELOS — : expected length of stay LOS — : length of stay RVU — : relative value unit In 1989, Congress enacted the Omnibus Budget Reconciliation Act, which authorized the Health Care Financing Administration to adopt the use of relative value units (RVUs) as the basis for Medicare and Medicaid reimbursement to physicians. Each RVU is related to the complexity of the services by a defined current procedural terminology (CPT) code, and each has 3 components: (1) physician work RVUs account for the time spent, the cognitive and technical skills needed, and the overall difficulty involved in providing a service or performing a procedure; (2) practice expense RVUs account for nonphysician clinical staff time, medical supplies, and equipment used to maintain and run the facility where the medical encounter occurs; and (3) professional liability RVUs account for the cost of malpractice insurance. Congress assigns a dollar value to an RVU as part of its annual budget process. The geographic differences in costs across the United States are equalized by a geographic practice cost index applied to each RVU. Over time, the use of RVUs has become the reimbursement basis for many private health insurance carriers and for Medicaid and Medicare and has been used as a surrogate measure of physician productivity; it is of paramount importance that the relative value of a physician’s work be accurately reflected by the RVUs generated, especially when comparing physicians’ work across specialties. Of the three RVU components, physician work RVUs have proven the most controversial and challenging to accurately quantify. The Center for Medicare and Medicaid Services is required by Congress to review and update RVUs every 5 years. The Center for Medicare and Medicaid Services seeks input from a variety of sources including the American Medical Association–Specialty Society Relative Value Scale Update Committee, which is composed of 29 members, most of whom represent medical specialty societies. This committee meets 3 times … Address correspondence to David Rubenstein, MD, College of Physicians and Surgeons, Columbia University Medical Center, 3959 Broadway, CHN 1200A, New York, NY 10032. E-mail: sdr26{at}columbia.edu

Public Reporting of Cardiovascular Care: An Opportunity to Shape the Future

William A. Zoghbi MD, FACC ACC President The unstated rationale for public reporting is that this information has impacts on market forces, payers, and practitioners to improve health care quality and reduce costs. In one of the first public reporting efforts, the Health Care Financing Administration (HCFA) published hospital mortality rates for Medicare patients undergoing coronary artery bypass graft surgery (CABG) (1). These data, derived from administrative and claims information, were not originally intended for this use and the report was criticized by hospitals and providers because they feared that the risk adjustment models were inadequate. Although adjustments were made, the usefulness of these reports has never been established, and many express negative opinions about these data (2). The HCFA experience led to the development of several private quality improvement registries and public state-wide reporting systems, such as the Northern New England Cardiovascular Study Group and the Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database (3). New York, Pennsylvania, Massachusetts, and California subsequently developed public reporting mechanisms for cardiac surgical outcomes (4–7). Some states even report physician-specific data and have expanded reporting to include percutaneous coronary interventions (PCI) (8). In 2005, the Centers for Medicare and Medicaid Services (CMS) launched the Hospital Compare website to publicly report hospital quality information derived from several sources (9). Certain core measures are reported for cardiac patients along with risk-adjusted mortality and readmission rates for acute myocardial infarction and heart failure derived from Medicare enrollment and claims data. The site also reports the results of patient surveys about their hospitalization and is considering adding measures from the Hospital Value Based Purchasing Program. The number of resources currently devoted to public reporting is unknown, but public reporti ng initiatives continue to proliferate with additional state initiatives, reports from payers that focus on costs, and reports from business consumer groups (10). There are now several internet-based forums where patients can report their individual experiences with physicians, both good and bad, in an unregulated and nonscientific manner. This, in turn, has resulted in some physicians requiring patients to agree to not participate in such activities before any treatment is provided. January 2011, under the authority of the Patient Protection and Affordable Care Act of 2010 (PPACA), CMS implemented the Physician Compare website (11). Several benchmarks for this effort were established: 1) providing information on the performance of physicians (and other health care providers) enrolled in Medicare; 2) reporting to Congress on the plans to use these data for value-based purchasing and consumer choice; and 3) demonstrating how financial incentives will be applied to beneficiaries who use “high-quality physicians.”

Palliative Care for Long-Term Care Residents: Effect on Clinical Outcomes

To determine whether a palliative care (PC) consult service in a long-term care (LTC) facility would result in a more favorable course of treatment and clinical outcomes for participating residents. We used a historical control design within a single LTC facility. Outcome data and potential confounding variables were obtained using the Minimum Data Set. (Health Care Financing Administration. (1995). Long term care resident assessment instrument user's manual version 2.0. Rockville, MD: Health Care Financing Administration.) Residents who died during the period of the PC service (2007-2009) were compared with matched residents who died in the year prior (2006, historical controls). The analysis sample included 250 residents (125 PC residents, 125 non-PC historical control residents). Our main analysis focused on a composite outcome based on utilization patterns, depression, and pain and other clinical indicators. We analyzed change on this component score (and the individual outcomes) over a 1-year period. PC residents experienced a significant reduction in emergency room (ER) visits (p < .001) and depression (p = .031). Change in the composite score indicated a significant difference over time between the 2 groups (p = .013). Although limited to 1 facility and drawn from a quasi-experimental design, the results demonstrate the potential for improved quality of care with PC consults. The PC team was effective in reducing ER visits and depression and promoted more appropriate care resulting in more favorable clinical outcomes toward the resident's end of life.

The Role of an Acute Care for the Elderly Unit in Achieving Hospital Quality Indicators While Caring for Frail Hospitalized Elders

Acute Care for the Elderly (ACE) units have successfully decreased length of stay, hospital costs, and readmission rates. Furthermore, patients return home with increased functional capacity and improved satisfaction with their hospital stay. The ACE unit concept was geared toward patients returning to independent living, but the average hospitalized geriatric patient is increasingly more frail, vulnerable, and dependent. The purpose of this study is 2-fold: (1) to determine if the ACE unit continues to offer the same benefit to the frail, often bedbound elderly, and (2) to determine if such a unit is able to maintain standard hospital quality indicators. A total of 1096 cases discharged from the Memorial-Hermann ACE unit between July 2008 and June 2010 were compared to a sample of 383 patients with similar illness severity who were discharged between July 2007 and June 2008. Metrics measured include: average length of stay (ALOS), case mix index (CMI), case mix adjusted average length of stay (CMI adj ALOS), average direct costs per case, and readmission rate. Patient satisfaction was measured using Hospital Consumer Assessment of Healthcare Providers and Systems and Press-Ganey surveys; quality and safety data were provided by Memorial-Hermann's Quality and Safety Department. The ACE unit resulted in a statistically significant decrease in ALOS and CMI adj LOS with a simultaneous increase in Health Care Financing Administration CMI, indicating that the unit was serving a sicker, more frail population. The readmission rate was 11.95%. The decrease in length of stay, readmission rate, and direct cost translates into a decrease in cost per case. Furthermore, the ACE unit successfully met hospital quality indicators.

Saga of Payment Systems of Ambulatory Surgery Centers for Interventional Techniques: An Update

The health care system in the United States has been criticized for skyrocketing expenditures and quality deficits. Simultaneously, health care providers and systems are under pressure to provide better and more proficient care. The landscape of the US health care system is shaped by federal and private payers which continue to develop initiatives designed to curtail costs. These include value-based reimbursement programs; cost-shifting expenses to the consumer and reducing reimbursement of providers and facilities. Moreover, there is an underlying thought to steer provision of health care to theoretically more efficient settings. Many of these initiatives are based on affordable health care reform. The major aspects of curtailing health care costs include hospital and other facility payments as well as physician payments and reductions in the approved services. Consequently, ambulatory surgery centers (ASCs) are not immune to these changes. Until 1970, all surgery was performed in hospitals The development of ASCs and site of service differential payments for in-office procedures have changed the dynamics of surgical trends with outpatient surgeries outpacing inpatient surgeries by as early as 1989. By 2008, approximately 65% of procedures were performed in all outpatient settings including hospital outpatient departments. ASCs claim that improved efficiency in health care delivery allows patients to spend less time in the health care setting with quicker turn over, improving the productivity of the health care team. However, since the majority of the ASCs are owned, in part, by the physicians who staff them, the financial incentives related to ownership have been alleged to potentially alter provider behavior. The number of Medicare certified ASCs and total Medicare payments from 1999 to 2010 increased significantly, but more recent year-to-year changes are far less substantial when compared to previous years. Net percent revenue growth from 2008 to 2009 was 3.2% and from 2009 to 2010 was 6.2% with an overall increase from 1999 of 183% over a period of 11 years. Similarly, the number of Medicare certified ASCs increased from 2,786 in 1999 to 5,316 in 2010, 1.1% increased from 2009 to 2010, however, a 91% increase from 1999 over a period of 11 years. Interventional pain management is one of the fastest growing specialties with a footprint in multiple disciplines. Interventional pain management in ASC settings has come a long way since June 1998 proposed Health Care Financing Administration’s ASC rule which seriously compromised interventional pain management in the ASC setting. There are many payment challenges facing interventional pain management (IPM) in 2012. Significant changes continue to occur in the payment systems with policies of paying a certain percent of hospital outpatient department payments to ASCs which declined from 63% in 2008 to 56% in 2011, with substantial reductions for add-on codes. The Centers for Medicare and Medicaid Services (CMS) evaluation of IPM codes also consists of multiple misvalued codes. In conclusion, overall the future of ASCs may appear optimistic, but in the near perspective, specifically in 2012 to 2014, there will be challenging times specifically for interventional pain management centers with the regulatory environment and rapid changes taking place with or without implementation of Affordable Care Act. Key words: Outpatient prospective payment system, ambulatory surgery center payment system, Government Accountability Office, Medicare Modernization and Improvement Act, interventional techniques

MTM services within community health centers

INTRODUCTION Pharmacists are well-trained, yet often underutilized within the primary care delivery system to identify, resolve, monitor and prevent medication-related problems (MRPs). Medication therapy management (MTM) is a term which describes a broad range of services that are provided by pharmacists to optimize individual patients’ therapeutic outcomes. The MTM care process includes conducting a comprehensive patient medication assessment to identify appropriateness of drug therapy, developing and documenting a care plan to achieve patient-specific goals of therapy and performing followup evaluation to resolve drug therapy problems. When structured to allow patients, pharmacists, physicians, and other caregivers to coordinate efforts toward achieving drug therapy treatment goals, MTM services can improve clinical outcomes, improve patient medication adherence, enhance medication safety, and stabilize or reduce health expenditures. In the state of Connecticut, a network of pharmacists provides diverse clinical services in various healthcare settings. Recently, this network provided MTM services within community health centers across the state; the network and process of MTM implemented is described here.

Are Higher or Lower Medicare Rates Ahead?

Are Higher or Lower Medicare Rates Ahead?

Health Reform Was Only an Opening Act

Health Reform Was Only an Opening Act