how do the prospective payment systems impact operations?10 marca 2023
Final Report. Fee-for-service has traditionally focused on reactive care and the result is that the USA is not a leader in chronic care management for diseases like diabetes and asthma. While PPS affected utilization of Medicare hospital, SNF And HHA care, systematic adverse effects of the policy on Medicare beneficiaries were not apparent. *** Defined as 100 percent chance of occurrence under competing risk adjustment methodology.# Chi-square = 8.80d.f. This finding suggests that in spite of the financial incentives, hospitals were unable to reduce LOS for certain types of patients. Table 8 presents the patterns of Medicare Part A service use by the "Mildly Disabled" group, which was characterized by relatively minor chronic problems such as arthritis and by 67 percent of the group specifying that their health status was good to excellent. Because of the large number of combinations of service use experienced by Medicare beneficiaries in a one-year period, it would be practical only to analyze a very limited number of different patterns if we used beneficiaries as the units of observation. Conventional fee-for-service payment systems, in contrast, may create an incentive to add unneeded treatments and therefore expend valuable resources unnecessarily. The study found that quality of care actually improved after PPS for three of the patient groups (AMI, CVA, and CHF), and did not change significantly for the other two (pneumonia, hip fracture). The next four tables highlight the Medicare service use patterns of each of the four GOM subgroups. Mortality was evaluated in a fixed 30-day interval from admission. Doing so ensures that they receive funds for the services rendered. Specific documentation supports coding and reporting of Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ). Patients hospitalized or institutionalized at the time of fracture, with a history of a previous hip fracture, or with a neoplasm as a known or suspected cause were excluded from the study. In contrast to post-acute SNF care, there was a distinct increase in the use of home health services that followed hospital discharges as well as Medicare SNF discharges. Statistically significant differences (p = .05) between 1982 and 1984 were detected in the hospital, length of stay for this group. Although our study focused on chronically disabled persons in the total elderly population, it is important to view the service use and mortality of this subgroup in the context of all major components of the total Medicare population. A federal program that assigns fixed payments for services rendered to patients covered by Medicare, with adjustments based on diagnosis code and other factors. Further research on the community services, nursing home use and other periods of care would be necessary to develop a complete picture of the effects of PPS on impaired Medicare beneficiaries. In order to differentiate among the individuals comprising the disabled noninstitutionalized Medicare population, we identified subgroups with Grade of Membership techniques. Hence, the research file contained detailed patient characteristics information for two points in time, straddling the implementation of PPS, and complete Medicare Part A hospital, SNF and home health utilization and mortality information. The data set that we assembled for this study provided a basis for addressing analytical dimensions that are not generally available on billing records and hospital discharge abstracts alone (Iezzoni, 1986). Additionally, prospective payment systems simplify administrative tasks such as claims processing, resulting in faster reimbursement times. To select a subset of the search results, click "Selective Export" button and make a selection of the items you want to export. As such, they can be used as linear weights to reproduce the observed attributes of each person as a composite of parts of the attributes associated with each of the K analytically determined profiles. Gauging the effects of PPS proved to be challenging. Table 1 also shows that for all three populations increases occurred in the use of HHA services after hospital discharge, with declines in the time spent in hospitals prior to HHA admission. We measured changes in hospital use, and use of post-acute SNF and HHA services, hospital readmissions and mortality during and after hospital stays. In the GOM procedure, a person may be described by more than one continuously varying case-mix dimension. Some common characteristics of Medicare PPS are: Medicare Hospital Outpatient PPS (OPPS) is not a "pure" PPS methodology consistent within the characteristics listed above because payment is made for individual evaluation and treatment visits. In addition to employing the GOM subgroups to adjust for overall utilization changes before and after PPS, we examined differences in the effects of PPS on the specific subgroups among the disabled elderly population. This suggests a reduction in hospital readmission from SNFs since most SNF stays are preceded by hospital stays. The characteristics of individuals entering hospitals differed between the pre- and post-PPS periods. Thus the GOM defined groups are distinctly different subgroups of the disabled elderly population, ranging from persons with mild disability to severely disabled individuals. Continuous Medicare Part A bills permitted a tracking of persons in the NLTCS samples through different parts of the health care system (i.e., Medicare hospital, SNF and HHA) so that we could examine transitions from acute care hospitals to subsequent experience in Medicare SNF or HHA services. formats are available for download. Jossey-Bass, pp.309-346. .gov Additionally, prospective payment plans have helped to drive a greater emphasis on quality and efficiency in healthcare provision, resulting in better outcomes for patients. This type is also prone to hip and other fractures; the relative risks of hip fracture in this group, for example, is three times greater than the average disabled person. Not surprisingly, the expected number of days before readmission were also similar--194 days versus 199 days. One issue is that it does not always accurately reflect the actual cost of care for a patient episode; this may cause providers to incur losses if their costs exceed what is reimbursed. Because of the potential heterogeneity of situations represented by the "other" episodes, pre-post PPS changes in this type of episode must be interpreted with caution. As with the total cases, we found a slightly different pattern of risk of readmission when we focused on time intervals shortly after admission (i.e., 30 days, 90 days). This study examined hospitalization rates and hospital lengths of stay and location of death of the Medicaid patients. In light of the potential effects of Medicare PPS on the utilization, costs and quality of care for Medicare beneficiaries, assessments of the effects of the new reimbursement policy have been of interest to the Administration and Congressional policy makers. In a comparison of the pre- and post-PPS periods, the proportion of persons with hospital admissions who eventually died in the 12-month period remained about the same--12.1% in 1982-83 and 12.5% in 1984-85. However, more Medicare patients were discharged from hospitals in unstable condition after PPS was implemented. For example, while LOS declined for persons with mild disabilities, they remained the same for those with medically acute conditions. Table 4 presents the patterns of Medicare hospital events for the two time periods, after adjusting for the events for which the discharge outcome was not known because of end-of-study. Krakauer found that while hospital admission rates continued to decline during the study period, 1983-85, there was not a significant increase in the incidence of readmissions. In addition, HHA use without prior hospital stay increased from 13.6% to 21.5%. The second component is a grade or weight for each person representing how much each person is described by the characteristics associated with a given case-mix dimension. There also appears to be a change in the hospital stays that resulted in admissions to SNFs, although this difference was significant at a .10 level. Table 15 presents the mortality patterns of hospital episodes stratified by use of Medicare SNF, Medicare home health and no post-acute Medicare services. Analyses of the characteristics of hospital admissions suggested that approximately half of the increase in post-hospital mortality was accounted for by an increase in the proportion of admissions for conditions associated with higher mortality risks. The payment amount is based on a unique assessment classification of each patient. These scores describe how close the observed attributes of individual cases are to the profile of attributes (i.e., the pattern of 's) for each of the K case-mix dimensions. You do not have JavaScript Enabled on this browser. This group had a longer expected period of time before hospital readmission (176 vs. 189 days) and had lower risks of readmission within the first 30 and first 45 days after the initiating hospital stay. Type I would appear to be the least vulnerable to inappropriate outcomes of hospital admissions--principally because of their overall good health. Sager and his colleagues also found that while mortality rates for Wisconsin's elderly population showed minimal variation during the study period (51.1/1000 in 1982 to 53.0/1000 in 1980) between 1982 and 1985, there was an increase of 26 percent in the rate of deaths occurring in nursing homes. Non-Prospective Payments, also called Retrospective payments, is a reimbursement method that pays providers on actual charges (Prospective Payment Plan vs. Retrospective Payment Plan, 2016). Medicares prospective payment system (PPS) did not lead to significant declines in the quality of hospital care. Life Table Analysis. DesHarnais, S., E. Kobrinski, J. Chesney, et al. Type II, the Oldest-Old, with hip fractures, for example, would be expected to require post-acute care for rehabilitation. Different from PPS effects on SNF use, the study found an increase in hospital episodes resulting in the use of HHA services (12.6% to 15.6%). One prospective payment system example is the Medicare prospective payment system. In summary, we did not find statistically significant changes in mortality patterns after hospital admissions (i.e., in hospital and after discharge to some other location). The data sources for this study were the 1982 and 1984 National Long-Term Care Surveys (NLTCS) of disabled elderly Medicare beneficiaries, and their Medicare Part A bills and Medicare records on mortality. Results of declining overed days of SNF care are consistent with HCFA statistics (Hall and Sangl, 1987). The only negative post-PPS change was an increase in the number of patients discharged in unstable condition. The goal is to provide quality patient care that engages patients, and strives for faster diagnosis and treatment, shorter hospital stays, and lower costs. Across all of these measures, mortality declined for all five patient groups. Hence, while hospital LOS has been noted to decrease with PPS, questions still remained about whether the observed declines were due to hospital behavior or to case-mix changes. Lastly, by creating a predictable prospective payment plan structure with standardized criteria, PPS in healthcare helps providers manage their finances while also helping to ensure patients receive similar quality care. In fact, only those SNF cases that resulted in discharges to episodes with no further Medicare services were marginally significant (p =.10). The amount of items that can be exported at once is similarly restricted as the full export. First, it is important to determine what types of services are included in the PPS model to ensure accurate reimbursement levels. The differences, including sources and types of data and methodological strategies, provide complementary results in most cases in describing the effects of PPS on Medicare service use and outcomes. The new system for prospective payment of Medicare pa-tients provided that most hospitals in the United States would be reimbursed a fixed fee for each Medicare patient. By termination status of SNF episodes, there was a reduction in discharge from SNFs to hospitals from 30.6 percent in the pre-PPS period to 18.0 percent in the post-PPS period. However, the increase in six month institutionalization rates suggested that the patients entering nursing homes at discharge were not subsequently regaining the skills needed for independent living. Section E addresses mortality patterns after hospital admission, including deaths in post-acute care settings after hospital discharge. In-hospital mortality rates for Medicare patients declined slightly in 1984 although the decline was not statistically significant. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. The Grade of Membership analysis of the period 1982-83 and 1984-85 NLTCS data produced four relatively homogeneous subgroups. This analysis focused on hospital admissions and outcomes of these admissions in terms of hospital readmissions. 11622 El Camino Real, Suite 100 San Diego, CA 92130. Other researchers, in contrast, addressed the PPS assessment issues using trend analysis strategies (DesHarnais, et al., 1987). Prepayment amounts cover defined periods (per diem, per stay, or 60-day episodes). Hence, a post-hospital SNF stay, if it started several days after a hospital discharge, would not be recorded as the disposition of the hospital episode. programs offered at an independent public policy research organizationthe RAND Corporation. That is, some hospital admissions result in death in the hospital; these cases would not be eligible for hospital readmission. Severity of principal disease, number of high risk comorbidities, age and sex formed the basis of the classification system. Prospective payment systems are intended to motivate providers to deliver patient care effectively, efficiently and without over utilization of services.The concept has its roots in the 1960s with the birth of health maintenance organizations (HMOs). In examining the length of time and percent of cases that terminate in a particular way we see that the nondisabled community elderly and the institutionalized elderly have slight increases in hospital episodes ending in death with the community disabled experiencing virtually no change. The implementation of a prospective, fixed rate payment system for hospitals under Medicare created both a perception that hospital efficiency could be improved and concern that incentives for efficiency could result in adverse consequences for Medicare beneficiaries. Because the exact dates of service were available from the Medicare Part A bills, it was possible to define periods of Medicare hospital, SNF and HHA service use as well as periods when such services were not used. Fifty-six (56) medical conditions, ADLs and IADLs were used in this analysis. Draper, David, William H. Rogers, Katherine L. Kahn, Emmett B. Keeler, Ellen R. Harrison, Marjorie J. Sherwood, Maureen F. Carney, Jacqueline Kosecoff, Harry Savitt, Harris Montgomery Allen, Lisa V. Rubenstein, Robert H. Brook, Carol P. Roth, Carole Chew, Stanley S. Bentow, and Caren Kamberg, Effects of Medicare's Prospective Payment System on the Quality of Hospital Care. Subgroups of the Population. Prospective payment plans assign a fixed payment rate to specific treatments based on predetermined factors. Instead of receiving a monthly premium to cover the whole family, the health care facility receives a single payment for a single Medicare beneficiary to cover a defined period of time or the entire inpatient stay. Appendix A discusses the technical details of GOM analyses. Subgroup Patterns of Hospital, SNF and HHA. It allows the provider and payer to negotiate and agree upon a prospective payment plan, with fixed payments for services rendered before care is provided. In this study, hospital readmission and mortality were viewed as indicators of quality of care. Table 3 shows a shift in the proportion of cases by service episodes of each of the four types between 1982 and 1984. For example, for hospital episodes there was a large decline in the "Severely ADL Dependent" (i.e., from 20.3% to 16.9%) but increases in the "Oldest-Old" and "Heart and Lung" suggesting an increase in the medical acuity of the population with a significant reduction in seriously impaired persons with less medical acuity. For these samples, Medicare Part A bills on hospital, skilled nursing facility (SNF) and home health service (HHA) use were obtained from the Health Care Financing Administration (HCFA). and R.L. Integrating these systems has numerous benefits for both healthcare providers and patients seeking to optimize their operations and provide the best possible service to their patients. The changes in nursing home death rates, which began in 1982, were also associated with a 10.3 percent decline in hospital deaths during the same period. Providers must make sure that their billing practices comply with the new rates as well as all applicable regulations. It is likely that this general finding is applicable to the subgroup of disabled beneficiaries. The first part presents a general context of mortality and Medicare service use of the various subgroups of the total Medicare beneficiary population based on the total population screened for the NLTCS. The patients studied were those aged 65 years or older with a new fracture. 1982. Overall, our analysis indicated no system-wide changes in hospital readmission risks between the pre- and post-PPS periods for hospital episodes. Similarly, relatively little information currently exists on the status of patients discharged from hospitals in terms of their health status and use of community based recuperative and rehabilitative care. When a system underperforms, stepping back and re-thinking processes can have a dramatic impact. The principal outcome of interest was mortality: short-term mortality, including in-hospital mortality and deaths within 30 days of acute-care admission, and medium-term mortality, measured by looking at deaths within 180 days of admission. This distribution across time periods allowed before-and-after comparisons among patient groups. The mortality increases that do exist are of the magnitude that could be caused by year to year changes in national mortality patterns found in Figure 1. For initial hospitalizations followed by SNF use, the risks of readmission to a hospital increased from 7.3 percent to 9.2 percent for the 0-30 days interval and from 31 percent to 33.2 percent for the 0-90 day interval. The initiating admission could be any hospital admission. There were indications of service substitution between hospital care and SNF and HHA care. Share sensitive information only on official, secure websites. In both the service use and the outcome analyses, we conducted analyses where we stratified the NLTCS samples by relatively homogeneous subgroups of the disabled population. HOW MANY DAYS DO THEY HELP PER WEEK TOGETHER? For these cases, non-Medicare nursing home and other post-acute services might have been received, although we are not able to make that distinction. In an analysis similar to that for hospital readmissions, we examined the timing of death after hospital admission. Explain the classification systems used with prospective payments. Finally, the life table contains functional relationships that provide rich descriptions of the patterns that are fundamentally important to this analysis. As noted in the figure, the number of such patients increased by 3 percentage points (a 22-percent rise). Hence, our decision rule probably produced lower rates of post-acute Medicare SNF and HHA utilization rates. In 1985, the corresponding rates were 6.8 percent and 21.2 percent. Results of our study provided further insights on the effects of PPS on utilization patterns and mortality outcomes in the two periods of time. GOM analysis is a multivariate technique that combines two types of analyses usually performed separately (Woodbury and Manton, 1982). Demographically, 50 percent are over 85 years of age, 70 percent are not married and 70 percent are female. With the population subgroups, we could determine whether any change in overall utilization changes between pre- and post-PPS periods remained after adjustments were made to account for case-mix effects. Each option comes with its own set of benefits and drawbacks. First, we examined the proportion of hospital admissions that resulted in readmissions during the one year windows of observation. In addition to the analysis of the total sample of Medicare hospital patients, Krakauer examined changes in the outcome of nine tracer conditions and procedures. The system tries to make these payments as accurate as possible, since they are designed to be fixed. Dittus. In comparing the proportion of hospital readmissions for the one-year windows between the pre-PPS and post-PPS periods, Table 13 shows a small decline in readmissions among the hospital episodes that were followed by SNF care (36% vs. 33.9%), similar proportions when HHA were used after hospitalization and a small decline for the cases involving no post-acute care. and S. Harrison. A multivariate clustering methodology was employed to identify relatively homogeneous subgroups of disabled Medicare beneficiaries so that utilization changes could be compared for medically and functionally similar cases as well as for the total disabled population. ( The broad focus of prospective payment system PPS on patient care contrast favorably to the interval care more prevalent in other long-established payment methods. Table 1 shows that nondisabled, noninstitutionalized persons had shorter hospital stays than either the community disabled or the institutionalized. In this way they are distinct from DRGs, for example, which differentiate the acute care requirements of persons being admitted to hospitals. In addition, the researchers found that an observed 8.7 percent decrease in Medicare hospital admission rates between the two years was primarily caused by a decline in the hospitalization of low severity patients. Read also Is anxiety curable in homeopathy? Subscribe to the weekly Policy Currents newsletter to receive updates on the issues that matter most.