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2.
Am J Kidney Dis ; 62(6): 1042-5, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24051080

RESUMO

The major principles that drive U.S. federal health policy-making are: (1) fixed or reduced costs, (2) ensured outcomes (or no evidence of undertreatment), (3) streamlined administration, and (4) political viability. A corollary is that providers are uniquely sensitive to financial incentives. Understanding these principles is vital to understanding federal health policy. Critically, these principles are nonpartisan and have been supported and used by all administrations since President Reagan. This article examines the end-stage renal disease (ESRD) prospective payment system, colloquially called "The Bundle," in the context of these major principles. Successful health policy, successful legislation, and successful regulation building all require executive leadership, mutual trust, and compromise. This is demonstrated by the events surrounding the passage of the Medicare inpatient prospective payment system, which governs hospital reimbursement for Medicare beneficiaries, including those not covered in the ESRD program. Given that the ESRD benefit consumes 6.3% of the Medicare budget for approximately 2% of Medicare beneficiaries, if nephrology is to experience future success, we must change how both policymakers and the wider field of medicine perceive our specialty. Understanding the major principles behind health care policy may facilitate this goal.


Assuntos
Atitude do Pessoal de Saúde , Governo Federal , Política de Saúde/legislação & jurisprudência , Falência Renal Crônica/terapia , Nefrologia , Formulação de Políticas , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Adulto , Idoso , Orçamentos/legislação & jurisprudência , Controle de Custos/legislação & jurisprudência , Feminino , Custos de Cuidados de Saúde/legislação & jurisprudência , Política de Saúde/economia , Preços Hospitalares/legislação & jurisprudência , Humanos , Cobertura do Seguro/economia , Cobertura do Seguro/legislação & jurisprudência , Falência Renal Crônica/economia , Masculino , Medicare/economia , Medicare/legislação & jurisprudência , Pessoa de Meia-Idade , Política , Sistema de Pagamento Prospectivo/economia , Previdência Social/economia , Previdência Social/legislação & jurisprudência , Tax Equity and Fiscal Responsibility Act/economia , Tax Equity and Fiscal Responsibility Act/legislação & jurisprudência , Estados Unidos
3.
Intellect Dev Disabil ; 50(3): 181-9, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22731967

RESUMO

We provide the first descriptive summary of selected programs developed to help expand the scope of coverage, mitigate family financial hardship, and provide health and support services that children with intellectual and developmental disabilities need to maximize their functional status and quality of life. State financing initiatives were identified through interviews with family advocacy, Title V, and Medicaid organizational representatives. Results showed that states use myriad strategies to pay for care and maximize supports, including benefits counseling, consumer- and family-directed care, flexible funding, mandated benefits, Medicaid buy-in programs, and Tax Equity and Fiscal Responsibility Act of 1982 funding. Although health reform may reduce variation among states, its impact on families of children with intellectual and developmental disabilities is not yet clear. As health reform is implemented, state strategies to ameliorate financial hardship among families of children with intellectual and developmental disabilities show promise for immediate use. However, further analysis and evaluation are required to understand their impact on family and child well-being.


Assuntos
Deficiências do Desenvolvimento/economia , Deficiência Intelectual/economia , Assistência Médica/economia , Governo Estadual , Criança , Assistência à Saúde/economia , Assistência à Saúde/organização & administração , Reforma dos Serviços de Saúde/economia , Reforma dos Serviços de Saúde/organização & administração , Humanos , Medicaid/economia , Medicaid/organização & administração , Assistência Médica/organização & administração , Política Pública , Tax Equity and Fiscal Responsibility Act/economia , Tax Equity and Fiscal Responsibility Act/organização & administração , Estados Unidos
4.
Am J Law Med ; 37(1): 81-127, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21614996

RESUMO

Children with significant disabilities may qualify for Medicaid benefits, regardless of household income, if their state elects to offer the Tax Equity Fiscal Responsibility Act (TEFRA) option. However, a significant number of children with serious medical problems presently are being denied eligibility for, or terminated from, this Medicaid program. This Article describes the ways in which the existing health insurance system inadequately meets the needs of children with significant disabilities, recounts the history and development of the TEFRA Medicaid coverage option, and analyzes the eligibility criteria used by the various states. It proceeds to consider how disability should be legally defined in the health care context and proposes reforms to modernize the eligibility standards so that these benefits can be more effectively, efficiently, and fairly allocated. To accomplish this goal, the federal statute and regulation that define disability, as well as corresponding state laws, must be reformed so that the law can keep pace with advances in modern medical science, and people with disabilities are not, in effect, penalized for receiving currently accepted preventative care that maintains health but will never cure the underlying disease.


Assuntos
Crianças com Deficiência/legislação & jurisprudência , Definição da Elegibilidade/legislação & jurisprudência , Medicaid/legislação & jurisprudência , Criança , Reforma dos Serviços de Saúde , Humanos , Deficiência Intelectual , Instituições para Cuidados Intermediários , Transtornos Mentais , Governo Estadual , Tax Equity and Fiscal Responsibility Act/legislação & jurisprudência , Estados Unidos
5.
Arch Phys Med Rehabil ; 89(11): 2066-79, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18996234

RESUMO

OBJECTIVES: Describe the supply of inpatient rehabilitation facilities (IRFs) services in 1996 and examine changes between 1996 and 2004, including the impact of the IRF prospective payment system (PPS) in 2002 on organizational trends. DESIGN: Retrospective pre-post design. SETTING: Freestanding and subprovider (distinct-part units) IRFs. PARTICIPANTS: IRFs (N=1424), including 257 freestanding IRFs and 1167 IRF units reported in the Healthcare Cost Report Information System database, from years 1996 to 2004. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of IRF openings, IRF closures, beds, and inpatient days. RESULTS: The number of IRFs grew from 1037 to 1183 between 1996 and 2001 and grew to 1235 between 2001 and 2004. The likelihood of IRF closures trended lower after PPS, and there was a significant increase in the likelihood of openings when PPS was introduced. For-profit, rural, and small IRFs were more likely to open over the entire period. There was a 12.9% increase in the number of total inpatient days, somewhat less than the 15.7% growth in IRF beds over the period. There was no impact of PPS on beds available but a significant decline in total inpatient days after PPS. CONCLUSIONS: Inpatient days rose under the Tax Equity and Fiscal Responsibility Act and declined after 2002. Yet the likelihood of openings and closures did not appear to respond to these changes, perhaps because they were modest compared with changes in local IRF markets. The IRF PPS did little to affect service distribution in less well-served areas, although we did find growth in rural areas. Occupancy rates in 2004 were close to rates at the start of the period (70%). This observation implies that IRFs were implementing strategies to recruit a sufficient number of patients, even though bed numbers were increasing and length of stay was declining. Consequently, policy that limits the potential of IRFs to increase patient admissions, such as the limits on admissions to IRFs of patients with conditions other than those included in the 75% rule, is likely to produce substantial decreases in total inpatient days.


Assuntos
Política de Saúde , Acesso aos Serviços de Saúde , Sistema de Pagamento Prospectivo , Centros de Reabilitação/provisão & distribução , Centros de Reabilitação/estatística & dados numéricos , Idoso , Estudos Transversais , Fechamento de Instituições de Saúde , Tamanho das Instituições de Saúde , Humanos , Tempo de Internação , Medicare/economia , Medicare/legislação & jurisprudência , Análise de Regressão , Centros de Reabilitação/economia , Centros de Reabilitação/tendências , Estudos Retrospectivos , Tax Equity and Fiscal Responsibility Act , Estados Unidos
6.
J Health Care Finance ; 33(2): 70-83, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-19175241

RESUMO

Implemented in 1986, Medicare's disproportionate share (DSH) adjustment is intended to recognize hospitals' additional resource investment in caring for low-income patients. This project analyzed changes in the DSH percentage between 1996 and 2003 and examined the association between selected hospital characteristics and such changes. Results obtained revealed some interesting findings. First, minimal changes in DSH percentage occurred during the period 1996-1999 with a hike in that ratio in 2000-2001. However, even with the absence of any legislative or executive changes to the DSH threshold or formula during 2002 and 2003, significant increases occurred during 2001-2003 (11 percent increase between 2001 and 2003). Such an increase may be caused by the nation's economic situation during that timeframe (i.e., more people depending on public programs for coverage).


Assuntos
Administração Financeira de Hospitais/tendências , Medicaid/tendências , Medicare Part A/tendências , Discrepância de GDH/economia , Discrepância de GDH/estatística & dados numéricos , Sistema de Pagamento Prospectivo/tendências , Cuidados de Saúde não Remunerados/estatística & dados numéricos , Idoso , Área Programática de Saúde/economia , Área Programática de Saúde/estatística & dados numéricos , Definição da Elegibilidade , Administração Financeira de Hospitais/estatística & dados numéricos , Acesso aos Serviços de Saúde/economia , Hospitais Privados/economia , Hospitais Privados/estatística & dados numéricos , Hospitais com Fins Lucrativos/economia , Hospitais com Fins Lucrativos/estatística & dados numéricos , Hospitais Públicos/economia , Hospitais Públicos/estatística & dados numéricos , Humanos , Medicaid/estatística & dados numéricos , Medicare Part A/estatística & dados numéricos , Análise Multivariada , Pobreza/estatística & dados numéricos , Tax Equity and Fiscal Responsibility Act , Cuidados de Saúde não Remunerados/economia , Estados Unidos
7.
J Behav Health Serv Res ; 31(3): 334-42, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15263871

RESUMO

The Tax Equity and Fiscal Responsibility Act (TEFRA) Medicaid Eligibility Option, also known as the Katie Beckett Option, was developed to allow children with disabilities from near-poor and middle-income families to qualify for Medicaid. TEFRA has been available since 1982; however, little is known about the number of children served and their qualifying disability. This first national study found that 20 states enrolled nearly 25,000 children in 2001. Only 10 of these states allowed children to qualify because of a mental health disability. Additional research is needed to understand the role of TEFRA in providing insurance to children with disabilities.


Assuntos
Crianças com Deficiência , Definição da Elegibilidade/legislação & jurisprudência , Medicaid/legislação & jurisprudência , Tax Equity and Fiscal Responsibility Act/legislação & jurisprudência , Adolescente , Criança , Pré-Escolar , Coleta de Dados , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Estados Unidos
8.
Mod Healthc ; 33(39): 6-7, 25-8, 1, 2003 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-14571566

RESUMO

In October 1983, Medicare launched a new payment system that would no longer write hospitals a blank check. It was called the prospective payment system and became known simply as the PPS. With its 20-year anniversary looming, the program's fundamental strengths and weaknesses have become apparent. Although some say it's vulnerable to politics, most agree it has imposed order on hospital finances.


Assuntos
Economia Hospitalar/tendências , Medicare Part A/legislação & jurisprudência , Sistema de Pagamento Prospectivo/legislação & jurisprudência , Idoso , Controle de Custos/legislação & jurisprudência , Grupos Diagnósticos Relacionados/economia , Economia Hospitalar/legislação & jurisprudência , Reforma dos Serviços de Saúde , Custos Hospitalares , Humanos , Inovação Organizacional , Garantia da Qualidade dos Cuidados de Saúde/economia , Tax Equity and Fiscal Responsibility Act , Estados Unidos
13.
Arch Phys Med Rehabil ; 81(6): 715-9, 2000 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-10857511

RESUMO

OBJECTIVE: To determine if Medicare's payment system for rehabilitation hospitals encourages discharges to skilled nursing facilities (SNFs). Medicare payments to hospitals are based on limits derived from a hospital's average allowable patient charge during a base year. Thereafter, payments are capped, but hospitals receive additional incentive payments if succeeding costs are reduced. It was a hypothesis of this study that discharges to SNFs would increase after the base year. In this way, rehabilitation hospitals would limit high-cost patients when under reimbursement limitation. METHODS: Medicare claims data for 162,239 discharges from 69 rehabilitation hospitals between 1987 and 1994 were analyzed. After controlling for patient and provider characteristics, we compared the odds of being discharged to a SNF before, during, and after the base year. RESULTS: Before and during the base year, 4.7% and 6.6% of patients were discharged to a SNF. After the base year, 9% of patients were sent to a SNF. After controlling for temporal and seasonal trends, as well as for patient and provider characteristics, those discharged after the base year were significantly more likely to be sent to a SNF than those discharged during the base year. These odds increased with increasing length of stay in the rehabilitation hospital. For those with a length of stay of 29 days (75th percentile) the odds increased by 11% (odds ratio, 1.11; 95% confidence interval, 1.04-1.18). CONCLUSIONS: The incentives of Medicare's reimbursement system may encourage an increase in the percentage of patients discharged to SNFs after the base year. These findings have significant implications regarding the structure of Medicare's prospective payment system currently planned for this class of hospital.


Assuntos
Medicare , Alta do Paciente/economia , Centros de Reabilitação/economia , Instituições de Cuidados Especializados de Enfermagem/economia , Tax Equity and Fiscal Responsibility Act , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Centros de Reabilitação/estatística & dados numéricos , Reembolso de Incentivo/economia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Estados Unidos
14.
Gen Hosp Psychiatry ; 22(1): 11-6, 2000.
Artigo em Inglês | MEDLINE | ID: mdl-10715499

RESUMO

Since 1983, the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 has determined payment for services in most psychiatry units located in general hospitals. This system provided reimbursement on a cost-per-discharge basis. In 1997, a Balanced Budget Act (BBA) was passed by Congress which has replaced the TEFRA system of 1982 (H.R 2015). As a result of this law, many general hospital psychiatry units, particularly those that address the needs of elderly patients with high levels of medical comorbidity, will experience a reduction in their reimbursement when compared with the old TEFRA system. This reduction will average 7.8% and affect up to 84% of health care organizations. Those with higher TEFRA target amounts, such as is found with most general hospital programs, will have proportionately greater reductions. This article summarizes legislation affecting Medicare reimbursement and suggests a service reorganization approach that would allow billing to both medical and psychiatric payers. Finally, it encourages active participation in psychiatric access and quality standards development and with legislation, such as The Medicare Psychiatric Hospital Prospective Payment System Act of 1999.


Assuntos
Orçamentos/legislação & jurisprudência , Hospitais Gerais/economia , Unidade Hospitalar de Psiquiatria/economia , Tax Equity and Fiscal Responsibility Act/legislação & jurisprudência , Idoso , Controle de Custos/legislação & jurisprudência , Humanos , Medicare/legislação & jurisprudência , Mecanismo de Reembolso/legislação & jurisprudência , Estados Unidos
16.
Health Care Financ Rev ; 20(1): 73-81, 1998.
Artigo em Inglês | MEDLINE | ID: mdl-10387427

RESUMO

This article identifies factors that influence health maintenance organizations' (HMOs) decisions about offering a Medicare risk product in rural areas; describes HMOs' recent experiences serving rural Medicare risk enrollees; and assesses the potential impact of Medicare program changes on the future willingness of HMOs to offer a Medicare risk product in rural areas. Data for the analysis were collected through interviews with a national sample of 27 HMOs. The results underscore the importance of adjusted average per capita cost (AAPCC) rates in HMOs' decisions to offer Medicare risk products in rural areas, but also indicate that other factors influence these decisions.


Assuntos
Tomada de Decisões Gerenciais , Sistemas Pré-Pagos de Saúde/economia , Medicare/organização & administração , Participação no Risco Financeiro , Serviços de Saúde Rural/economia , Idoso , Capitação , Humanos , Cobertura do Seguro , Medicare/economia , Política Organizacional , Métodos de Controle de Pagamentos , Tax Equity and Fiscal Responsibility Act , Estados Unidos
17.
N Engl J Med ; 337(14): 978-85, 1997 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-9309104

RESUMO

BACKGROUND: Medicare's system for the payment of rehabilitation hospitals is based on limits derived from a hospital's average allowable charges per patient discharged during a base year. Thereafter, payments are capped but hospitals receive incentive payments if charges per patient are reduced in succeeding years. We hypothesized that per-patient charges would increase during the base year and then decrease in subsequent years. Hospitals would thus have higher reimbursement limits and receive incentive payments for reducing their charges. METHODS: We analyzed Medicare claims data for 190,921 discharges from 69 rehabilitation hospitals from 1987 through 1994. We compared total charges, length of stay, and interim payments before, during, and after each hospital's base year. RESULTS: After we controlled for inflation and temporal and seasonal trends, mean charges per patient discharged increased from $25,131 for patients discharged before the base year to $32,167 for patients discharged in the base year (a 28 percent increase, P<0.001) and the mean length of stay increased from 22.1 to 26.7 days (a 21 percent increase, P<0.001). After the base year, mean charges decreased to $29,307 (a 9 percent decrease) and the mean length of stay decreased to 24.0 days (a 10 percent decrease) (P<0.001 for both comparisons). Analysis of data on patients according to diagnosis -- for example, spinal cord injury, brain injury, stroke, amputations and deformities, hip fracture, and arthritis and joint disorders -- showed similar findings for each, with increases in charges and length of stay in the base year, followed by smaller reductions thereafter. For-profit hospitals had greater increases than nonprofit hospitals in their per-patient charges (mean increase, $7,434 vs. $2,929; P<0.001) and length of stay (mean increase, 4.6 vs. 2.3 days, P<0.001) during the base year. CONCLUSIONS: Although Medicare's reimbursement system for rehabilitation hospitals put an upper limit on total payments, its design was associated with substantial extra costs, including significantly increased payments to hospitals and doctors and increased numbers of hospital days for the average patient.


Assuntos
Preços Hospitalares/estatística & dados numéricos , Medicare/estatística & dados numéricos , Alta do Paciente/economia , Centros de Reabilitação/economia , Centros de Reabilitação/estatística & dados numéricos , Reembolso de Incentivo , Idoso , Grupos Diagnósticos Relacionados/tendências , Feminino , Pesquisa sobre Serviços de Saúde , Número de Leitos em Hospital , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Tax Equity and Fiscal Responsibility Act/economia , Estados Unidos
19.
Manag Care Interface ; 10(9): 95-6, 107, 1997 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-10175550

RESUMO

Early last month, President Clinton signed into law the historic balanced Budget Act of 1997. The Act contains many sweeping changes, including provisions that authorize provider-sponsored organizations to contract directly with the Medicare program on a risk basis.


Assuntos
Redes Comunitárias/legislação & jurisprudência , Programas de Assistência Gerenciada/legislação & jurisprudência , Medicare/legislação & jurisprudência , Orçamentos/legislação & jurisprudência , Redes Comunitárias/organização & administração , Serviços Contratados , Humanos , Licenciamento , Programas de Assistência Gerenciada/organização & administração , Medicare/organização & administração , Gestão de Riscos , Tax Equity and Fiscal Responsibility Act , Estados Unidos
20.
J Health Hum Serv Adm ; 19(4): 410-24, 1997.
Artigo em Inglês | MEDLINE | ID: mdl-10175520

RESUMO

Health providers are rapidly establishing integrated delivery systems to prepare for managed care and capitation. However, acute and primary services for the elderly continue to be reimbursed through DRGs or fee-for-service (FFS) payments. Different incentives and care patterns are described for providers caring for elderly populations and younger, capitated groups. Pilot programs to provide Medicare services to the elderly may become models or foundations for a future, capitated health system for the elderly. Existing models of elderly health care that receive capitated payments are described in this article, including Social HMOs, TEFRA HMOs. and PACE programs. The potential significance of these programs for the synchrony of operational incentives, comprehensiveness of health care, volume of institutional services, and primary care orientation is analyzed.


Assuntos
Sistemas Pré-Pagos de Saúde/economia , Serviços de Saúde para Idosos/economia , Medicare/organização & administração , Idoso , Capitação , Assistência Integral à Saúde/organização & administração , Prestação Integrada de Cuidados de Saúde , Sistemas Pré-Pagos de Saúde/organização & administração , Serviços de Saúde para Idosos/organização & administração , Humanos , Modelos Organizacionais , Projetos Piloto , Reembolso de Incentivo , Tax Equity and Fiscal Responsibility Act , Estados Unidos
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