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Premium member Presentation Transcript The Business of caring: An introduction to health care financing The Business of caringThe healthcare debate: The healthcare debatePowerPoint Presentation: Kaiser Foundation Poll October 2010How did we get to this place?: How did we get to this place? Where so many are uninsured/underinsured even when working. Where healthcare providers and agencies have increasing bad debt from non-payment for services. Where patients die because of access issues.Criticisms of the current health care delivery system: Criticisms of the current health care delivery system Quality of care is highly variable. Access is inequitable and declining. Widespread evidence of inefficiency in delivery. Financing is inefficient and uneven. Source: Commonwealth Fund report; Bending the Curve, December 2007 Innovation is Needed: Innovation is Needed “Our healthcare system is in critical condition. Each year, fewer Americans can afford it. Fewer businesses can provide it. Fewer government programs can promise it for the future generation”. Clayton Christensen 2009Our topics: Our topicstopics for Discussion: topics for Discussion H ealth care financing - the drivers for health care reform Medicaid, Medicare and other Payers The Movement to Pay for Performance P4P Financial Challenges for Hospitals and other Health Care Agencies Implications for Beginning Nurse LeadersUS Healthcare Spending: US Healthcare Spending California Healthcare Foundation 2011Other developed countries: Other developed countries California Healthcare Foundation 2011The Path we are on: The Path we are on Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (Historical data from NHE summary including share of GDP, CY 1960-2007, file nhegdp07.zip; Projected data from NHE Projections 2008-2018, Forecast summary and selected tables, file proj2008.pdf). $8,160 (2009) $13,100 (2018) $2,814 (1990) Actual ProjectedPayers in the system: Payers in the system Kaiser Healthcare Foundation 2011How costs have risen: How costs have risen California Healthcare Foundation 2011How Health Dollars are spent: How Health Dollars are spent California Healthcare Foundation – 2011 http ://www.chcf.org/publications/2011/05/health-care-costs-101Medicare basics: Medicare basics Originally introduced by John F. Kennedy but passed in 1965 during the Lyndon Johnson administration. Designed to insure coverage for those over 65. Federally administered plan Three major parts to Medicare Part A Hospitalization Part B Providers Part D Drug ProvisionMedicare in Florida: Medicare in Florida Medicare Beneficiaries 3.3 Million % of Florida Population 17.8% 46% of the 2.3 million patients hospitalized in Florida in 2011 were covered by Medicare. *** Florida has the 2 nd highest Medicare Population so any change in Medicare reimbursement will have significant ramifications particularly in South Florida. Florida Hospital Association Date 2011Grow anticipated in Medicare: Source: IFTF; U.S. Census Bureau Chapter 2 Grow anticipated in MedicareMedicare Challenges: Medicare Challenges Single Most Critical Healthcare Issue Probably OK until 2016 By 2030 the Tax Burden could be as high as 24% By 2030 - there will be 2 workers per 1 Medicare Recipient There are plans to cut Medicare payments to both hospitals and providers in 2012. If cuts in Medicare occur – access to care could be an issue for Medicare Patients,Medicaid: Medicaid Grew out of Medicare debate Provided for care of indigent population – designed as a safety net for the disabled, low income, children. Joint program with funding from the State and Federal Government - Controlled by states Vast differences in how Medicaid is managed across all state and how is eligible. Provider and hospital payments under Medicaid have not always even covered costs. Access to Care is a major issue for Medicaid patients.Medicaid in Florida: Medicaid in Florida There are now 2.9 Million Floridians covered by Medicaid with the eligibility increasing by the year because of poverty. 16.9% of the 2.3 Million Patients in Florida who were hospitalized were Medicaid funded. Steep cuts in the Medicaid budget in Florida are proposed to fund an increase to education. The biggest impact would be on the care of children. 2 Billion dollars in reduced funded are proposed to hospitals. Florida will give up matching funds for any cuts made. Florida Hospital Association Date 2011So what would that mean: So what would that mean Jackson, the hospital with the largest Medicaid population in Florida, would lose $133.5 million, according to the Safety Net Hospital Alliance of Florida, a lobbying group for 15 of the state’s largest hospitals . All Children’s would lose $39 million and Tampa General would lose $32.5 million. Miami Children’s Hospital would lose $34 million . After Jackson, the biggest overall loser would be Shands Gainesville at $52 million. http :// www.miamiherald.com/2011/12/08/2537974/scott-aides-defend-medicaid-cuts.html#storylink=cpyHospitals must give emergency care: Hospitals must give emergency care History of EMTALA: History of EMTALA Passed by Congress in 1986 (Emergency Treatment & Liability Act) “Anti-Dumping Law” Required all hospitals that participate in Medicare to provide a medical screening exam to anyone who comes to the ER regardless of ability to pay. If the patient has a medical treatment requiring treatment – the hospital must stabilize the condition or facilitate transfer to a hospital capable of providing treatment. In 1988 Florida passed legislation creating a cause for civil action against a hospital or staff person who violates EMTALA.Pay for performance: Pay for performance A dramatic change in reimbursementThe Movement toward Pay for Performance: The Movement toward Pay for Performance What is Pay for Performance P4P? Initiated by the Center for Medicare and Medicaid Provides Financial incentives and Penalties – top 10% get 2% more in reimbursement – lower 10% lose money. Predefines performance targets – in terms of efficiency, productivity, QUALITY Targets hospitals, providers and health agenciesWhy P4P?: 26 Why P4P? Quality problems – Insurance has historically paid for errors. Escalating costs – business case for quality Managed care not a silver bulletCore Measure examples: Core Measure examples AMI: aspirin at arrival AMI: thrombolytic within 30 minutes of arrival AMI: percutaneous coronary intervention within 120 minutes of arrival Heart failure: smoking cessation counseling provided Hip and knee replacement: prophylactic antibiotic within one hour prior to surgical incision Number of measures evaluated for P4P continues to expand – many are nursing sensitive.Never events: Never events Beginning in October 2008 - Medicare stopped paying for the costs incurred with eight specific conditions that could generally be avoided if the hospital followed proven preventive procedures or common-sense precautions. Many of these conditions are directly related to the quality of nursing care – i.e. Nursing SensitiveEight original events: Eight original events air embolism objects left in the body after surgery bed sores falls wrong surgery catheter associated infections (either urinary or vascular) transfusion reactions from being given the wrong blood type hospital acquired infectionsAdditions to the list 2011: Additions to the list 2011 Wrong site surgery (existing ) Wrong implant/prosthesis (new) Retained foreign object post-operation (existing) Wrongly prepared high-risk injectable medication (new) Maladministration of potassium-containing solutions (modified) Wrong route administration of chemotherapy (existing) Wrong route administration of oral/enteral treatment (new) Intravenous administration of epidural medication (new) Maladministration of Insulin (new) Overdose of midazolam during conscious sedation (new) Opioid overdose of an opioid-naïve patient (new ) Inappropriate administration of daily oral methotrexate (new) Suicide using non-collapsible rails (existing) Escape of a transferred prisoner (existing) Falls from unrestricted windows (new) Entrapment in bedrails (new) Transfusion of ABO-incompatible blood components (new) Transplantation of ABO or HLA-incompatible Organs (new) Misplaced naso- or oro-gastric tubes (modified) Wrong gas administered (new) Failure to monitor and respond to oxygen saturation (new) Air embolism (new) Misidentification of patients (new) Severe scalding of patients (new) Maternal death due to post partum haemorrhage after elective Caesarean section (modified)Other indicators Impacting reimbursement: Other indicators Impacting reimbursement HCAHPS: Patients' Perspectives of Care Survey Publicly reported on Hospital Compare Care Administered to patients 48 hours to 6 weeks after discharge. The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay. The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012.HCAHPS Public Reporting: HCAHPS Public Reporting On Hospital Compare Care Website Sample Questions How often did nurses treat you with courtesy? How often did nurses listen to you with respect? How often did nurses explain things in a way that you understood? During this hospital stay, after you pressed the call button, how often did you get help when you wanted it? How often did you get help to the bathroom or in using a bedpan as soon as you wanted it? How often was your pain well controlled? How often did the hospital staff do everything they could to help you with your pain? Rate this hospital on a scale of 1-10. Would you recommend this hospital to friends and family?Penalty for Readmissions under the Affordable care act: Penalty for Readmissions under the Affordable care act Hospitals and Providers could be penalized for patients who are readmitted within 30 days beginning October 2012. Initially the focus will be on patients with these Diagnoses: • Heart Failure • Acute Myocardial Infarction • Pneumonia Followed by in the future focusing on: • Chronic Obstructive Lung Disease • Coronary Bypass Grafting • Percutaneous Coronary Interventions • Vascular ProceduresImpact of Reimbursement on hospitals and providers: Impact of Reimbursement on hospitals and providersMajor Economic Pressures impacting Hospitals and providers Today: Major Economic Pressures impacting Hospitals and providers Today Pay for Performance Initiatives Workforce Shortages Costs of New Technology Costs and Unavailabilityof Pharmaceuticals Professional Liability Insurance for Hospitals and Physicians Increasing numbers of uninsured and underinsured patients. Losses in the treatment of Medicare & Medicaid Patients Focus on Patient Safety and regulation to increase quality and safety – often unfunded mandatesChallenges: Challenges What will happen with healthcare reform? Healthcare Workforce Shortages could reach crisis levels by 2020. Rapidly aging population Rising obesity in the population Pharmaceutical Industry is unregulated & Costs of Drugs continue to increase Inadequate Preventative Care Medicare & Medicaid Systems will run out of money in 2019.Challenges for Nursing Leaders: Challenges for Nursing Leaders The single largest healthcare expenditure for most agencies today is on personnel. The Nursing Budget is often 60-80% of the entire hospital staffing budget. Declining reimbursement and revenues is leading to increasing pressure to control labor costs. Nurses are very involved with monitoring all of the measures. The Quality of Care versus Cost issues are competing demands for today’s nursing leaders.Key Points : Key Points Nurse leaders are the voice of the patient at the budget table. Healthcare is a business that all nurses need to understand to help their organizations make the best decisions for patient care. Healthcare reimbursement will continue to be challenging and more care will move to community-based settings to save money. Healthcare Reform will bring new opportunities for nurses and new roles.My Contact Information: My Contact Information Rose O. Sherman, EdD, RN, NEA-BC, FAAN Emerging Leader Practicum Supervisor Associate Professor/Director, Nursing Leadership Institute (561) 297-0055 E-Mail firstname.lastname@example.org Read my Blog www.emergingrnleader.com You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.