The Emergency Medical Treatment and Active Labor Act (EMTALA) is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital emergency departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) to anyone seeking treatment for a medical condition, regardless of citizenship, legal status, or ability to pay. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when their condition requires transfer to a hospital better equipped to administer the treatment.
Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and personal care services. The main difference between the two programs is that Medicaid covers healthcare costs for people with low incomes while Medicare provides health coverage for the elderly. There are also dual health plans for people who have both Medicaid and Medicare. The Health Insurance Association of America describes Medicaid as "a government insurance program for persons of all ages whose income and resources are insufficient to pay for health care."
Medicare is a national health insurance program in the United States, begun in 1965 under the Social Security Administration (SSA) and now administered by the Centers for Medicare and Medicaid Services (CMS). It primarily provides health insurance for Americans aged 65 and older, but also for some younger people with disability status as determined by the SSA, including people with end stage renal disease and amyotrophic lateral sclerosis.
Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups, with the last group being "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management, and John D. Thompson, MPH, of the Yale School of Public Health. The system is also referred to as "the DRGs", and its intent was to identify the "products" that a hospital provides. One example of a "product" is an appendectomy. The system was developed in anticipation of convincing Congress to use it for reimbursement, to replace "cost based" reimbursement that had been used up to that point. DRGs are assigned by a "grouper" program based on ICD diagnoses, procedures, age, sex, discharge status, and the presence of complications or comorbidities. DRGs have been used in the US since 1982 to determine how much Medicare pays the hospital for each "product", since patients within each category are clinically similar and are expected to use the same level of hospital resources. DRGs may be further grouped into Major Diagnostic Categories (MDCs). DRGs are also standard practice for establishing reimbursements for other Medicare related reimbursements such as to home healthcare providers.
Mark Barr McClellan is the director of the Robert J Margolis Center for Health Policy and the Margolis Professor of Business, Medicine and Health Policy at Duke University. Formerly, he was a senior fellow and director of the Health Care Innovation and Value Initiative at the Engelberg Center for Health Care Reform at The Brookings Institution, in Washington, D.C. McClellan served as commissioner of the United States Food and Drug Administration under President George W. Bush from 2002 through 2004, and subsequently as administrator of the Centers for Medicare and Medicaid Services from 2004 through 2006.
In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.
The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems.
Medical necessity is a legal doctrine in the United States related to activities that may be justified as reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care. In contrast, unnecessary health care lacks such justification.
CentraCare Health is an integrated health care system in Central Minnesota. The nonprofit includes six hospitals, seven senior care facilities, 18 clinics, four pharmacies and numerous inpatient and outpatient specialty care services. The organization received national attention in the spring of 2021 for its innovative outreach via mobile Covid vaccine unit especially to address vaccine hesitancy by meeting people on their turf and providing extended time for one-on-one consultations, answering questions and helping to dispel disinformation-based fears.
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Work on ICD-10 began in 1983, became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. It will be replaced by ICD-11 on January 1, 2022.
Severity of illness (SOI) is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines.
A national coverage determination (NCD) is a United States nationwide determination of whether Medicare will pay for an item or service. It is a form of utilization management and forms a medical guideline on treatment.
The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act, and colloquially known as Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965.
Aspirus Medford Hospital is a not-for-profit, primary care health care organization in Taylor and Price Counties in north-central Wisconsin, United States. Headquartered in Medford, Wisconsin, it is composed of a hospital, a continuum of senior care services, therapy centers, a pharmacy, a fitness center and gym, and primary care clinics located in Gilman, Medford, Prentice, Rib Lake, and Phillips, Wisconsin. The organization is partnered with Aspirus in Wausau, Wisconsin. It employs 525 individuals in the region.
A long-term acute care hospital (LTACH), also known as a long-term care hospital (LTCH), is a hospital specializing in treating patients requiring extended hospitalization. Hospitals specializing in long-term care have existed for decades in the form of sanatoriums for patients with tuberculosis and other chronic diseases. The modern hospital known as an LTACH came into existence as a result of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999. The Act defines an LTACH as “a hospital which has an average inpatient length of stay of greater than 25 days.” Traditionally, LTACHs provide care for patients receiving prolonged mechanical ventilation.
Bundled payment is the reimbursement of health care providers "on the basis of expected costs for clinically-defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement and capitation, given that risk is shared between payer and provider. Bundled payments have been proposed in the health care reform debate in the United States as a strategy for reducing health care costs, especially during the Obama administration (2009–2016). Commercial payers have shown interest in bundled payments in order to reduce costs. In 2012, it was estimated that approximately one-third of the United States healthcare reimbursement used bundled methodology.
The Medicare Physician Group Practice (PGP) demonstration is Medicare's first physician pay-for-performance (P4P) initiative. The demonstration establishes incentives for quality improvement and cost efficiency. Ten large physician groups are participating in the demonstration, which started on April 1, 2005, and will run for 3 years. Previous funding arrangements, like the volume performance standard (VPS) and the sustainable growth rate (SGR) did not provide incentives to slow the growth of services. The Medicare PGP demonstration is an attempt to overcome these limitations.
Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets sanctioned by the Health Insurance Portability and Accountability Act in the United States.
A hospital readmission is an episode when a patient who had been discharged from a hospital is admitted again within a specified time interval. Readmission rates have increasingly been used as an outcome measure in health services research and as a quality benchmark for health systems. Generally, higher readmission rate indicates ineffectiveness of treatment during past hospitalizations. Hospital readmission rates were formally included in reimbursement decisions for the Centers for Medicare and Medicaid Services (CMS) as part of the Patient Protection and Affordable Care Act (ACA) of 2010, which penalizes health systems with higher than expected readmission rates through the Hospital Readmission Reduction Program. Since the inception of this penalty, there have been other programs that have been introduced, with the aim to decrease hospital readmission. The Community Based Care Transition Program, Independence At Home Demonstration Program, and Bundled Payments for Care Improvement Initiative are all examples of these programs. While many time frames have been used historically, the most common time frame is within 30 days of discharge, and this is what CMS uses.
The United States has many regions which have been described as medical deserts, regions with inadequate access to one or more kinds of medical services. An estimated 30 million Americans, many in rural regions of the country, live at least 60 minutes drive from a hospital with trauma care services. Limited access to emergency room services, as well as medical specialists, leads to increases in mortality rates and long-term health problems, such as heart disease and diabetes. Regions with higher rates of Medicaid and Medicare patients, as well patients who are uninsured are less likely to live within an hour's drive of a hospital emergency room.
