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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.
The Centers for Medicare &Medicaid Services (CMS) is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid,the Children's Health Insurance Program (CHIP),and health insurance portability standards. In addition to these programs,CMS has other responsibilities,including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA),quality standards in long-term care facilities through its survey and certification process,clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments,and oversight of HealthCare.gov. CMS was previously known as the Health Care Financing Administration (HCFA) until 2001.
Dual-eligible beneficiaries refers to those qualifying for both Medicare and Medicaid benefits. In the United States,approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment,yet they are responsible for approximately 36% of Medicaid expenditures. Similarly,duals total 20% of Medicare enrollment,and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.
UnitedHealth Group Incorporated is an American multinational health insurance and services company based in Minnetonka,Minnesota. Selling insurance products under UnitedHealthcare,and health care services under the Optum brand,it is the world's ninth-largest company by revenue and the largest health care company by revenue. It is based on a market based health insurance system as opposed to universal health care.
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.
Blue Cross Blue Shield Association,also known as BCBS,BCBSA,or The Blues,is a United States–based federation with 33 independent and locally operated BCBSA companies that provide health insurance in the United States to more than 115 million people as of 2022.
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Healthcare reform in the United States has had a long history. Reforms have often been proposed but have rarely been accomplished. In 2010,landmark reform was passed through two federal statutes:the Patient Protection and Affordable Care Act (PPACA),signed March 23,2010,and the Health Care and Education Reconciliation Act of 2010,which amended the PPACA and became law on March 30,2010.
George M. Rapier III is an American businessman,and chairman and CEO of WellMed Medical Management,Inc.,a diversified healthcare company and Physicians Health Choice,a physician-owned Medicare Advantage Organization contracted with the Centers for Medicare and Medicaid Services (CMS). WellMed is headquartered in San Antonio,Texas. It is South Texas’largest physician‐owned practice management company,specializing in senior health care,and the largest primary care provider for seniors in this region. Wellmed is affiliated with Optum,part of UnitedHealth Group.
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.
Stephen L. Ondra is the chief medical adviser for the MITRE Corporation’s work as operator of the CMS Alliance to Modernize Healthcare federally funded research and development center. Ondra advises all HHS organizations to advance private insurance markets,Medicare and Medicaid,value-based payments,and healthcare quality. Ondra was most recently CEO of Cygnus-AI Inc.,a company specializing in artificial intelligence and clinical decision support tools for diagnostic radiology. He was also founder and chief executive officer of North Star Health Care Consulting,and served on the board of directors of Triple-S Management and electroCore. A neurosurgeon and neuroscientist,Ondra has also served in senior positions in the Federal government,having a role in health reform efforts and the implementation of the Affordable Care Act. He advises corporations,provider organizations and early-stage start-ups on the transition to value-based care and health IT strategy.
An accountable care organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models,normally,capitation. The organization is accountable to patients and third-party payers for the quality,appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services,an ACO is "an organization of health care practitioners that agrees to be accountable for the quality,cost,and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".
The Center for Medicare and Medicaid Innovation is an organization of the United States government under the Centers for Medicare and Medicaid Services (CMS). It was created by the Patient Protection and Affordable Care Act,the 2010 U.S. health care reform legislation. CMS provides healthcare coverage to more than 100 million Americans through Medicare,Medicaid,the Children’s Health Insurance Program (CHIP),and the Health Insurance Marketplace.
Atrius Health is a Massachusetts based healthcare organization with a system of connected care for adult and pediatric patients in eastern and central Massachusetts. Atrius Health's medical practices work together with the home health and hospice services of its VNA Care subsidiary and in collaboration with hospital partners,community specialists and skilled nursing facilities. Atrius was acquired by Optum on May 31,2022,which caused it to lose its tax-exempt status,although its charitable assets were transferred to the Atrius Health Equity Foundation.
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The Physician Quality Reporting System (PQRS),formerly known as the Physician Quality Reporting Initiative (PQRI),is a health care quality improvement incentive program initiated by the Centers for Medicare and Medicaid Services (CMS) in the United States in 2006. It is an example of a "pay for performance" program which rewards providers financially for reporting healthcare quality data to CMS. PQRS ended in 2016,beginning with the 2018 payment adjustment. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced this and other CMS quality programs with a new umbrella program called the Quality Payment Program (QPP),under which clinicians formerly reporting under PQRS would instead report quality data under one of two QPP program tracks:the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APMs) track.
The Center for Value-Based Insurance Design at The University of Michigan is an advocate for development,implementation and evaluation of clinically nuanced health benefit plans and payment models. Since its inception in 2005,the V-BID Center has been actively engaged in understanding the impact of value-based insurance design (V-BID) on clinical outcomes and economic efficiency in the U.S. health care system. The V-BID Center also works with employers,consumer advocates,health plans,policy leaders,and academics to promote the implementation and demonstration of value-based insurance design in health benefit plans,as well as in state and federal legislation. Co-founded by A. Mark Fendrick,MD,and Michael Chernew,PhD,the V-BID Center is based in Ann Arbor,Michigan and operates collaboratively with the University of Michigan School of Public Health,the University of Michigan Medical School,and the University of Michigan Institute for Healthcare Policy and Innovation.
The Oncology Care Model (OCM) is an episode-based payment system developed by the Center for Medicare and Medicaid Innovation. The multipayer model is designed for discrete instances of care,especially those involving chemotherapy,which triggers the six-month episode. The program combines fee-for-service (FFS) payments for established services,monthly payments for additional care under a structured guideline,and performance-based payments weighed against quality metrics and benchmarks.
References
- 1 2 3 Robert Pear. "Shaping Health Policy for Millions, and Still Treating Some on the Side". The New York Times . Retrieved March 29, 2016.
- ↑ Larry Beresford. "Conway to Head Medicare Innovation Center". No. July. The Hospitalist. Retrieved July 7, 2013.
- ↑ Mark Hagland. "Patrick Conway, M.D., CEO of Blue Cross and Blue Shield of North Carolina, was interviewed as part of a general session at the HLTH Conference—looking back on his tenure as CMMI Director, and forward into the future". Healthcare Innovation. Retrieved May 8, 2018.
- ↑ Rebecca Pifer (August 4, 2023). "Former CMS, BCBS exec steps up as CEO of OptumRx in UnitedHealth leadership shakeup". healthcaredive.com. Retrieved January 23, 2024.
- ↑ Susan Morse. "Patrick Conway is leaving CMS to head Blue Cross Blue Shield North Carolina". Healthcare Finance. Healthcare Finance. Retrieved August 8, 2017.
- ↑ "Dr. Patrick Conway discusses the move to value based care". AJMC. AJMC. Retrieved March 25, 2020.
- ↑ Steve Lohr. "Inside North Carolina's Big Effort to Transform Health Care". The New York Times . Retrieved August 26, 2019.
- ↑ Merrill Goozner (February 3, 2018). "Q&A with Dr. Patrick Conway: 'I do believe we need more outcome-oriented measures'". Modern Healthcare. Retrieved February 3, 2018.
- 1 2 3 WRAL (October 8, 2019). "Former Blue Cross CEO found guilty of DWI, child abuse". WRAL.com. Retrieved January 5, 2022.
- 1 2 "No prison time for former Blue Cross Blue Shield of NC CEO Patrick Conway found guilty of DWI, child abuse charges". WXII. October 8, 2019. Retrieved February 16, 2022.
- ↑ Arrest Report (PDF) (Report). Archdale Police Department. June 22, 2019.
- ↑ "Blue Cross CEO of NC resigns following DWI, child abuse arrest". wsoctv.com. September 26, 2019. Retrieved January 17, 2024.
- ↑ "Advisory Board" . Retrieved January 23, 2024.
- ↑ "Leadership - Help at Home" . Retrieved January 23, 2024.
- ↑ "National Academy of Medicine member". The National Academics of Sciences, Engineering and Medicine. Retrieved March 25, 2020.
- ↑ "Deputy Administrator for Innovation and Quality and Chief Medical Officer, Centers for Medicare and Medicaid Services". Healthcare of Tomorrow. U.S. News. Retrieved March 25, 2020.
- ↑ "Patrick H. Conway, MD, MSc" . Retrieved January 23, 2024.
- ↑ "Patrick Conway: NCBI - US National Library of Medicine National Institutes of Health". NCBI - US National Library of Medicine National Institutes of Health.