Your SlideShare is downloading. ×
0
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
The History of Medicare
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

The History of Medicare

608

Published on

An overview of Medicare's history in the United States.

An overview of Medicare's history in the United States.

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
608
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
30
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • \n
  • Transcript

    • 1. Understanding Medicare in the United StatesBy Craig B. Garner, Esq. 1
    • 2. Understanding Medicare in the United StatesBy Craig B. Garner, Esq. 1
    • 3. INTRODUCTION 2
    • 4. BEFORE MEDICAREFor much of its first two centuries in America’s history, the burden of caring for the sickand injured fell to neighbors, friends and relatives, with additional support from individualcommunities and religious groups.Visits by an actual doctor were generally limited to the home and dictated by localdemographics. Almshouses and charity wards provided a certain degree of medicalservice, as hospitals were few and far between.Those who had the opportunity to visit a hospital prior to the twentieth century morethan likely did so after an accident or as the result of an unfortunate designation ofinsanity. 3
    • 5. MEDICINE IN THE NINETEENTH CENTURYFor Through the 1800s the delivery of carerendered by the few hospitals in cities likeNew York, Boston and Philadelphia farexceeded the treatment one would expectfrom a local almshouse or charity ward.The need to provide health care for an entirenation was strong. With fewer than 200hospitals in 1873, that number grew to nearly5,000 by the 1920s, including mentalinstitutions. The Medical Laboratory, University of Pennsylvania 4
    • 6. HOSPITAL AND COMMUNITY WORKING TOGETHER In 1946 Congress sought to influence health care nationwide through the Hospital Survey and Construction Act (the Hill Burton Act) which disbursed approximately $3.7 billion to hospitals. The Hill Burton Act wanted to create 4.5 hospital beds per 1,000 people nationwide. Congress would eventually require participation in Medicare and Medicaid as a condition to receiveLister Hill monies under the Hill Burton Act. Harold H. Burton 5
    • 7. MEDICARE 6
    • 8. MEDICARE BEGINSBy the 1960s, America’s health care system was at a crossroads. Though the earlier Social Security Act of 1935 hadestablished a general welfare system for the elderly, it did not include health insurance. President Harry Truman hadwanted to create a system of national health insurance during his tenure, but his efforts were continually stalled by thelobbying power of the American Medical Association (AMA).Ultimately, a compromise of sorts was reached by diluting Truman’s grand ambitions with an addition to the Social Securitysystem created 30 years earlier. As President Johnson symbolically handed former President Truman the first Medicarecard on July 30, 1965, America’s commitment to government-sponsored health care became permanent. 7
    • 9. Medicare sought to provide coverage to all persons 65years of age or older who could satisfy certain legalresidency requirements.Within a year’s time, nearly 19 million elderlyAmericans were enrolled in the program, withMedicaid providing similar access to heath care on aState level for qualifying low-income individuals. 8
    • 10. THE FOUNDATION OF MEDICAREPart A provided health insurance coverage for qualified individuals requiringhospitalization.Part B initially offered a set of optional benefits addressing medically necessary servicessuch as doctor services, outpatient care, and home health services, and soon includeddurable medical equipment, podiatric care, and outpatient physical therapy.In 1972 the Federal government extended Medicare eligibility to people under the age of65 with certain long-term disabilities and others with chronic kidney disease.Medicaid eligibility for elderly, blind and disabled residents of an individual state becamelinked to a newly enacted Federal program. 9
    • 11. HEALTH MAINTENANCE ORGANIZATIONS 10
    • 12. HMOS ENTER THE PICTURE . . .In 1973, Congress passed the Health Maintenance Organization Act. The HMO Actoffered government subsidies and loans to HMOs, helping these managed care entitiesto attain much needed financial stability, in part so they could carry Medicare’s increasingburden.As a result, a new power was extended to HMO administrators that authorized theirability to challenge the medical judgment of licensed physicians.The HMO Act represents the first instance of business concerns gaining the upper handover medical judgment in the health care system, and marked the first step toward thediscrepancy of power between the two that still exists today. 11
    • 13. . . . AND EXPANDThanks to the consistency of government subsidies, the HMO model expanded tobecome the preeminent template for American health providers.There were 168 HMOs in 1978, with 6 million enrolled.By 1990, there were 652 HMO plans, covering 34.7 million people.In 1996, the number of enrollees grew to 60 million.In 2010 there were an estimated 154 million people enrolled in managed care (109.7million in preferred provider organizations, and 44.3 million in HMOs). 12
    • 14. THE WAY OF THE DRG 13
    • 15. A NEW WAY TO PAY -- THE DRGPrior to 1983, most patients remained in the hospital until the doctor decided it was time forthem to leave, which resulted in an inconsistent range of hospital days for treating similarconditions.To correct this issue, Medicare’s cost-based reimbursement policy was scrapped in favor of anewly developed classification system designed to standardize patient care by devoting a setprice to a given procedure. Called the diagnosis-related group (DRG), this prospective paymentsystem did away with reimbursing providers for the actual cost of their services, creating insteada predetermined rate per illness based on a patient’s diagnosis.In doing so, the burden now fell on hospitals to provide the necessary care for a set procedurethat kept within the payment cap if they wished to see a profit. 14
    • 16. THE DRG (continued)This shift away from Medicare’s earlier “fee-for-services” policy was intended to curtail whatmany saw as the overuse of testing andtreatments by doctors in a hospital setting whoknew these patient expenses would be coveredunder Part A.By providing a set fee per diagnosis, proponentsargued that providers would be motivated tobecome more efficient in their diagnosis andtreatment 15
    • 17. THE DRG (continued)Diagnosis-related units are assigned to almost every aspect of acute hospital care.Today, the top ten most used DRGs include: heart failure and shock pneumonia certain cerebrovascular diseases psychoses pulmonary disease joint, limb and lower extremity procedures angina certain digestive disorders, such as esophagitis and gastroenteritis gastrointestinal hemorrhage nutritional and certain metabolic disorders 16
    • 18. CONGRESS FLEXES ITS MUSCLES AND MEDICARE EXPANDS 17
    • 19. EMTALAIn 1986, Congress passed the Emergency Medical Treatment andActive Labor Act (EMTALA). Designed to counteract “patientdumping,” EMTALA requires every hospital that receives federalfunding to treat any patient with an emergency condition.Federal law defines an “emergency medical condition” as “amedical condition manifesting itself by acute symptoms ofsufficient severity (including severe pain) such that the absence ofimmediate medical attention could reasonably be expected toresult in . . . placing the health of the individual . . . in seriousjeopardy.” 18
    • 20. EMTALA, continuedMedicare’s annual reimbursements add up to nearly 20% of medicalexpenditures in the U.S., so most hospitals have little choice but toparticipate.In 2008 the uncompensated medical care in the United Statesapproached $57 billion, about $43 billion.Hospitals shoulder close to 60% of this uncompensated medical care,mostly due to the nature of the services they provide for patients withheightened levels of acuity.Are hospitals becoming an endangered institution? 19
    • 21. PORTABILITY AND ACCOUNTABILITYThe Health Insurance Portability and Accountability Act of1996 (HIPAA) sought to provide new Federal rules improvingcontinuity or "portability" of coverage in the large group,small group, and individual health insurance markets, whilereinforcing the need to protect the privacy of patient healthrecords.Health providers were instructed to comply with HIPAA’sPrivacy and Security Acts by 2003 or risk severe financialpenalties. 20
    • 22. MEDICARE+CHOICE (MEDICARE ADVANTAGE) Enacted in 1997, the bill included an array of new Medicare managed care and other private health plan choices for beneficiaries, all of which were offered through a coordinated open enrollment process. The new regulations expanded education and information to help beneficiaries make informed choices.Created five new prospective payment systems (PPS) for Medicare services: (1) inpatientrehabilitation hospital or unit services, (2) skilled nursing facility (SNF) services, (3) home healthservices, (4) hospital outpatient department services, and (5) outpatient rehabilitation services. 21
    • 23. PART DIn 2003, the Medicare Prescription Drug, Improvement,and Modernization Act established a voluntary outpatientprescription drug benefit for Medicare beneficiaries.Known as “Part D,” this prescription drug coverage wasmade available to all Medicare beneficiaries as of January1, 2006, through a variety of plans that had been pre-approved by the federal government 22
    • 24. BRINGING RX DRUG COVERAGE TO THE SENIORS OF AMERICA“With the Medicare Act of 2003, our government is finally bringing prescription drug coverageto the seniors of America.  With this law, were giving older Americans better choices and morecontrol over their health care, so they can receive the modern medical care they deserve. . . .Our nation has the best health care system in the world. And we want our seniors to share inthe benefits of that system.   Our nation has made a promise, a solemn promise to Americasseniors.  We have pledged to help our citizens find affordable medical care in the later years oflife.  Lyndon Johnson established that commitment by signing the Medicare Act of 1965.  Andtoday, by reforming and modernizing this vital program, we are honoring the commitments ofMedicare to all our seniors.” 23
    • 25. POLICING THE PROVIDERSAlso in 2003, the federal government initiated a three-yeardemonstration program using Recovery Audit Contractors(RACs) to detect and correct improper payments withinMedicare.The program recovered more than $1.03 billion (96% of thesepayments were overpayments collected from providers (85% ofwhich were collected from hospital providers) and the remaining4% were underpayments).In 2005, the federal government launched the Medicaid IntegrityProgram (MIP), focusing on Medicaid payments. MedicaidIntegrity Contractors (MICs) work with CMS to carry out thisprogram. 24
    • 26. NEVER EVENTSTo improve patient safety and rein in health care costs, in 2007 CMS announced that Medicareand Medicaid would no longer cover “conditions that could reasonably have been prevented.” Medicare assembled a list of complications so egregious that they called them “never events,” meaning they should never occur in a hospital setting. “Never events” included complications stemming from operating on the wrong side of the body to leaving instruments in a patient after a procedure. According to CMS, patients developed 1.7 million infections in hospitals each year, causing or contributing to the death of 99,000 people a year — about 270 a day. Regardless of the health of a patient’s immune system at the time of admittance, hospitals suddenly found themselves responsible for any and all hospital acquired illnesses. 25
    • 27. MEDICARE IN THE MODERN AGE 26
    • 28. HEALTH CARE GOES HITECHUnder the Health Information Technology for Economic and Clinical Health Act (HITECH). Seekingto protect patient privacy and tighten the rules of accountability for the sharing of a patient’smedical information. HITECH made most of the HIPAA requirements for patient health information directly applicable to business associates as well health care providers. Hospitals were required to develop a system for identifying breaches and notify covered entities following discovery of a breach. We should be mindful of the speed with which technology changes, as well as the dilution of privacy expectations progressing from generation to generation. HIPAA is a critical facet of America’s march toward paperless medicine, though at times it may appear to be more of an obstacle. 27
    • 29. PAPERLESS MEDICINEIn 2010, CMS proposed the adoption of what was toconstitute “meaningful use” of electronic health records(EHRs), while also implementing financial incentive programsthrough Medicare and Medicaid that would reward or penalizehospitals and physicians for their ability to institute certifiedEHRs within an established time frame.CMS proposed that hospitals adopt “meaningful use” in threestages of increasingly technological sophistication.Hospitals and physicians must meet the initial requirementsand in the future enhance their EHR capability to receiveincentive payments and avoid penalties beginning in 2015. 28
    • 30. REFORM, RESTRUCTURE, REVIEW 29
    • 31. HEALTH CARE REFORMOn March 23, 2010, President Obama signed the Patient Protection and Affordable Care Actinto law (followed by the Health Care and Education Reconciliation Act). Health Care Reform is a comprehensive plan embracing a multitude of revisions to the structure of the American health care system. Taking place over several years, it will include in part: The prohibition of health insurers from denying coverage or refusing claims based on pre-existing conditions The expansion of Medicaid eligibility, including families who did not previously qualify Providing incentives for businesses to provide health care benefits Increasing support for medical research. 30
    • 32. THE FUTURE OF HOSPITAL REIMBURSEMENT“The incentives were putting into place have created a whole new way to think about hospital care." Jonathan Blum, deputy administrator of CMSUnder Health Care Reform, in the future CMS will start paying hospitals Medicare “bonuses”based upon overall performance, adherence to quality measures, and patient satisfaction. This hospital value-based purchasing program is another step toward shifting thereimbursement infrastructure from cost-based to  performance-driven.Beginning in October 2012, hospitals can share bonus money from an $850 million fund basedupon their performance scores.The following year, hospitals will face a 1% reduction overall on Medicare payments under thissystem.By 2015, hospitals with poor performance ratings may be excluded from the bonus pool andface additional cuts in reimbursement. 31
    • 33. HOSPITAL PERFORMANCE MEASURESHospitals must closely track their performance on various measuresof quality, patient experience, and operations. This includes thefollowing examples: Readmission rates for cardiac cases Readmission rates for pneumonia patients Mortality rates for cardiac and pneumonia patients Average waiting time in the emergency department Patients who would recommend a hospital Patients who were happy with their levels of communication with doctors and nurses 32
    • 34. THE FUTURE OF MEDICARE FOR PHYSICIANSIn 2015, roughly 750,000 physicians in the Medicare program willbe asked to revalidate their individual enrollment records during amassive anti-fraud effort mandated by PPACA.Medicare will also require a value-based purchasing modifier thatadjusts physician fees based on quality and efficiency measures.Although not starting until 2015, CMS measure physicianperformance as early as 2013.2015: CMS starts applying the modifier to specific physicians andgroups.2017: CMS starts applying the modifier to all physicians and groups. 33
    • 35. ACCOUNTABLE CARE ORGANIZATIONSMedicare encourages the formation of AccountableCare Organizations (ACOs) to monitor thecollective quality and efficiency of doctors andhospitals alike, while at the same time creating anentirely new set of standards for compensation. 34
    • 36. ACCOUNTABLE CARE ORGANIZATIONS (continued)Assignment of patients: a preliminary prospective-assignment method with beneficiariesidentified quarterly (there will still be a final reconciliation after each performance year basedon patients served by the ACO).Quality: Measures: 33 quality measures in 4 domains.Application: The first round of applications due in early 2012. In the beginning, ACOs willalso have some flexibility within each of the performance years, rather than the originaluniform 3-year agreement based only on a calendar year.EHR: No longer a mandatory condition of participation, although it is retained as animportant quality measure. 35
    • 37. ACCOUNTABLE CARE ORGANIZATIONS (continued)In addition to the October 2011 modifications surroundingformation, other federal agencies have clarified issues ofconcern in the revised regulations: The Office of the Inspector General clarified the implications of physician self referral laws and the federal anti- kickback statutes. The Federal Trade Commission clarified there will no longer require mandatory antitrust review, and there will be an antitrust “safety zone” for ACOs approved by CMS The Internal Revenue Service clarified the ways in which a charitable organization can participate. 36
    • 38. MEDICARE AND PREVENTATIVE CARE“The Affordable Care Act helps stop health problems before they start.” --HHS Secretary Kathleen Sebelius Under Health Care Reform, the future of Medicare is about: Pilot Programs Preventative Health Care Services Forward Thinking Research 37
    • 39. MEDICARE AND PREVENTATIVE CARE, continuedLast summer, new regulations recommendedpreventative services free for Medicare beneficiaries.Health Care Reform also created the Patient-Centered Outcomes Research Institute (PCORI) toproduce groundbreaking, evidence based information.A report issued by the Prevention and Public HealthFund estimates that a $10 per person investmenteach year in community-based, preventative healthprograms could result in an annual savings of morethan $15 billion over the next five years. 38
    • 40. ADDITIONAL INFORMATION 39
    • 41. WHAT IS A MEDICAL EMERGENCY?* Possible Medical Emergency Potential Symptoms Heart Attack Chest discomfort; discomfort in other areas of the upper body, including one or both arms; shortness of breath. Uncontrolled Bleeding Just about all bleeding can be controlled, but shock or even death may result if left unattended. Altered Mental Status The individual may be unresponsive. This may include fainting, unconsciousness or any other sudden change in mental status. Commonly known as “respiratory distress,” this may include Difficulty Breathing sudden breathlessness and/or severe shortness of breath. In some cases, a person makes a sound, followed by unusual Seizures stiffening, progressing to possible jerking of the arms and legs. Serious or body-altering physical injury, including blunt force Physical Trauma trauma to the head, neck, spine and/or abdomen. *This list is not a substitute for an examination by a medical practitioner. If you are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately. 40
    • 42. CALLING 9-1-1 DURING A MEDICAL EMERGENCY*A few examples of medical emergencies when it is imperative to call9-1-1: Anaphylaxis (life-threatening allergic reaction) Stroke Chest pain Sudden blindness Drug overdose Serious burns Heart attack Bleeding that will not stop Shortness of breath Broken bones with an open woundA few examples of when 9-1-1 should not be called: For information To get a ride to a doctor’s appointment When the power goes out For paying tickets To report a broken fire hydrant For your pet When your water pipes burst As a prank *This list is not a substitute for an examination by a medical practitioner. If you are ever in doubt of whether a situation is an emergency, call 9-1-1 immediately. 41
    • 43. Craig B. GarnerCraig is an attorney and health care consultant, specializing in issues surrounding modernAmerican health care and the ways it should be managed in its current climate ofreform.  Between 2002 and 2011, Craig was the CEO at  Coast Plaza Hospital where hewas  responsible for administration and oversight of this general acute care hospital providingservices in southeast Los Angeles County.Last fall, he published his book Hospital Stay: Health Care Made Simple, a guide for patients andfamily members who find themselves in the confusing confines of a hospital environment. Craigregularly writes specialized articles for various health care publications, and in January 2012he will be teaching a Hospital Law course at Pepperdine University School of Law. 1299 Ocean Avenue, Suite 400 Santa Monica, CA 90401 T. (310) 458-1560 E. craig@craiggarner.com W. www.craiggarner.com 42
    • 44. Additional Resources http://www.healthcare.gov http://www.cms.gov http://www.hhs.gov/ http://healthreform.kff.org/ http://www.craiggarner.com 43

    ×