Health Information Technology (Hit) Medicare Databases

In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American

In 2009 The American Recovery and Reinvestment Act (ARRA) allocated approximately $19 billion to support physicians and hospitals in attaining meaningful use of health information technology (HIT). The meaningful use program is intended to facilitate providers to amass

The Improving Medicare Post-Acute Care Transformation Act (IMPACT) standardizes data collection and data sharing among post-acute providers. The IMPACT Act is part of the Centers for Medicare and Medicaid services (CMS) effort on basing reimbursement on quality as it moves from voluntary reporting of quality measures to mandatory reporting, basing reimbursement on the data reported. Presently, post-acute providers are paid on a fee-for-service basis but with the IMPACT act, bundle payment will replace the fee-for-service. The bundle or value based payment pays for outcomes and not for the volume of services. The Act gives post-acute providers an incentive to work on

The HITECH Act supports the concept of electronic health records - meaningful use, an effort led by Centers for Medicare & Medicaid Services (CMS ) and the Office of the National Coordinator for Health IT (ONC). HITECH proposes the meaningful use of interoperable electronic health records throughout the United States health care delivery system as a critical national goal. Meaningful Use is defined as the minimum U.S. government standards for using electronic health records (EHR) and for exchanging patient clinical data between healthcare providers, between healthcare providers and insurers, and between healthcare providers and patients. Its rules, known as meaningful use measures or meaningful use criteria, determine whether a healthcare provider may receive federal funds from the Medicare EHR Incentive Program, the Medicaid EHR Incentive Program or both, in cases of "dually eligible" practitioners (EP) and eligible

Compare and contrast Medicare and Medicaid; including funding sources, fraud and/or abuse, and eligibility requirements for recipients

Since the late 1980s, Medicare has reimbursed physician services using the Medicare Physician Fee Schedule (MPFS), which encompasses 10,000 procedure codes. Each code is assigned resource-based relative value units (RVUs), which are designed to reflect physician work, practice expense, and malpractice expense. To adjust for local differences in cost of living, each RVU is modified using geographic practice cost indexes (GPCIs) and then converted to dollars using a “conversion factor.” This system rewards physicians who produce a high volume of services; not surprisingly, Medicare Part B expenditures have grown rapidly.

One of the biggest impacts on the healthcare industry is the transition from a fee-for-service model to a value-based payment model. This transition is emphasizing the importance of utilizing data captured electronically in EHRs, HIEs, and other clinical and business systems to improve patient care. Payers are implementing payment incentives and penalties based on performance in defined quality and safety metrics through programs such as Blue Cross’ Pay for Performance (P4P) or CMS’ Value-Based Purchasing (VBP). These programs, along with other factors, are resulting in a growing that utilizes data analytics and business intelligence to provide healthcare leaders and physicians with insight into their quality and safety metric status.

Medicare and Medicaid information can be overwhelming and confusing to both the consumer and the healthcare professional. The information highway known as the World Wide Web (WWW) can provide the answers to questions about these government benefits, but getting clear, informative and accurate knowledge can be overwhelming. O’Sullivan (2011) identified the WWW as “a primary repository for health information for the medically naïve yet technically savvy healthcare consumer.” One internet website that provides information about Medicare and Medicaid is CMS.gov ("Cms.gov centers for”). The Centers for Medicare & Medicaid Services (CMS) is the United States agency that administers Medicare,

In 2013 readmission following hospital stays for AMI, CHF, COPD or pneumonia the cost for readmissions totaled $7.0 billion, which accounted for 13 percent of the cost for total readmissions in the nation (Fingar & Washington, 2015). The highest readmissions fell with HF, followed by COPD, pneumonia then AMI. Trends from 2009-2013 showed a decrease in the overall hospital Medicare readmissions by an average of 9 percent and this was from these top four diagnosis (Fingar & Washington, 2015). This information came from Healthcare Cost and Utilization Project (H-CUP) which is a group of healthcare data bases. Through technological use of several software tools the data needed for this project was abstracted. This is a perfect example of using technology to improve the processes for healthcare improvement by supplying needed data for analyzing to gain the knowledge for change within the healthcare systems (Fingar & Washington, 2015).

According to L. Horton, LTACHs are funded by commercial insurance, Medicare, and charity (personal communication, March 7, 2014). For claims reimbursed by Medicare, patient satisfaction survey’s or Hospital Consumer Assessment of Healthcare Providers and Systems/HCAHPS help determine the hospital’s reimbursement scores. Value Based Purchasing (VBP) was established by the Affordable Care Act, which implements a pay-for-performance approach to the Medicare payment system (“Linking Quality to Payment,” n.d.). This program can help hospitals evaluate the performance of the services they provide to the public. Part of the VBP plan includes a questionnaire to patients that determines 30% of the weight of the hospital’s reimbursement scores. There are eight measures included in the HCAPS: nursing communication, doctor communication, responsiveness of staff, pain management, communication of medications, discharge information, cleanliness and quietness of hospital environment, and overall rating (Grellner, 2012, p.57).

Quality physician documentation is not only essential to providing superior clinical communication, but also allows for the delivery of useful data that “supports quality metrics, acuity of care, billing, and accurate representation of medical conditions” (Rosenbaum et al., 2014). The Centers for Medicare and Medicaid Services (CMS) uses a system to classify Medicare patient’s hospital stays into various groups in order to facilitate payment of services called Medicare Severity-Diagnosis Related Group (MS-DRG). Some payers also use all patient refined (APR)-DRG reimbursement systems. MS-DRG groups are outlined by a specific collection of patient characteristics which include areas specific to the “principle diagnosis, specific secondary diagnoses,

Health care has become a target for unscrupulous individuals. Both private industry and government are employing a variety of tools to combat fraud and abuse. Since 1992, we have made tremendous progress in protecting the fiscal integrity of the Medicare program. An example is the HCFA initiated partnership with the enforcement agencies targeting fraud and abuse in those five states that account for nearly 40 percent of all Medicare and Medicaid beneficiaries. This two-year project, Operation Restore Trust, encompassed a wide range of projects aimed at eliminating fraud schemes and identifying vulnerabilities in the Medicare programs. The reforms enacted in the Balanced Budget Act of 1997 and the Health Insurance Portability and Accountability Act of 1996 provide significant new tools to further assist us. But I think we all know that equally tremendous challenges he ahead. Our goal is to ensure that the Medicare and Medicaid programs have the necessary arsenal to combat fraud and

In an office setting, RBRVS determines overall cost of visit. The Relative Value Unit (RVU) is a created value to measure resource consumption by assigning numeric values. RVUs are divided into three domains, each with different weight. This metric sums the salary of provider, facility/practice expense (inclusive of utilized resources), and malpractice adjustment (exposure level to account for). This determines the overall Relative Value Unit (RVU) which is then multiplied by the GPCI (geographic index specific for each factor) which adjusts for cost differences in different areas. The total RVU is multiplied by conversion factor to equal reimbursement. Doctors working more and producing more RVUs are making more

Health Information Technology (HIT) Medicare databases are useful tools to obtain health information. Medicare collects information on all its beneficiaries and those providers that receive payments from Medicare. The data that Medicare collects can be used to recognize the variations in healthcare cost and the use of services. Spending for Medicare beneficiaries should be the same throughout the country but, it is not. Numerous studies have shown there are differences in cost and the quality of health care with Medicare beneficiaries, with the biggest spending difference being post-acute

The road to patient-centered care was paved with the passing of the HITECH act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use EHRs privately and securely to achieve specified improvements in care delivery. If providers do not become meaningful users of EHRs by 2015, penalties will be triggered through reduced Medicare payments. These provisions aim to create a nationwide electronic health system that is efficient and secure to improve health outcomes and lower the cost of healthcare. To accomplish these goals, the federal government allotted $19.2 billion of funding to promote the adoption and meaningful use of interoperable health information technology and electronic health records (EHRs).