Management
the process, comprised of social and technical functions and activities, occurring within organizations for the
purpose of accomplishing predetermined objectives through human and other resources.
Six Management Functions:
Planning
Organizing
Staffing
Controlling
Directing
Decision Making
Tripple Aim
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fee-for-service
developed by Blue Cross Blue Shield plans
based on the idea of an insured individual purchasing coverage of a set of
benefits, utilizing individual medical services, and paying the health care provider for the services rendered.
The provider is
paid either by the insurer or out of pocket by the insured, who, in turn, is reimbursed by the insurer.
Typically, the insured
must meet deductibles and make copayments for their care.
Managed Care Plans:
these health plans seek to manage cost, quality, and access to health services through
control mechanisms on both patients and providers.
These delivery systems attempt to integrate both the financing and provision of health care into one organization.
Health Maintenance Organization (HMO):
Individuals become members of the organization by paying a
fixed prepayment amount.
Enrollees are eligible to get care from the providers and facilities that are
ALLIGNED with the HMO.
Administration is centralized, with providers typically being reimbursed under a
capitated rate.
Preferred Provider Organization (PPO):
Administration is centralized, with providers typically being
reimbursed under a capitated rate. Insured individuals purchase coverage on a fee-for-service basis, with
deductibles, copays, and coinsurances to be met.
Care is managed in the sense that insured individuals
pay less if care is obtained from a network of preferred providers with which the insurer contracts for
discounted rates.
Preferred providers include physicians, hospitals, diagnostic facilities, and other service
providers. If care is not provided by a preferred provider, the insured individual pays a higher
undiscounted rate and must meet higher deductibles and coinsurances for these services.
Point of Service (POS) Plan:
open ended plan" An enrollee can use services that are out of plan, in
exchange for deductibles and coinsurance payments. The plan tries to address some of the shortcomings
of the pure HMO approach.
High Deductible Health Plan with Savings Option (HDHP/SO):
consumer driven; offer the enrollee
catastrophic coverage for a relatively low premium that is coupled with a high deductible.
Offer the
enrollee catastrophic coverage for a relatively low premium that is coupled with a high deductible.
Medicare:
provides access to health care for the elderly over 65 years of age, for permanently disabled younger
adults, and for those suffering from end-stage renal disease (ESRD). End-of-life "palliative" care (or comfort care) is
also provided for terminally ill enrollees in their last six months of life.
Part A:
Hospital Insurance - 90 days hospital; 100 days per episode in SNF; HH/hospice
Part B:
Supplemental Medical Insurance - coverage for PCP, OP tx, vaccines, mammograpghy, Pap Smears
Part C:
Medicare Advantage Plans - allowing beneficiaries to enroll in a variety of capitated health
insurance plans, which are required to provide the same types of services covered under traditional
Medicare plans and may offer the option of additional benefits.
Part D
Prescription Drug Benefit
Medicaid
2 nd largest provider; provides health care coverage to the medically indigent (those below certain
poverty-level determinations) and is jointly funded by state and federal governments. Mandatory services required
by the federal government include: "physician, midwife and certified nurse practitioner services; inpatient and
outpatient hospital services; laboratory and x-ray services; family planning services and supplies; rural health
clinic/federally qualified health center services; nursing facility and home health care for adults over 21; and Early
Periodic Screening, Diagnostic, and Treatment (EPSDT) services for children under age 21. Additional benefts vary
by state.
Children's Health Insurance Program (CHIP):
Children whose parents have income too high for Medicaid but too
low for private insurance, use CHIP. Covers children in families with slightly higher incomes with respect to the
federal poverty level.
Tricare and Department of Defense
covers active duty military personnel, retired military personnel, and
their family members.
DOD: private sector and overseas
Tricare: Offers HMO, PPO, & fee-for-service
In 2006, the US was...
#1 in terms of health care spending per capita, but...
#39 for infant mortality
#43 for adult female mortality
#42 for adult male mortality
#36 for life expectancy
What problems do persons who are uninsured face?
go without care and are unable to make copays and or meet deductibles
not eligible for other public coverage programs, do not get health benefits at work, and cannot afford to buy coverage
outright
Providing health care to the uninsured continues to fall primarily to hospitals, where much of it becomes uncompensated
care
budgeting
the process of converting the goals and objectives of the organization's operating plan into financial terms: expenses, revenues, and cash flow projections. The budget, then, is a financial plan for turning these objectives into programs for
earning revenues and expending funds.
Operating budget, or cash budget:
annual budget that is a forecast of cash inflows, outflows, and net lending or
borrowing needs.
Expense budget:
allocation of funds necessary to cover monthly operations
Revenue budget:
type of budget used to allocate funds for growth and maintenance of business. Result of a
business' forecast of sales revenues, expenses, and capital expenditures.
Capital budget:
plan for expenditures for long-term assets whose useful life is more than a year.
How are health care services paid for?
Out-of-pocket (including health savings accounts)
Private health insurance (i.e. PPO, HMO, POS, etc.)
Public/social health insurance (i.e. Medicare, Medicaid, CHIP, military/VA)
What are fixed, variable, and start-up expenses?
Fixed: A cost that does not change with an increase or decrease in the amount of goods or services produced
Variable: Costs that vary depending on a company's production volume; they rise as production increases and fall as production decreases.
Start Up: expenses at start up??
What is working capital?
A measure of both a company's efficiency and its short-term financial health that is calculated as current assets minus
current liabilities
Working Capital = Current Assets - Current Liabilities.
What is a capital budget?
refers to the plan for expenditures for new facilities and equipment (often referred to as fixed assets).
may be defined as the process of selecting long-term assets, whose useful life is greater than one year, according to
financial decision rules.
determines funding amounts, what capital equipment will be acquired, what buildings will be built or renovated,
depreciation expenses, and the estimated useful life to be assigned to each asset.
identify the specific capital items to be acquired. The problem in almost all healthcare organizations is which capital
projects should be funded
What is an ICD-10 code?
standard diagnostic tool for epidemiology, health management, and clinical purposes.
What are CPT codes?
describe medical procedures and other services
How does the Medicare rule of "8" influence our billing?
Charge set amount of units based on length of time see person
Each unit = 15 minutes
U/A to bill until see person for at least 8 minutes
Used for all timed billing
What are typical CPT treatment codes?
OT evaluation (low, mod, high)
Therapeutic exercise
Therapeutic activity
Self-care
Neuromuscular Re-Education
Manual therapy
Modalities
What are the differences between the initial evaluation complexity codes?
Low: 1-3 performance deficits, 30 min eval, no major co-morbidities, low level clinical reasoning
Medium: 3-5 performance deficits, 45 min eval, cues needed to complete eval, moderate clinical
reasoning (cognitive defects, starts of dementia)
High: 5 + performance deficits, 60 min eval, cues, high level clinical reasoning (child with ASD, pt really
involved)
Re-evaluation: only when change medical status
Know examples
Initial Eval Complexity Codes: Based on "The level of the occupational therapy evaluation performed is determined by patient condition, complexity of clinical decision making, and the scope and nature of the patient's performance deficits relating to physical, cognitive, or psychosocial skills to be assessed
What type of payment and data collection systems are currently in use in acute care, in-patient rehab, SNF, HH, outpatient adult,
school systems, mental health settings?
SNF:
Medicare Part A: up to 100 days
Medicare Part B: converts from Part A or N.H. patient
Commercial Insurance: limits/bundled payment
Self-pay
HH
Private commercial insurance: check restrictions on # visits, total amount can be billed
o Medicare:
-Most common payor
-60 days treatment
-Typical frequency: 2x/week
-Medicare A coverage-typical, 100 days
-Medicare B coverage-less common-no hospitalization required
Outpatient Adult:
Medicare Part B covers 80% of OP therapy
--Small deductible that needs to be met before Medicare will pay
--Supplemental insurance can cover all or part of the remaining 20%
Medicare replacement policies: have limitations
Commercial insurance
Private pay
School:
IDEA Part B
MH:
Medicare
Medicaid
Private
Self-Pay
changes in SNF
RUGS to PPS in 10/2019
Replacing with patient characteristic groups
--OT& PT therapy-combined-limit amount OT
--Group & concurrent therapy: limited to 25% of all charges billed
--Co-morbidities: not taken into account
What changes in payment system and data collection will occur in January 2019?
January 1, 2020: new PPS HH system
January 1, 2020: new PPS HH system
o Patient Driven Groupings Model (PDGM)
Removing amount of therapy determinant for amount payment
NO therapy thresholds
Patients admitted from hospital, SNF, IRF, etc. (institutions) will receive higher payment compared to community
admissions
What is Strategic Planning?
The process of identifying a desired future state for an organization and a means to achieve it.
What does SWOT analysis mean
� Strengths, Weaknesses, Opportunities, and Threats.
why is SWOT important to health care organizations?
Functions:
-Describes organization's internal factors (strengths and weaknesses) that affect interaction with market
-Identifies market opportunities and threats that influence ability to succeed in the market
-Basis for strategies identification
-Growth
-Protecting
How do mission, vision and values of an organization relate to its strategic plan?
--Driving purpose of the organization
--Assessed to ensure aligned with organization's future
--Mission: statement of purpose
--Vision: desired future state
--Values: defines organization's culture
What are the steps involved in strategic planning?
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What is marketing?
The activity, set of institutions, and processes for creating, communicating, delivering, and exchanging offerings that have value for customers, clients, partners, and society at large
Who is a customer or consumer in health care environment?
� Patients/Clients
� Family members/ caregivers
� Referral sources
� Private 3rd party payers
� Federal and state government
� Rehab staff
What factors are considered to be controllable
expenses that healthcare org has the power over
EX: CEO of a healthcare org is able to control the amount of money spent in wages by limiting number of employees hired in a given period of time
What factors are considered to be non-controllable in the health care market?
taxes, fees imposed on the company from outside entities
What is market segmentation?
Process of dividing the total market into segments that have similar needs for products and services.
o EX: Pediatric vs Geriatric
What is a target market?
Narrowly defined group with similar needs for organization's products and services.
What are the 7 "P"s in the marketing mix?
product: actual product/service
place:location
promotion: marketing
price:
packaging:
presentation of
product/service
people: target market
positioning: what do people think of you?
health information system
o Focus on total health of patient
o Goes beyond clinical data in provider's office
o Broader view of patient's care than EMR
o Built to share information with other providers
Electronic Medical Record
o Used to document, manage, and monitor health care delivery
o Facility/provider-based
o Used to document, manage, and monitor care delivery
o Different types for different settings
o Often contains:
Clinical data repository
Clinical decision support
Controlled medical vocabulary
Order entry
CPOE
Pharmacy (inpatient facility)
Specific department clinical documentation applications