Presentation on theme: "Hospital Finance 101. Hospital Charges Hospitals CHARGE everyone the same rates…BUT No two payers PAY the same rates Government payers pay BELOW costs."— Presentation transcript:
Hospital Charges Hospitals CHARGE everyone the same rates…BUT No two payers PAY the same rates Government payers pay BELOW costs Commercial payers NEGOTIATE rates based on market share Charity care and underpayment impacts overall costs for everyone else
Payment for Iowa Hospital Services Source: IHA Databank – 2010 Data
Medicare Background Established as Title 18 in 1965 as Health Insurance for the Aged –Expanded in 1972 to cover individuals under 65 with permanent disabilities Today, the program covers 46 million beneficiaries Medicare’s diverse population includes : –56% female/44% male beneficiaries –39% over age 75 –77% living at home –32% with incomes below 150% of FPL
Legislative Action Balanced Budget Act of 1997 (BBA) –$116 billion cut nationally –$600+ million impact on Iowa hospitals over 6 years (1998-2002) Balanced Budget Refinement Act of 1999 (BBRA) –Restored $100 million to Iowa hospitals from BBA
Legislative Action cont. Benefits Improvement Protection Act of 2000 (BIPA) –Restored $35 billion nationally from BBA –$86+ million over 5 years to Iowa hospitals Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) –$273 million to Iowa hospitals over 5 years –National impact $400 billion-$600 billion
Medicare Background Medicare consists of 4 parts: Part A, the Hospital Insurance program Part B, Supplementary Medical insurance Part C, Medicare Managed Care Part D, the Outpatient Prescription Drug Benefit
Medicare Part A Covers inpatient hospital, skilled nursing facility care, hospice and some home health. Accounts for 39% of Medicare spending (2007) Financed largely (86%) by a 2.9% payroll tax (1.45% paid by both employee and employer) Also known as the Hospital Insurance Trust Fund Fund reserves projected to be exhausted by 2019, funds less and less of program each year
Medicare Part B Covers physician and outpatient hospital care, lab tests, medical supplies and some home health. Financed by beneficiary premiums (24%), general revenue (75%), income investments (2%) Accounts for 33% of Medicare benefit spending
Medicare Part C Managed care plans that provide Part A and Part B benefits Formerly called “Medicare+Choice”; now called Medicare Advantage 10.3 million beneficiaries are enrolled in Medicare managed care plans
Medicare Part D Outpatient prescription drug benefit, effective 1-1-06 Accounts for 9% benefit payments Benefit offered by private insurance plans Financed through beneficiary premiums (8%), payments from states (11%) and general revenues (81%) Estimates of average monthly Part D premium was be $35 in 2006, now in 2010 (in Iowa) Minimum Premium: $22.80 Maximum Premium: $104.10 Weighted Average: $41.59
Structural Elements of a PPS Classification System –e.g. MS-DRGs for inpatient; APCs for outpatient Base Rate –Unadjusted national payment rate (standardized amount) Must report on Quality measures to receive payment updates to rate (3.3% in 2008) If do not report measures, receive cut to rate (-2% in 2008) Facility Adjustments –Differences in area wages –Urban versus rural setting –Medical education –Disproportionate share of low income patients Patient Adjustments –Intensity of service –Excessive case costs – outliers –Partial treatment – transfer cases
Medicare-Severity Diagnosis Related Groups (MS-DRGs) Identify patients with similar conditions who receive similar treatments Assignment is based on factors such as the patient’s diagnosis, complications, surgical procedure, age, sex New payment system beginning in 2008 (50-50 blend in 08) Moves from 546 DRGs categories to 745 new severity adjusted DRGs: 335 Base DRGs, 106 split into 2 subgroups, 152 spit into 3 subgroups Each MS-DRG is assigned a relative weight to compare its resource utilization to the average –[DRG127, Heart Failure & Shock Weight 1.0490 (split into 3 MS-DRGS)] –MS-DRG 291with MCCWeight 1.4850 –MS-DRG 292with CCWeight 1.0216 –MS-DRG 293without CC/MCCWeight.7317
DRG Assignment Principal Diagnosis Heart Failure & Shock Comorbidities and/or Complications (2ndary diagnosis codes) (2ndary diagnosis codes) MS-DRG 291 With MCC MS-DRG 293 Without CC MS-DRG 292 With CC
Iowa Wage Values LocationFY 2010 Wage Index FY 2009 Wage Index FY 2008 Wage Index Rural IA (14).8564.8954.8476 Ames (1).9533.9399.9976 Cedar Rapids.8908.8954.8685 Council Bluffs/Omaha.9541.9329.9474 Davenport.8564.8954.8894 Des Moines (5).9521.9442.9158 Dubuque.8626.8954.8876 Iowa City.9407.9319.9424 Sioux City.8937.8954.9083 Waterloo/Cedar Falls (3).8564.8954.8720
Example Wage-Adjusted Federal Rate for Hospital Inpatient Operating PPS Based on 2010 Final Rule
Inpatient PPS Other Issues Disproportionate Share Hospitals (DSH) –Adjustment to partially offset losses from uncompensated care –Based on hospital’s share of Medicare patients and Medicare SSI patients –Hospital must meet 15% DSH threshold –Adjustment is capped for certain categories of hospitals
Inpatient PPS Other Issues Outliers –Additional payment for high cost cases Transfers –Reduced payments for short stay patients in selected DRGs and transferred to post-acute care or other PPS hosptial. New Technology –Additional payment for new technology costs
Special Medicare Rural Status Rural Referral Centers – 6 in Iowa –Based on bed size, patient distance from hospital Sole Community Hospitals – 7 in Iowa –Criteria based on distance to other hospitals Medicare Dependent Hospitals – 6 in Iowa –Based on hospital’s share of Medicare patients
Outpatient PPS Outpatient PPS replaced previous cost-based system on August 1, 2000 Hospitals receive predetermined payments for individual services or procedures Payments are based on APC assignment which divides outpatient services into 661 groups Services within each APC are clinically similar and require similar resources Each APC is assigned a relative weight based on the median cost of the services within the APC No recognition of medical education or disproportionate share
Cost Reimbursement CAH program created by BBA of 1997 82 Iowa Hospitals Criteria for designation: –located in a rural area –Is more than 35 miles from a similar hospital –Provides 24 hour emergency services –Has no more than 25 beds, operated as either acute or swing beds MMA change allows 10 bed distinct part psych or rehab units –Has an annual average length of stay less than 96 hours
Other Medicare issues on horizon Value-Based Purchasing Pay 4 Performance No payment for hospital acquired conditions No payment for Never events?
Medicaid Overview Title 19 of the Social Security Act provides medical assistance for low-income recipients Funded by a combination of State and federal funds. –Approximately 2 for 1 federal match Medicaid is an “entitlement” program – everyone who meets the eligibility criteria must be served. 470,000 Iowans Enrolled (2007)
Medicaid Overview Enrollees meet income limits + other criteria In general, Medicaid covers four groups: –Pregnant women and children. –Members of families with dependent children. –Age 65 and over. –Blind and Disabled.
Medicaid Overview Under Federal law, some eligibility categories and services are mandatory and some are optional. –Mandatory examples – Children, pregnant women, disabled, hospital, physician, nursing home, early screening and treatment services for children. –Optional examples – Eligibility at higher income levels than required (Medicaid expansion, people in institutions), working disabled, prescription drugs, chiropractor, podiatrist, durable medical equipment.
Iowa Medicaid Enrollment Iowa Medicaid Expenditures *May not total to 100.0% due to rounding.
Medicaid Hospital Payment Inpatient Services – DRGs Outpatient Services – APGs –First in the nation outpatient PPS –Moved to APCs in 2008 Critical Access Hospitals – retrospective cost- based reimbursement at 100% for inpatient, outpatient and swing bed care Inflation factor determined by legislation PPS rebasing and recalibration occurs every 3 years
Other Iowa Payers Wellmark –State’s largest insurer offering indemnity, PPO, HMO, Medicare supplemental and products to over 1.2 million Iowans –Contracts with providers for service –Contracts modeled after Medicare rates –Has approximately 70% business in Iowa United Healthcare Coventry Principal
Employer Based Health Coverage Largest Employer 1964: General Motors –Covered all employees, families, retirees Largest Employer 1974: AT&T –Covered all employees, families, retirees Largest Employer Today: Wal-Mart –1/3 employees on Medicaid, etc. –1/3 employees have no coverage –1/3 employees have high deductible plans
The Uninsured 7-9% of Iowans (one of lowest in nation) 97% of Children Covered 250,000 – 270,000 People Generally Speaking –1/3 Are Self Insured –1/3 Have Access to Insurance –1/3 Truly Without Access to Coverage
Uninsured Are Not “Self Pay” All Iowa Hospitals Share IHA Principles Care Not Denied Based Upon Resources Written Financial Aid Policies –Discounts Up To 1000% of Poverty Level Refrain From Aggressive Collection Policies –No Sale of Home –No body Liens –No Bankruptcies
Iowa Hospital Losses (Cost) - $115 Million annually in Medicare - $196 Million annually in Medicaid (Medicaid pays below Medicare rates) - $231 Million annually in Charity Care - $326 Million in Bad Debt -$39 Million in Community Health Improvement Services
Impact of Shortfalls/Losses Impacts ability to attract physicians Impacts ability to retain nurses, clinical staff Impacts health care costs for private sector Impacts ability to provide charity care and to support IowaCare program Impacts technology/infrastructure Impacts wellness/preventive programs Impacts communities—diminishes hospital economic impact
Iowa Hospitals Economic Impact Conducted annually by IHA since 2003 Main Objective: Derive the direct economic impact and total economic impact of the five health sectors and the total health sector Use data system derived by Oklahoma State University using existing data sets
Health Sector Components Hospitals Doctors and Dentists (all practitioners and staff) Nursing Homes & Assisted Living Other Medical and Health Services (includes home health care, county health departments, hospice, durable medical equipment suppliers, etc.) Pharmacies (Includes all pharmacy personnel)
Economic Impact Is Measured In Terms Of: Employment Income (Salary & Benefits) Taxable Retail Sales (Please note it does not include total retail sales) Sales Tax Collections (6% Statewide Sales Tax)
Secondary Impact Is Measured Through Use of Multipliers: Employment Multiplier: Indicates total jobs created due to one job in the health sector. Income Multiplier: Indicates total income generated in the county due to one dollar worth of income in the health sector.
Iowa Health Care: What Does It Mean For Our State Economy? Health care is more than clinics, the hospital and doctors –3,007,856 - Iowa 2009 population –1,671,900 – Iowa 2009 employment Iowa health care is: –189,318 health care jobs (11.3% of all employment in Iowa!) –$8.9 billion in worker income These health jobs fuel the local economy through: –354,307 total jobs (21.2% of all employment in Iowa!) –$14.3 billion in total economic impact –$4.6 billion in taxable retail sales –$273 million in state sales tax paid to State of Iowa
Iowa Hospital Economic Impact Iowa hospitals provide: –74,027 direct jobs with 147,980 total jobs either directly or indirectly tied to hospitals –$3.7 billion in direct worker income with $6.1 billion in worker income directly or indirectly tied to hospitals –$2.0 billion in retail sales, generating $117.1 million in state sales tax revenue
Life Without Hospitals? Health Care, Education, & Workers Are the Keys to Economic Development No Hospitals = No Physicians No Hospitals = No New Business Payment issues are critical to specialists and access to diverse services