Intro to PT study guide

CLASS 1: KNOW ALL SLIDES

Settings a physical therapist can work in Hospital: specialty units Inpatient rehab: Medical rehabilitation unit, nursing home Home care Outpatient Education Schools Industrial Sports teams Fitness/wellness centers Administrative Regulatory

Professionals

Abbreviation Medical meaning

Abbreviation Medical meaning

MD Medical doctor OT Occupational therapistDO Doctor of

osteopathyCOTA Certified occupational therapists

assistantOB GYN Obstetrician

gynecologistRN Registered nurse

DPM Doctor of pediatric medicine

LPN Licensed practical nurse

DC Doctor of chiropractics

CNA Certified nursing aide: no certificate needed unless long term facility

PA Physicians assistant

RT Respiratory therapist/recreational therapy

NP Nurse practitioner SLP Speech and language pathologistANP Adult nurse

practitionerSW Social worker

FNP Family nurse practitioner

LMT Licensed massage therapist

PTA Physical therapists assistant

CPO Certified prosthetist and orthotist

Other professionals: Equipment vendors: exercise machines Case managers

Facility staff Insurance companies Coaches/teams/teachers Human resources Regulatory agencies Physical therapy programs

Department of Health and Human Services (HHS) US government principal agency for protecting the health of all Americans

and providing essential human services, especially for those who are least able to help themselves

Medicare run by HHS, and is the nation’s largest health insurer. 1 in 4 Americans

Organizations within HHS (bold and * are important ones)- Administration for Children and Families (ACF)

- Administration for Children, Youth, and Families (ACYF)- Administration on Aging (AoA)- Agency for Healthcare Research and Quality (AHRQ)- Agency for Toxic Substances and Disease Registry (ATSDR)- Centers for Disease Control and Prevention (CDC)*- Centers for Medicare and Medicaid Service (CMS)* -Healthcare financing administration (HCFA)- Food and Drug Administration (FDA)*- Health Resources and Services Administration (HRSA)- Indian Health Service (IHS)- National Institute of Health (NIH)*[fund research to study problem]

- National Cancer Institute (NCI)- Office of the Inspector General (OIG)*

Mission to protect the integrity of HHS programs, as well as the welfare of the beneficiaries of those programs

Report both to the Secretary and to Congress regarding problems and recommendations to correct them

Duties carried out through a nationwide network of audits, investigations, and inspections through the health dept

Daniel R. Levinson is the current inspector general -since September 8, 2004

Encompasses Medicare, Medicaid, public health, medical research, food and drug safety, welfare, child and family services, disease prevention, Indian health, and mental health services

Exercises leadership responsibilities in public health emergency preparedness and combating bioterrorism

Branch locations and types differ - located throughout the US and Puerto Rico

Department of Health (DOH) Unique to each individual state Richard Daines MD is the commissioner Oversees health care facilities and can perform annual inspections Any patient complaints are directed here Telephone number to the DOH must be posted Everything must be documented for inspections by DOH

Joint Commission Independent nonprofit organization Accredits and certifies more than 18,000 health care organizations and

programs in US Accreditation and certification is recognized nationwide as a symbol of

quality reflecting certain performance standards are being met- Accreditation: earned by an entire health care organization.

Larger system: hospital, nursing home, etc.- Certification: earned by programs based within a health care

organization. Diabetes, heart disease programs within a hospital. Smaller divisions within the larger system Mission: to continuously improve health care for the public by evaluating

health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value

Vision statement: All people always experience the safest, highest quality, best-value health are across all settings

Optional enrollment No ability to fine, close or punish any establishment Inspection every 2-3 years Provides an increased confidence to patients that the care provided is high

quality Partner/application fee

Commission on Accreditation of Rehabilitation Facilities (CARF) Founded in 1966 Independent, nonprofit accreditor of certain health and human

services(only rehabilitation facilities): Aging services Behavioral healthVision rehab Opioid treatment programsMedical rehab Business and services management networksDurable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

Child and youth services

Employment and community services

Accreditation extends to 17 countries in N America, S America, Europe, Asia, and Africa with 47,000 programs at 20,000 locations

Can not do any harm to a program if it does not meet expectations

Terms Beneficiary : anyone holding a health insurance plan Participating provider : any health care provider with an agreement

between an insurance company to provide services to patients Provider participation agreements : contract b/w particular provider and an

insurance company Benefit plan : individual person’s health care plan Capitation : set amount of money to care for needs of a patient Referral : Script a MD/Prim care physician gives for a specialist

Abbreviations CMS: center of Medicare (MCR)/Medicaid (MCD) services HCFA: health care financial administrator ICD9CM: International classification of diseases 9th edition clinical modification CPT: Current procedural terminology MDS: minimal data sets RUG: Resource utilization group DRG: Diagnosis related group HMO: health maintenance organization PPO: preferred provider organization POS: point of service plan

CLASS 2: DO NOT need to know $ amounts, MDS subcategories, Medicaid income guidelines

Medicare (MDR) Signed into law in 1965. Title 18 of Social Security Act Provides care for elderly, permanently disable, and those with end-stage

renal disease (kidney dialysis, transplant) Eligible if worked at least 10 years and paid MCR taxes, at least 65 years

old, permanent resident of US. Must have received social security or railroad retirement board disability

for at least 24 months 4 parts: A, B, C, D

Part A: “Hospital insurance” covers costs for inpatient stays, critical access hospitals, skilled nursing facilities, hospice

and some home health care. Usually receive it automatically at 65 w/ no monthly

premium as long as they/spouse paid Medicare taxes while employed for more than 10 years. Can buy into it if not

After 150 days, patient incurs all costs of hospital bills Days 1-20 covered in full at rehab or skilled nursing

facility, after day 20 money owed

Part B: “Medical insurance” covers costs for doctor’s visits, outpatient hospital care, PT, OT, and Speech, prosthetics and durable medical equipment

Optional : must sign up for it to get it. Initial enrollment period is 3 months before you turn 65 and lasts 7 months. Benefits begin July 1 of that year.

If do not sign up right away, cost rises 10% every year you could have and did not

Part C: “Advantage plans” run by private companies but approved by Medicare

Optional . Covers parts A and B as well as give prescription drug plans

Since 1982, known as Medicare Risk contracts or Medicare Choice Plans previously

Acts as a replacement for traditional Medicare HMO, PPO, Private Fee-for-Service plans, Medicare

Special Needs Plans Must have Part A and B to get the advantage plan May require referral to see specialists Co-pays for treatments and office visits Often have networks, which require you going to a certain

hospital or doctor May have limited benefits and services 65 plans in Erie County to choose from

Part D: “Prescription Drug Plan” covers brand-name and generic medication

Designed to provide protection for patients with high medication costs and unexpected medical bills in the future

Optional , must sign up for it. If do not sign up right away, late enrollment penalty usually applied

Monthly premium and yearly deductibles May have a coverage limit, then pay full costs

Medicare Special Needs Plan

Special Medicare advantage plan providing part A and B to people who can benefit most from special care for chronic illnesses, care management of multiple diseases, and focused care management.

Membership limited to people in certain institutions, eligible for both MCR and MCD, or with certain chronic or disabling conditions

Diagnosis-Related Group (DRG) System to classify hospital cases into one of 500 groups expected

to have similar hospital resource use. Developed for MCR as part of the prospective payment system Assigned by a grouper program based on ICD diagnoses,

procedures, age, sex and presence of complications/co-morbidities. Used since 1983 to determine how much MCR pays the hospital Patients within each category are similar clinically and expected to

use the same level of resources. Pay same amount even if something happens Based on diagnoses

Long Term Care Minimum Data Set (MDS) Standardized primary screening tool of health status Forms the foundation of the comprehensive assessment for all

residents of long-term care facilities certified to participate in MCR/MCD

Contain items that measure physical, psychological, and psycho-social functioning.

Items give a multidimensional view of patient’s functional capacities

Can be used to present a nursing home’s profile Plays a key role in MCR and MCD reimbursement system and

monitoring the quality of care provided to residents Regularly completed for a 5 day, 14 day, 30 day, 60 day, and 90

day report on a patient’s statusResource Utilization Groups (RUGs)

Intended to identify the service needs of persons in skilled nursing facilities and to pay an all-inclusive per diem payment to providers for the care

Help figure out the MDS score Look at overall health of a person 7 categories with subcategories

- ultra high, very high, high, medium, low

Recovery Audit Contractors (RACs) Tax Relief and Health Care act of 2006 required permanent and

national RAC program to be in place by Jan 1, 2010. Outgrowth of a successful demonstration program used to identify

Medicare overpayments and underpayments to health care providers

o resulted in over $900 million in overpayments being returned to MCR b/w 2005 and 2008 and $38 million in underpayments returned to health care providers

Goal is to identify improper payments made on claims of health care services provided to MCR beneficiaries

Under or over payments Under review include hospitals, physician practices, nursing

homes, home health agencies, durable medical equipment suppliers and any other provider or supplier that bills MCR parts A and B

Fiscal Intermediary (FI)o Private insurance companies that serve as the federal government’s

agents in the administration of the MCR programo 2 primary functions

- reimbursement review : paid what needed to be paid- medical coverage review : patient needed the service

o Manages funds, makes payments, and accounts for expenditure made on behalf of the consumer

o Not a direct service provider , but handles the business end of securing services and supports

o Can be nonprofit agency, payroll service, individual, or any organization that the person selects

Medicaid

o Signed into law by Title 19 of the Social Security Acto Can qualify if

- have high medical bills - receive Supplemental Security Income (SSI)

o meet certain income, resource, age, or disability requirementso Funded by both state and federal governmentso Can differ state to stateo Money provided by government depends on the financial status of the stateo Everything covered in full, except certain medications (brand names)o Supposed to be a 50/50 split b/w state and government but never has happened

- poorer states: 30% government 70%- wealthier states: 40% government 60%- Baumgarden mentioned 20% 80% but the notes say

30/70 so just a heads up

CLASS 3: DO NOT need to know individual differences b/w companies

Managed Care Plans vary greatly in what and how much they cover as well as how much they

cost Co-pays range depending on the plan Deductibles vary as do coverage plans Some plans require pre-authorization or referrals for certain treatments

Some have limited visits for outpatient services and some have no limit as long as it’s medically necessary

Comparison Medicare Managed CareDeductible cost Set deductible Deductible variesCo-pay cost 20% co-pay for outpatient Varies from $0-40 and upNeed for referral No referrals/pre-authorizations Needed for some plansPrescription Separate coverage Often included in basic

Health Maintenance Organizations (HMO) Health insurance plan that assumes all responsibility for all of the subscribers’

health care costs for a fixed, all inclusive price Responsible for the quality and cost of care the enrollee receives Restricts the choice of health care providers to those with agreement with plan Providers contract with an HMO to receive more patients and usually agrees to

provide services at a discount Manage their patients health care and reduce unnecessary services Manage care through utilization review

- intended to identify providers providing an unusually high amount of services, which may not be necessary, or an unusually low amount

of services, which may be endangering patients 2 models

- Staff Model: physicians are salaried and have offices in HMO buildings : physicians are direct employees of the HMOs

- Group Model: HMO does not pay the physicians directly : HMO pays physician group : group decides how to distribute the money to the

individual physicians

Preferred Provider Organization (PPO) Managed care organization of medical doctors, hospitals, and other health care

providers who have contracted with an insurer or 3 rd party administrator to provide health care at reduced rates to the insurer’s clients

Similar to HMO Providers give insured members of the group a substantial discount below the

regularly-charged rates Provider hopes to see an increase in its business, as almost all insured clients in

the organization will use only providers who are members Can refer yourself to a specialist without getting approval (if in-network) If choose to go out of network, you pay full price out of pocket May require pre-authorization for non-emergency hospital admission or

outpatient surgery Generally include a utilization review to verify treatments are appropriate for the

condition being treated

Point of Service Plan (POS) Similar to PPO but introduce a gatekeeper [primary care physician (PCP)] You choose your PCP from the network of doctors Can go outside the network and still get some level of coverage “HMO/PPO” hybrid

- Minimal fees if stay in network- Additional fee if want to go out of network

Consumer Driven Health Plans (CDHP) Provide reliable coverage while still saving members and employers Plans are customized solutions designed to allow you to make educated decisions

about your own health care Can be combined with consumer driven accounts (health savings accounts, health

retirement accounts) which are funded by you or sponsored by your employer Offer tax deduction or benefit of pre-tax dollar contributions

Managed care plans: (Baumgarden mentioned knowing who can get the plans…I do not know the answer to that for Univera, Community Blue, or Independent Health. Let me know if anyone has that info)

Univera All plans have some form of prescription drug coverage All rates, deductibles, and co-pays vary Pre-authorization required for inpatient stays or surgery No pre-authorization or referral for outpatient Evaluation plus 16 visits then need request for more

Community Blue All plans have some form of prescription drug coverage Rates deductibles and co-pays vary Pre-authorization required for inpatient stays or surgery No pre-authorization or referral for outpatient Plans vary greatly in terms of number of visits No need for updates or notification

Independent Health All plans have some prescription Rates deductibles and co-pays vary Pre-authorization required for inpatient stays or surgery Evaluation plus 16 visits need updates and request for more Some plans have visit limits others do not

Tricare (CHAMPUS [old name]) Civilian Health and Medical Program of the Uniformed Services Federal insurance for people in military

Covers active duty and retired uniformed services member and their families

Move over to Medicare at 65

Workers compensation Insurance for people hurt at work Patient pays NOTHING Medical treatment guidelines Claims from physician Progress note after 3-4 weeks

No-fault Insurance for people injured in motor vehicle accidents, at work Patient pays NOTHING Monthly updates to insurance Benefits as long as treatment is medically necessary

COBRA Consolidated Omnibus Budget Reconciliation Act Passed by Congress in 1986 Temporary continuation of health coverage at group rates to

former employees, retirees, spouses and dependents Rates are higher than active employees but less than buying own

CLASS 4: KNOW EVERY SLIDE

Healthcare Reform Why is it such a hot topic?

o nearly 46 million Americans do not have insuranceo 25 million Americans are underinsuredo Lack of insurance because many employers have stopped offering

insurance to employers because of the high costo $2.4 trillion dollars in 2007o US spends 52% more per person than the next costly nation (Norway)o No debate that reform is necessary between any of the involved programs:

there’s disagreement on how it should be changed though How does president plan to pay for reform?

o Says he’s identified “hundreds of billions of dollars” worth of saving in the federal government. Ex. Rooting out waste, fraud, and abuse in MCR and MCD as well as reducing tax deductions for high-income Americans

How do doctors feel about health care reform?- AMA feels public health insurance option is not the best way to expand

insurance coverage- Doctors fear a government sponsored health program would reimburse

them at MCR rates, which do not keep pace with the cost of practice- MCR rates are at 2001 rates, not where bills are

- Some doctors’ groups do support Obama’s plan: American Academy of Family Physicians, National Physicians Alliance -they feel it will help make health care more affordable for

patients, foster greater competition in insurance market and guarantee quality and affordable coverage will be there for

patients no matter what

CONS- will make health care more expensive- raise taxes- ration care- allow bureaucrats to make key medical decisions instead of patients and

doctors- will force at least 23 million Americans to lose their current health plan

and forced into the government-run plan- will crowd out all competition- middle class families and small businesses do not support

PROS- Stability and Security for all Americans

--provide more security to those with health insurance-ends discrimination against those with pre-existing

conditions- prevents insurance companies from dropping coverage

when people are sick and need it most- caps out-of pocket expenses

-- give those w/out insurance comfort of health care- creates new insurance marketplace

-the Exchange- allows people w/out insurance to compare plans and buy

insurance at competitive prices- provides new tax credits to help people buy insurance and to help small businesses cover their employees- offers a public health insurance option if can not afford - offers new low-cost coverage to protect “high-risk”

people with pre-existing conditions from financial ruin

-- lowers cost of health care- eliminates extra charges for preventive care- won’t add to the deficit- paid for upfront- creates an independent commission of doctors and

medical experts to identify waste, fraud, and abuse in the health care system

- orders immediate medical malpractice reform projects that could help doctors focus on putting their

patients first, not practicing defensive medicine- requires large employers to cover their employees and

individuals who can afford it to buy insurance so everyone shares in the responsibility of reform

American Recovery and Reinvestment Act (ARRA)- signed into law by Obama in Feb 2009- aims to stimulate the economy through investments in infrastructure,

unemployment benefits, transportation, education, and healthcare- $155.1 billion split between MCD, technology investments and incentive

payments, 65% subsidy of health care insurance premiums for unemployed, health research and construction of health facilities, community health centers, military hospitals, study comparative effectiveness of treatments, prevention and wellness, veterans health admin, healthcare services on Indian reservations, training, temporary moratorium for certain MCR regulations, aid in development of IT

- Designed to improve US healthcare through development of a solid health information infrastructure while simultaneously stimulating the economy through new investment and job growth

a. improve quality, safety, efficiency, and reduce health disparities

b. engage patients and familiesc. improve care coordinationd. ensure adequate privacy and security protections for personal

health infoe. improve population and public health

Accountable Care Organizations (ACO)- phrase attributed to Dr. Elliot Fisher of Dartmouth Medical School

-- led Dartmouth Atlas Project- project that has documented the variation in care

across the US for last 30 years- focused on both quality of health care and its cost

and reported on the relationship between the two

- findings show there is a wide variation in the cost of care across the country and the regions that spend more per patient do not obtain better outcomes.

- Coordinates a broad continuum of care designed to improve/maintain the health of a large number of patients

- Would be paid a flat rate for each person in its care as opposed to billing for each procedure or treatment

- Care is closely coordinated and stresses prevention and chronic disease management its expected to reduce emergency room visits and return hospitalizations, leading to reduced costs

- Who can become an ACO?1. Physicians and other professionals in group practices2. Physicians and other professionals in networks3. Partnerships b/w hospitals and physicians4. Hospitals employing physicians5. Other forms the Secretary of Health and Human

Services may determine appropriate- Requirements

1. have a formal legal structure to receive and distribute shared savings

2. have a sufficient number of primary care professionals for the number of assigned beneficiaries

3. agree to participate in the program for not less than 3 years4. have sufficient information regarding participating ACO health

care professionals as the Secretary determines necessary to support beneficiary assignment and for the determination of payments for shared savings

5. have a leadership and management structure that includes clinical and administrative systems

6. have defined processes to a. promote EBMb. report necessary data to evaluate quality and cost

measuresc. coordinate care

7. demonstrate it meets patient-centeredness criteria, as determined by the Secretary

- Plan to establish the program by January 1, 2012-- agreements will begin for performance periods, at least 3 years,

on or after that date

Meaningful Use- Give more money for efficiency- Incentive program for providers to transform healthcare through IT

product- 15 criteria must be met by eligible professionals (EPs) and 14 for eligible

hospitals (EHs)- First year of eligibility under MCR EPs and EHs will have to attest to

having used certified electronic health records (EHR) for 90 consecutive days in their reporting year

- EPs will have to report on specific meaningful use measures met as well as summary data on applicable quality measures

- For those seeking MCD incentives, it will only be necessary to demonstrate adoption, implementation, or upgrade of certified HER technology in the first year

- Future years will require meaningful use for 365 days and electronic reporting of quality measures from the HER

- Revisions-- eliminate the “all or nothing” approach to meaningful use, allowing some flexibility for providers with core and menu objectives and measures-- computerized provider order entry (CPOE) for EPs reduced from 80% to 30% and refined--CPOE for EHs and CAHs threshold changed from 10% to 30% and includes only medication orders-- E-Prescribing EPs were changed from 75% to 40% of their prescriptions-- providing patients with an e-copy of their health information changed from 48 hours to 72 hours and reduced threshold from 80% to 50% that request and electronic copy-- provide patients with an e-copy of their discharge summary changed from 80% to 50% of all patients who are discharged from an EH or CAH who request the electronic copy

Research Paper helphttps://www.homeworkping.com/