PURPOSE In this commentary, we examine nursing home quality and indicators that have been used to measure nursing home quality. DESIGN AND METHODS A brief review of the history of nursing home quality is presented that provides some context and insight into currently used quality indicators. Donabedian's structure, process, and outcome (SPO) model is used to frame the discussion. Current qual...

Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs utilize a volunteer-based and locally-sponsored support system to deliver free and unbiased counse...

T he three years that i s pent at hcfa / cms were the most rewarding of my career. I had worked with the Health Care Financing Administration (HCFA) as a Senate staffer, in the White House (George H.W. Bush), and as an outside lawyer and president of a hospital association. I thought I understood HCFA. I really did not. The issues are endless, as is the complexity. It is a fairly small agency (...

very practice treating Medicare patients is subject to an audit by the Center for Medicare and Medicaid Services (cms), formerly known as the Health Care Financing Administration (hcfa). In the year  the federal government won or negotiated more than $. billion in judgments, settlements, and administrative impositions in health care fraud cases and proceedings; federal prosecutors filed ...

In October 2014, the U.S. Centers for Medicare and Medicaid Services (CMS) will expand its Hospital Readmission Reduction Program (HRRP) to include chronic obstructive pulmonary disease (COPD). Under the new policy, hospitals with high risk-adjusted, 30-day all-cause unplanned readmission rates after an index hospitalization for a COPD exacerbation will be penalized with reduced reimbursement f...

INTRODUCTION The Centers for Medicare and Medicaid Services (CMS) requires reporting of multiple time-sensitive metrics. Most facilities use triage time as the time of arrival. Little is known about how long patients wait prior to triage. As reimbursement to the hospital may be tied to these metrics, it is essential to accurately record the time of arrival. Our objective was to quantify the tim...

Since 1989, the Medicare hospice benefit has been available to terminally ill individuals residing in nursing homes. We first describe the evolution and nature of hospice care for nursing home residents. We then utilize recent On-line Survey and Certification of Automated Records data on a national sample of Medicare/Medicaid certified nursing homes, merged with hospice Provider of Service and ...

It may well be that Congress might not be able to put any of Humpty’s pieces back together again. Even if this is the case, pharmacy groups agree on at least some key areas and have turned that con sensus into legislative provisions that could come to political fruition via alternative paths, such as (1) health care reform “lite,” (2) amendments to other non–health care reform (HCR) bills, (3) ...

This final rule revises the procedures that the Department of Health and Human Services (HHS) follows at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations for items and services furnished to Medicare beneficiaries, enrollees in Medicare Advantage (MA) and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well...