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Affordable Care Act and Medicare in Comparative Context [Kõva köide]

(Indiana University)
  • Formaat: Hardback, 488 pages, kõrgus x laius x paksus: 235x158x31 mm, kaal: 840 g, 74 Tables, unspecified; 1 Halftones, unspecified
  • Sari: Cambridge Bioethics and Law
  • Ilmumisaeg: 20-Jul-2015
  • Kirjastus: Cambridge University Press
  • ISBN-10: 1107110556
  • ISBN-13: 9781107110557
Teised raamatud teemal:
Affordable Care Act and Medicare in Comparative ContextSuurem pilt
  • Formaat: Hardback, 488 pages, kõrgus x laius x paksus: 235x158x31 mm, kaal: 840 g, 74 Tables, unspecified; 1 Halftones, unspecified
  • Sari: Cambridge Bioethics and Law
  • Ilmumisaeg: 20-Jul-2015
  • Kirjastus: Cambridge University Press
  • ISBN-10: 1107110556
  • ISBN-13: 9781107110557
Teised raamatud teemal:
Püsilink: https://www.kriso.ee/db/9781107110557.html
Märksõnad:
Burdened with perennially rising costs and responsible for providing health insurance to more than one sixth of all Americans, Medicare in its original form is fiscally and demographically unsustainable. In light of dramatic reforms under the Affordable Care Act (ACA), this book provides a comprehensive overview of the current state of Medicare. Eleanor D. Kinney explains how the ACA addresses systemic problems of cost and volume inflation, quality assurance, and fraud. Recognizing the potential for more radical change in the future, Kinney also explores the potential of Medicare to become a single-payer system. Comparisons are made with national health systems in Canada and the United Kingdom, from which the United States can draw valuable lessons. An approachable yet comprehensive account of Medicare and the ACA, this book will be invaluable for health care professionals and informed citizens.

Muu info

This book provides a comprehensive and approachable overview of Medicare under the Affordable Care Act.
List of Figures
xviii
List of Tables
xix
Acknowledgments xxiii
List of Acronyms
xxv
1 Introduction
1(8)
PART I THE MEDICARE PROGRAM
2 The Medicare Program
9(21)
2.1 Enactment of the Medicare Program
9(6)
2.2 Evolution of the Medicare Program
15(4)
2.2.1 Fee-for-Service or "Original" Medicare
15(1)
2.2.2 Medicare HMOs and Medicare Part C
16(2)
2.2.3 The Medicare Prescription Drug Benefit and Medicare Part D
18(1)
2.3 Design of the Medicare Program
19(9)
2.3.1 Eligibility
19(2)
2.3.2 Benefits
21(3)
2.3.3 Coverage
24(1)
2.3.4 Administration
24(3)
2.3.5 Payment Methods
27(1)
2.3.6 Financing
28(1)
2.4 Contributions of the Medicare Program
28(2)
3 Medicare Policy-Making Processes, Appeals, and Judicial Review
30(29)
3.1 Policy Making under the Medicare Program
30(16)
3.1.1 Predominant Medicare Policy-Making Process
32(5)
3.1.2 Medicare Coverage Policy Making
37(6)
3.1.3 Medicare Payment Policy Making
43(2)
3.1.4 Medicare Fraud and Abuse Policy Making
45(1)
3.2 Appeals
46(5)
3.2.1 FFS Medicare Beneficiary Appeals
46(4)
3.2.2 Grievance Procedures and Appeals for Beneficiaries in MA Plans and PDPs
50(1)
3.2.3 HHS Departmental Appeals Board (DAB)
50(1)
3.3 Judicial Review of Medicare Program Policy and Decisions
51(8)
3.3.1 Bar to Federal Question Jurisdiction under the Social Security Act
52(2)
3.3.2 Judicial Review of Medicare Coverage Policy
54(2)
3.3.3 Statutory Preclusions of Judicial Review of Medicare Payment Policy
56(3)
4 Taming the Growth in Medicare Expenditures
59(24)
4.1 The Challenge of Inflation in Medicare Expenditures
60(15)
4.1.1 Institutional Provider Payment
61(9)
4.1.2 Physician and Other Fee-for-Service Provider Payment
70(4)
4.1.3 Health Plan Payment
74(1)
4.2 The Challenge of the Burgeoning Volume of Medicare Services
75(3)
4.2.1 Retrospective Utilization Review for Institutional Providers
76(2)
4.2.2 Volume Controls for Physicians and Other Fee-for-Service Providers
78(1)
4.3 Prospects for Success
78(5)
5 Improving the Quality of Health Care Services
83(29)
5.1 Enrollment in the Medicare Program
83(4)
5.1.1 Survey and Certification Process for Institutional Providers
84(3)
5.1.2 Enrollment of Physicians and Nonphysician Practitioners
87(1)
5.2 The Advent of Health Services Research
87(9)
5.2.1 The Development of Standards of Care and Quality Measures
90(1)
5.2.2 Health Service Research on Outcomes of Care
91(1)
5.2.3 Total Quality Management, Continuous Quality Improvement, and Patient Safety
92(1)
5.2.4 Small Area Analysis and Geographic Variation in Medicare Spending
93(1)
5.2.5 Social Determinants of Health
94(2)
5.2.6 Translating Medical Research Progress into Better Medical Practice
96(1)
5.3 Federal Investment in Health Services Research
96(10)
5.3.1 Early Programs in the Public Health Service
97(2)
5.3.2 The Agency for Healthcare Research and Quality (AHRQ)
99(2)
5.3.3 The Early HCFA Quality Initiatives
101(1)
5.3.4 CMS Quality Improvement Initiative
102(3)
5.3.5 The Clinical Translational Science Award Program
105(1)
5.4 Health Information Technology Development
106(4)
5.5 Prospects for Success
110(2)
6 Curbing Fraud and Abuse in the Medicare Program
112(25)
6.1 The Extent of the Problem
113(9)
6.1.1 False Statements, False Claims, and Kickbacks
116(1)
6.1.2 Physician Self-Referral
117(5)
6.2 Legal Prohibitions Regarding Fraud and Abuse
122(5)
6.2.1 False Claims and False Statements Prohibitions
122(1)
6.2.2 Antikickback Prohibitions
123(2)
6.2.3 Physician Self-Referral Prohibitions
125(2)
6.2.4 Criminal Health Care Fraud
127(1)
6.3 Remedies
127(5)
6.3.1 Civil Monetary Penalties Act (CMPA)
128(1)
6.3.2 False Claims Act
128(1)
6.3.3 Health Insurance Portability and Accountability Act of 1996 (HIPAA)
129(2)
6.3.4 Exclusions from Federal Healthcare Programs
131(1)
6.3.5 Administrative Review and Appeals
132(1)
6.4 Prospects for Success
132(5)
PART II THE AFFORDABLE CARE ACT AND THE MEDICARE PROGRAM
7 The Affordable Care Act
137(30)
7.1 Organization of the U.S. Health Care Sector
138(4)
7.1.1 Private Health Insurance Coverage
138(2)
7.1.2 Public Health Insurance Program
140(1)
7.1.3 The Uninsured
141(1)
7.2 ACA Coverage Expansions and Protections
142(11)
7.2.1 Title I -- Quality, Affordable Health Care for All Americans
142(9)
7.2.2 Title II -- The Role of Public Programs
151(2)
7.2.3 The Community Living Assistance Services and Support Act
153(1)
7.3 Other Provisions of the ACA
153(4)
7.3.1 The ACA and Public Health
153(2)
7.3.2 The ACA and the Health Care Workforce
155(2)
7.3.3 Remaining Titles of the ACA
157(1)
7.4 Prospects for Success
157(10)
7.4.1 Success of Insurance Market Reforms in Title I
160(1)
7.4.2 Establishment of State and Federal Exchanges in Title I
160(3)
7.4.3 Mandates to Participate in the Insurance Marketplaces
163(1)
7.4.4 Medicaid Expansion and Reforms in Title II
164(1)
7.4.5 Public Health Reforms in Title IV
165(1)
7.4.6 Workforce Improvements in Title V
166(1)
8 Title III: Improving the Quality and Efficiency of Health Care
167(23)
8.1 Transforming the Health Care Delivery System
167(10)
8.1.1 Linking Payment to Quality Outcomes under the Medicare Program
168(1)
8.1.2 Developing a National Strategy to Improve Health Care Quality
169(2)
8.1.3 Developing New Patient Care Models
171(6)
8.2 Improving Medicare for Patients and Providers
177(4)
8.2.1 Ensuring Beneficiary Access to Physician Care and Other Services
177(2)
8.2.2 Rural Protections
179(1)
8.2.3 Improving Payment Accuracy
179(2)
8.3 Provisions Relating to Part C
181(2)
8.4 Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans
183(3)
8.5 Ensuring Medicare Sustainability
186(1)
8.6 Health Care Quality Improvements
187(1)
8.7 Protecting and Improving Guaranteed Medicare Benefits
188(1)
8.8 Prospects for Success
189(1)
9 Major Initiative under Title III: Value-Based Purchasing of Health Care Services
190(29)
9.1 The Concept of Value-Based Purchasing
190(3)
9.2 Getting to Value-Based Purchasing
193(6)
9.2.1 Inpatient Acute Care Hospitals
195(1)
9.2.2 Physicians and Other Eligible Professionals
196(1)
9.2.3 Other Institutional Providers
197(2)
9.3 Value-Based Purchasing for Inpatient PPS Hospitals
199(7)
9.3.1 Program Design
199(6)
9.3.2 Implementation Issues
205(1)
9.4 Value-Based Purchasing for Physicians and Other Health Professionals
206(10)
9.4.1 Improvements to the Physician Quality Reporting System
206(5)
9.4.2 Improvements to the Physician Feedback Program
211(2)
9.4.3 Maintenance of Certification Program (MOCP)
213(2)
9.4.4 Implementation Issues
215(1)
9.5 Value-Based Purchasing for Other Providers
216(1)
9.6 Prospects for Success
216(3)
10 Major Initiatives under Title III: Pilot Programs for Payment and Quality Reform
219(25)
10.1 The Medicare Shared Savings Program
219(10)
10.1.1 Development and Implementation of ACOs
220(1)
10.1.2 Program Design
221(6)
10.1.3 Administrative Issues
227(1)
10.1.4 Current Models of ACOs
228(1)
10.2 National Pilot Program for Payment Bundling
229(5)
10.2.1 Getting to the Pilot on Payment Bundling
229(1)
10.2.2 The Pilot Program
230(3)
10.2.3 Administrative Issues
233(1)
10.3 Community Health Teams to Support Medical Homes
234(4)
10.3.1 Getting to the Medical Home Pilot
235(1)
10.3.2 Demonstration Design
236(2)
10.4 Prospects for Success
238(6)
10.4.1 The Shared Savings Program
239(3)
10.4.2 The National Pilot Program for Payment Bundling
242(1)
10.4.3 The Medical Home Pilot Demonstration
243(1)
11 Title VI: Improving Transparency and Program Integrity
244(30)
11.1 Physician Ownership of Specialty Hospitals
244(5)
11.1.1 The Rationale for the Prohibitions
245(1)
11.1.2 Requirements to Qualify for Whole Hospital or Rural Provider Exceptions
246(2)
11.1.3 Exception to Prohibition on Expansion of Facility Capacity
248(1)
11.1.4 Collection of Ownership and Investment Information
248(1)
11.1.5 Enforcement
249(1)
11.2 Transparency and Reporting Requirements for Physicians and Industry
249(10)
11.2.1 The Problem of Conflicts of Interest
249(4)
11.2.2 Transparency and Reporting of Physician Ownership and/or Investment Interests
253(5)
11.2.3 Disclosure Requirements for Physician Ownership of Imaging Services
258(1)
11.2.4 Reporting Requirements for Gifts of Prescription Drug Samples
258(1)
11.2.5 Transparency Requirements for Pharmacy Benefit Managers (PBMs)
258(1)
11.3 Nursing Home Transparency and Improvement
259(4)
11.3.1 Problems with Nursing Home Quality and Safety
260(3)
11.4 Subtitle D -- Patient-Centered Outcomes Research
263(1)
11.5 Medicare, Medicaid, and SCHIP Program Integrity Provisions
264(6)
11.5.1 Provider Screening and Other Enrollment Requirements under Medicare
264(1)
11.5.2 Enhanced Medicare and Medicaid Program Integrity Provisions
265(2)
11.5.3 Elimination of Duplication between HHS Data Banks
267(1)
11.5.4 Miscellaneous Program Integrity Provisions
267(1)
11.5.5 Expansion of the Recovery Audit Contractor (RAC) Program
268(2)
11.6 Prospects for Success
270(4)
11.6.1 Physician Ownership and Transparency
270(1)
11.6.2 Nursing Home Transparency and Improvement
271(1)
11.6.3 Medicare, Medicaid, and CHIP Program Integrity Provisions
272(2)
12 Major Initiative under Title VI: The Patient-Centered Outcomes Research Institute
274(31)
12.1 The Road to Comparative Effectiveness Research
275(3)
12.2 Patient-Centered Outcomes Research Institute
278(12)
12.2.1 Key Definitions
278(1)
12.2.2 Purpose of the PCORI
279(1)
12.2.3 Duties
279(4)
12.2.4 Institutional Design, Governance, and Administration
283(2)
12.2.5 Dissemination and Building Capacity for Research
285(2)
12.2.6 Limitations on Use of Comparative Effectiveness Research
287(1)
12.2.7 Establishment and Funding of the Patient-Centered Outcomes Research Trust Fund (PCORTF)
288(2)
12.3 Prospects for Success
290(15)
12.3.1 Challenges for Patients
293(1)
12.3.2 Challenges for Physicians
294(3)
12.3.3 Challenges for Payers
297(1)
12.3.4 Challenges for Pharmaceutical and Medical Device Manufacturers
298(7)
PART III THE FUTURE OF MEDICARE IN A GLOBAL CONTEXT
13 The Impact of the Affordable Care Act on the Medicare Program
305(17)
13.1 Reforming the Medicare Program in the ACA
308(4)
13.2 Medicare as a Single Payer for Universal Coverage
312(7)
13.2.1 Necessary Steps
314(3)
13.2.2 Remaining Issues for Resolution
317(1)
13.2.3 Interest in a Single-Payet System
318(1)
13.3 The Burden of Ideology in Health Reform
319(3)
14 The Historical Foundations for Public Health Coverage in the United Kingdom, Canada, and the United States
322(18)
14.1 Constitutional Arrangements
323(10)
14.1.1 The Police Power and Federalism
324(6)
14.1.2 Impact of Federalism and Location of the Police Power over Health Policy
330(3)
14.2 Economic Conditions Following World War II
333(3)
14.2.1 United Kingdom
333(1)
14.2.2 Canada
334(1)
14.2.3 United States
335(1)
14.3 The Rhetoric of Health Reform in the United Kingdom, Canada, and the United States
336(4)
15 The Health Care Systems of the United Kingdom, Canada, and the United States
340(19)
15.1 Health Care in the United Kingdom
340(7)
15.1.1 Enactment of the National Health Service for England and Wales
341(2)
15.1.2 Evolution of the National Health Service for England and Wales
343(4)
15.2 Health Care in Canada
347(7)
15.2.1 Canadian Health Care in the Postwar Period
348(1)
15.2.2 Enactment and Evolution of Publicly Sponsored Health Insurance
349(5)
15.3 The Saga of Health Reform in the United States
354(5)
15.3.1 American Health Care in the Postwar Period
354(1)
15.3.2 Enactment of Public Health Insurance Programs at the State and Federal Levels
355(1)
15.3.3 American Health Care in the 1980s and 1990s
356(1)
15.3.4 Health Reform in the Twenty-First Century
357(2)
16 The United Kingdom, Canada, and the United States Compared
359(20)
16.1 Comparative Health Sector Performance
359(4)
16.2 Stakeholders and Their Influence
363(11)
16.2.1 Physicians
364(7)
16.2.2 Hospitals
371(1)
16.2.3 Private Health Insurers
372(1)
16.2.4 Pharmaceutical and Medical Device Manufacturers and Suppliers
373(1)
16.3 Mechanisms for Social Control of Stakeholders
374(5)
16.3.1 Collegiality
374(1)
16.3.2 Hierarchy
375(1)
16.3.3 The Market
376(3)
17 Convergence on Pragmatic Health Reform Strategies for Common Problems
379(22)
17.1 Common Solutions for Common Problems
380(13)
17.1.1 Enhancing Primary Care Delivery While Accommodating Integrated Specialty Care
382(5)
17.1.2 Coordinating Health Care Services across Provider Sites
387(2)
17.1.3 Getting Better Value for Payment
389(2)
17.1.4 Addressing Health Disparities
391(1)
17.1.5 Refocusing Health Care Delivery on Population Health
392(1)
17.2 Common Tools for Health Reform
393(6)
17.2.1 Health Services Research in Canada and the United Kingdom
394(2)
17.2.2 Adoption and Use of Information Technology
396(2)
17.2.3 The Promise of Comparative Effectiveness Research
398(1)
17.3 The Centrist Consensus
399(2)
18 Entrepreneurship in Health Care
401(26)
18.1 The Concept of Entrepreneurism
402(4)
18.1.1 Conventional, For-Profit Entrepreneurship
402(1)
18.1.2 Social Entrepreneurship
403(2)
18.1.3 Institutional Entrepreneurship
405(1)
18.2 Entrepreneurship in Health Care
406(10)
18.2.1 Productive Entrepreneurship
409(4)
18.2.2 Unproductive/Destructive Entrepreneurship in Health Care
413(3)
18.3 The Principle of Social Responsibility
416(3)
18.4 Opportunities for Productive Entrepreneurship in the ACA
419(5)
18.4.1 Opportunities in Title I
420(1)
18.4.2 Opportunities in Title II
420(1)
18.4.3 Opportunities in Title III
420(1)
18.4.4 Opportunities in Title IV
421(1)
18.4.5 Opportunities in Title V
421(1)
18.4.6 Opportunities in Title VI
422(2)
18.5 Entrepreneurship in the United Kingdom and Canada
424(3)
Epilogue 427(2)
Index 429
Eleanor D. Kinney is an Emeritus Professor at Indiana University's Robert H. McKinney School of Law and one of the nation's leading experts on health law. She has served as a consultant to numerous health commissions, including President Clinton's Task Force for Health Care Reform. Her most recent book is Protecting American Health Care Consumers (2002).