Prospective Payment System
The presence of prospective payment system (PPS), that caters certain health care were implemented last October of the year 2000, changing such reimbursing health care agencies on fee per service basis. Then, under the prospective payment model, such care agencies are reimburse flat rate per patient based on case mix adjusters. The change in payment system have ripple effect on how health services are provided, as there were shifts from focusing on service output to service outcomes. The payment system changes then, presents valuable opportunity for heath workers to become a more integral part of the home health team and to offer much needed psychosocial services to elderly patients. The one caveat in the covered services is that Medicare beneficiaries must need skilled nursing care and physical or speech therapy to also receive occupational therapy, services from a medical social worker, and home health aide services. In addition, only occupational therapy can be provided after the need for skilled nursing care and physical and speech therapy end (, 2000 ). Moreover, patient and family are payment system that influences how they function. Due to the system, the health providers give direct patient activities such as counseling patients and family members, crisis intervention and short-term therapy as well as provide placement services for patients after discharge that is on available services and legal rights.
Generally, the prospective payment system in health care was a modern progression of cost-control efforts in the Medicare program since the cost containment became a priority for corporations and the federal government’s Medicare program. Aside, there indicates that the first managed health care that was tried on a large national scale was the prospective payment system through the methods being utilized by the Diagnosis Related Groups. In addition, hospitals were reimbursed for Medicare patients on a flat-rate basis, determined by the patient’s DRG. If they spent less, they gained financially; if they spent more, they lost. The theory was that gains and losses would balance out in the end. The question of case mix became crucial regarding the types of patients admitted, and social work-conducted discharge planning became central to the survival of hospitals. In today’s managed care framework, PPS is a modified version of episode of disease capitation (, 2002 ). Furthermore, under the new payment system, Medicare pays home health agencies a predetermined base payment. The payment is adjusted for the health condition and care needs of the beneficiary and geographic differences in wages for home health agencies across the country. The adjustment for health conditions, or clinical characteristics and service needs are referred to as case basis adjustment. However, the current prospective payment system situational methodology does not integrate the agency’s professional resources required for educating and supporting the caregiver and natural helping network roles. The health care payment system will then pay home health agencies for every sixty day episode of care for each beneficiary and there is no limit to the number of episodes a beneficiary can receive as long as they remain eligible for health care benefits.
Henceforth, payment for each episode is adjusted to reflect the beneficiaries health condition and needs, but an outlier provision exists to ensure appropriate payment the health care agency’s cost in caring for the sickest beneficiaries and to ensure beneficiaries’ access to health care services for which they are eligible. Aside, the adjustments to payments will basically be created for beneficiaries who experience a significant change in their health condition and for those who change home health agencies (, 1999 ). Furthermore, timely and appropriate social work interventions have been proven to reduce lengths of stay ( and , 1981 ). In both hospital and primary care settings, having social workers on interdisciplinary teams has been shown to improve patient outcomes (, , and , 2000 ). Despite the contribution of social workers to patient care, social workers still struggle to be accepted by other health care professionals (, , , and , 1984 ). Moreover, under the prospective payment system, the health agencies must develop an optimal mix of services that has the best chance of improving patient outcomes under the set rate. Thus, several agencies will look to an interdisciplinary model to deliver services. The integration of diverse health care professionals will be easy, but without understanding of each other’s expertise and effectiveness, the weakness then, is that such negative issues could be exacerbated under the prospective payment system. Then, the government should create an integrated health care system with seamless transition between acute and long-term care. The current payment model has emphasize certain acute care such as possible clause in the original Medicare legislation limits reimbursement to services that can demonstrate patient improvement.
Thus, the payment system can possibly minimize the social work role and thus limited appropriate psychosocial care. There is considerable concern in the professional community that PPS, as so much else in the Medicare program, is based on a biomedical view of health care and ignores or limits social and psychosocial factors, systematic attention to which has been demonstrated to be value added to both cost containment and quality. Meanwhile, through such years of experience with prospective payment system in health care and the managed care experience, as there is health care system that reimburses prospectively or on a flat rate or capitated basis runs the risk of denial of appropriate care when the cost of such care greatly exceeds the flat or case-based reimbursement. As of the present, the PPS has begun for home care, which has become the fastest cost-growing sector of the Medicare program, because home care was the logical sequel and the outlet to such cost-contained hospital and nursing home industry. With the addition of both public and private managed care arrangements throughout the health care system as there can be danger of rationing necessary care for the most vulnerable population ( and , 1979 , , 1987 ). For instance, the health care in US has experienced progressively greater cost containment through the prospective payment systems and managed care, quality assurance has taken on new importance. The challenge is how to guarantee quality in the face of more limited or rationed resources. The home care industry must be vigilant in demonstrating quality of care under PPS and must document when limitations of PPS interfere with quality. PPS may also enhance quality, and this too needs to be codified. It is essential that social workers in HHC become proactive to make sure that the psychosocial dimensions of care are integrated into all quality assurance protocols and procedures.
Furthermore, the home health nurse is usually the care manager and determines the need for social work services and makes the referral. Under PPS, social work services will be weighed carefully against the agency’s PPS rate for the patient and the use of these services will depend on the interdisciplinary understanding between nurses and social workers about social work’s professional role and value in health care ways. Therefore, it is critical that medical work roles in health care are clearly defined and communicated to other members of the home health care team. Thus, for effective care under prospective payment system, the health work must become a true member of the interdisciplinary team to address the psychosocial issues for many of these chronically ill patients. Furthermore, given the present payment environment in health care, knowing how to work as a team to improve patient outcomes is critical to the survival of social work in health care settings. Also, within the payment process, the advocacy for changes to include social work services can only begin with the social work profession’s ability to demonstrate their capacity to improve patient outcomes in health care settings. It is critical to demonstrate social work’s effectiveness on the traditional cost-based outcomes, such as length of stay, hospitalization and readmission, as health agencies will need to show such cost-effectiveness and efficiency related to positive patient outcomes. In addressing the psychosocial needs of home health patients appropriately, effective screening is the key to determining which patient needs social work intervention. Thus, the value of the prospective payment system as it can be critical to provide easy to use tools to help nurses identify patients in need of health work services to determine the identification and intervention are critical to address the patient’s psychosocial needs while receiving medical care and to plan for the discharge respectively.
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