• Prospective Payments and DRGs
• Effects on Patients
• Health Care Alternatives and Hospitalization Effects on Patients
• How You Can Help
The availability of quality health care services and access to such services is important to every community. In order to maintain such services for the elderly and to keep it affordable, the federal government has made major changes in the way health care will be paid for and how it will be delivered in the most cost effective way.
Medicare, which is the federal health insurance program for the elderly and disabled, makes the federal government the largest purchaser of hospital services. Changes instituted by the government are aimed at controlling this growing expense.
In the past, hospitals were reimbursed for services provided to Medicare patients based on the hospital's actual incurred costs. Under the current Medicare Prospective Payment System, hospitals receive a fixed payment as established by the federal government for each patient according to diagnosis (i.e. illness) and health conditions. There is no further reimbursement based on actual incurred costs.
Prospective Payments and DRGs
The Prospective Payment System (PPS) is based on Diagnosis Related Groups (DRGs). Medicare has categorized all illnesses into 511 groups or DRGs and each has a predetermined length of stay for hospitalization and a fixed price. Kuakini receives payment for each Medicare patient based on the patient's DRG, regardless of the number of tests run, days spent in the hospital or intensity of services provided.
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Effects on Patients
Kuakini Medical Center is dedicated to providing comprehensive health care to all patients regardless of who pays for the cost of the care or the ability to pay. Your health and well being are the main concern of the Medical Center and your physician(s).
Kuakini and its physicians strive to keep the overall costs of treatment within the DRG payment rate while maintaining quality care. Treatment costs that exceed the DRG rate are losses to Kuakini which must be absorbed.
This prospective payment system does not affect your deductibles, co-payments or premiums.
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Health Care Alternatives and Hospitalization
Expenses associated with the length of stay in a hospital may be reduced when pre-admission testing is done. Physicians are encouraged to do as much of their patient's diagnostic workup - such as lab tests and X-rays - before admission to the hospital. This helps to maximize the best use of the health care resources. Minor medical and surgical procedures can be done on an outpatient basis through Ambulatory Care Services.
Daily home nursing services can be provided through any certified home health provider selected by the patient for home care following discharge from the hospital. Home health providers offer services for patients receiving post-hospital care in the privacy of their home or may provide services as an alternative to hospitalization. Professional nursing, rehabilitation services, medical social work, intravenous infusions and enteral therapies and assistance by home health aides are available from these home health providers.
Many services such as rehabilitation services, chemotherapy and radiation therapy treatments can be provided on an outpatient basis.
A Medical Social Worker may visit you soon after your hospital admission to discuss the plans regarding your care, to assist with special discharge planning and to make any necessary continuing care arrangements.
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How You Can Help
Patients and their families should talk to their physicians to get a realistic idea of what to expect from an illness and the course of treatment during hospitalization. The physicians and the Medical Center staff are sometimes forced into making critical choices and decisions on behalf of patients because the patients and/or their families have not made their wishes known to the physicians in advance of receiving any diagnostic and treatment services.
As a patient, you should make your physician(s) aware of your wishes regarding your treatment plan such as the use of life support measures and treatment in the event of emergency situations. Ask your physician(s) what these measures mean and what the implications are for you and your family.
Be sure to obtain answers to all your questions so that you can make informed decisions on your plan of care.
Your general understanding of the Medicare prospective payment system and/or other applicable health insurance payment plans and your cooperation in hospital discharge planning will be very helpful and much appreciated.
When a Medical Center staff member contacts you for this purpose, please make every effort to keep the appointment to discuss the plans for your disposition following hospitalization. If you have any questions or concerns, please contact the following:
- Medical Social Workers at 547-9189 or in-house extension 8189
- Care Management Coordinators at 547-9279 or in-house extension 8279
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