N108: Transition to the Registered Professional Nurse

N108: Transition to the Registered Professional Nurse Role Study Guide Most of the controversy surrounding the implementation of DRGs has not been concerned with the incentive for cost control, but how the payment amounts are determined and how the system is being administered. Many believe the individual situation should be considered when determining regulations for length of stay. The proponents of shortened stays point out that shortened stays are effective cost containment measures. Resource Utilization Groups (RUGs) This is the payment system used to determine prospective payment for nursing home clients. Each RUG represents a group of residents who require a similar amount of care and would have similar cost of daily care. Unlike the hospital PPS system, which is a flat amount for the entire hospital stay, the PPS for nursing home care is a fixed daily rate. The daily rate must include all of the necessary services, including medications and treatments for a resident. The actual daily rate of reimbursement to the nursing home is the average of the RUGs for all residents. This is often referred to as case mix. The basis for determining to which RUG a nursing home resident will be assigned for reimbursement purposes is the comprehensive minimum data set (MDS) prepared by the RN. The MDS must be transmitted electronically to the appropriate center for review and payment categorization. If the assessments are not filled out properly or submitted on time, residents are automatically assigned to the lowest reimbursement RUG. The facility can never recover difference between lowest RUG and actual RUG. Reassessments are required at specific intervals and are used to reassign the resident to a RUG. The nursing home industry is lobbying for changes in the reimbursement plan because it believes that low reimbursement is undermining its ability to provide appropriate care. The costs of compliance are high, the reimbursements are low, and there are restrictions on such items as the provision of therapy services. Many nursing homes have reduced staff, changed practice patterns, and made other arrangements to adapt to the effect of RUGs. 2.11 Quality and Affordable Care Act Patient Protection and Affordable Care Act (passed in 2010) The Patient Protection and Affordable Care Act is designed to ensure that all Americans have access to quality, affordable health care and will create the transformation within the health care system necessary to contain costs. The Patient Protection and Affordable Care Act contains nine titles, each addressing an essential component of reform: • Quality, affordable health care for all Americans • The role of public programs • Improving the quality and efficiency of health care • Prevention of chronic disease and improving public health • Health care workforce • Transparency and program integrity

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