HealthCareQualityEvolutionMilestoneChart

Healthcare Quality Evolution Milestone Events Chart Healthcare Legislation, Regulatory Agencies, and Quality Initiatives Milestone Description 1) 1791 Regulating Healthcare States were given the right to regulate health and formally began licensing physicians (Chaudhry, 2010). 2) 1800 State medical boards State medical boards do licensing, disciplining and regulating physicians and other healthcare professionals to protect the public (Truex, 2014) 3) 1850 First health insurance policy The Franklin Health Assurance Company of Massachusetts was the first commercial insurance company in the U.S. to provide private health care coverage benefits for injuries not resulting in death ( Scofea, 1994). 4) 1862 U.S. Army Medical Department and the United States Sanitary Commission formed. Post-civil war, new health-related agencies, hospitals, and medical research and care implemented to care for the post- civil war injured and increase population health awareness (Reilly, 2016). 5) 1886 U.S. Army established the Hospital Corps. The first U.S. data repository to collect medical data. This was implemented by the Surgeon General’s Office and the Library of the Surgeon General (Weedn. 2020). 6) 1900 Self-pay is the primary source of payment for healthcare services. Most Americans continued to pay their own health care expenses, which often meant either uncompensated charity care or no care. Hospitals were voluntary institutions that were privately supported (University of PA, 2021). 7) 1908 Workers’ compensation legislation President Theodore Roosevelt signed legislation to provide workers’ compensation (WC) for certain federal employees in unusually hazardous jobs (DOL, 2021). 8) 1915 American Association of Labor Legislation (AALL) The first universal access health Insurance legislation. It would provide limited insurance benefits to working class, their dependents and others who earned less than $1,200 a year. Although, supported by the American Medical Association (AMA) it was never passed into law (Derickson, 2002). 9) 1916 The Federal Employees’ Compensation Act (FECA) Replaced the 1908 WC legislation to include civilian employees of the federal government. They were provided medical care, survivors’ benefits, and compensation for lost wages under FECA (DOL, 2021). 10) 1920 Introduction of prepaid health plans (Direct Contracting) Direct contracting between employers, local hospitals and physicians for medical services was the first predetermined, fee that was paid monthly or yearly basis. These prepaid health plans were the precursor of today’s managed care plans and capitation payments (Kroth & Young, 2018) 11) 1921 -1976 Indian Health Services (IHS) The Snyder Act of 1921 and the Indian Health Care Improvement Act (IHCIA) of 1976 created the legislative authority for Congress to provide funding to Native Americans for healthcare services, which is now known as the Indian Health Services (IHS) (Warne & Frizzell, 2014). 12) 1921 Sheppard-Towner Maternity and Infancy Act Legislation to reduce maternal and infant mortality. The Act was challenged and then said to be unconstitutional by the Supreme Court. Additionally, the Act was opposed by the American Medical Association. The act was not renewed and expired in 1929. (Moehling & Thomasson, 2012). 1

13) 1927 Workers’ Compensation Act Office of Workers’ Compensation Programs (OWCP) administers FECA as well as the Longshore and Harbor Workers’ Compensation Act of 1927 and the Black Lung Benefits Reform Act of 1977 ( Kroth, & Young, 2018). 14) 1929 Blue Cross (BC) Insurance Policy Baylor University, Dallas, TX guaranteed schoolteachers 21 days of hospital care for $6 a year. Other groups of employees in Dallas joined, and in a short time period BC becomes hospital insurance nationwide ( Kroth, & Young, 2018). 15) 1930 Blue Shield (BS) Plans Blue Shield was founded to provide insurance to lumber and mining camps of the Pacific Northwest at the turn of the century. Employers paid fees to medical service bureaus, which were composed of groups of physicians. BS becomes physician insurance nationwide ( Kroth, & Young, 2018). 16) 1938 The Food, Drug, and Cosmetic Act was signed by President Franklin Delano Roosevelt Food, drug, and cosmetic safety implemented. The new law brought cosmetics and medical devices under control, and it required that drugs should be labeled with adequate directions for safe use ( Kroth, & Young, 2018; FDA, n.d.). 17) 1939 Wagner National Health Act (S.1620) The bill would have allow the states to implement mandatory and universal healthcare but did not pass due to WWII (U.S. National Health program, 1939). 18) 1946 Hill-Burton Act Provided federal grants for modernizing hospitals during the Great Depression and WWII (1929-1945). In return for federal funds, hospitals were required to provide services free or at reduced rates to patients unable to pay for care (Kroth, & Young, 2018). 19) 1947 Taft-Hartley Act Amended the National Labor Relations Act of 1932, restoring a more balanced relationship between labor and management. An indirect result of Taft-Hartley was the creation of third-party administrators (TPAs), which administer health care plans and process claims, thus serving as a system of checks and balances for labor and management (Achermann, 2009). 20) 1948 International Classification of Disease (ICD), World Health Organization (WHO). Classification system used to collect diagnoses for statistical purposes. Originally used for mortality reporting, but later and today used for morbidity reporting as well ( Kroth, & Young, 2018) . 21) 1950 Major medical insurance Birth of the major medical insurance for catastrophic and prolonged illness, with deductibles and lifetime maximum benefit amounts ( Kroth, & Young, 2018). 22) 1951 The Joint Commission (JC): Facility Accreditation The Joint Commission does accreditation for hospitals and other medical facilities to ensure the facilities pass CMS, State and other inspections, and ensure that services and facilities are safe and effective care of the highest quality and value. ( Kroth, & Young, 2018). 23) 1956 Dependents’ Medical Care Act The Dependents’ Medical Care Act of 1956 was signed into law and provided health care to dependents of active military personnel (precursor to CHAMPVA 1973 and now TriCare 1988 ( Kroth, & Young, 2018). 24) 1966 Social Security Amendments of 1965 Medicare-Title XVIII insurance for Americans over the age of sixty- five (65). Medicaid-Title XIX a cost-sharing program between the federal and state governments to provide health care services to low-income Americans ( Kroth, & Young, 2018). 2

Health and Human Services (DHHS) (DHHS, 2021). 36) 1981 Omnibus Budget Reconciliation Act The OBRA was federal legislation that expanded the Medicare and Medicaid programs. Government became more involved in nursing homes, including restraint restrictions (Svahn, 1981). 37) 1982 BCBS Association The Blue Cross Association and the National Association of Blue Shield merge to create the BlueCross BlueShield Association (BCBSA) ( Kroth, & Young, 2018). 38) 1983 Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) TEFRA created Medicare risk programs, which allowed federally qualified HMOs and competitive medical plans that met specified Medicare requirements to provide Medicare-covered services under a risk contract. TEFRA, today this is known as Medicare Part C or Medicare Advantage. The Act also enacted a prospective payment system (PPS), which is a predetermined payment for inpatient services based on diagnoses codes. The PPS went into effect in 1983 and is called diagnosis-related groups (DRGs), which is the hospital inpatient reimbursement system. Peer review organizations (PROs) (now called quality improvement organizations, or QIOs) were also created ( Kroth, & Young, 2018). 39) 1983 Inpatient Perspective Payment System (IPPS) Medicare IPPS is how hospitals are paid for inpatient stays. Each admission is coded with ICD-10-CM diagnoses and ICD-10-PCS hospital procedure codes. Based on the reason for the admission and the severity of illness and procedures performed, the inpatient stay is assigned a Diagnostic Related Group (DRG). The hospital is paid a flat fee for the cost-based DRG. Reimbursement is based on the primary diagnoses, comorbidities and complications (Severity of Illness) and procedures performed. ( Kroth, & Young, 2018; CMS, 2021e). 40) 1984 CMS Standardization of Information submitted on Medicare Claims HCFA (now known as CMS) required providers to use the HCFA- 1500 (now called the CMS- 1500) to submit Medicare claims. The HCFA Common Procedure Coding System (HCPCS) (now called Health Care Procedure Coding System) was created, which included CPT, level II (national), and level III (local) codes. Commercial payers also adopted HCPCS coding and use of the CMS-1500 claim form. The CPT codes change yearly because technology and medical advancements drive the changes ( Kroth, & Young, 2018). 41) 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) Provides workers and their families who lose their health benefits the right to continue those benefits for 18 months or 36 months due to the death of a spouse ( Kroth, & Young, 2018). 42) 1988 Clinical Laboratory Improvement Act (CLIA) Clinical Laboratory Improvement Act (CLIA) legislation established quality standards for all laboratory testing to ensure the accuracy, reliability, and timeliness of patient test results regardless of where the test was performed (CMS, 2021a) 43) 1989 Agency for Healthcare Research and Quality's (AHRQ) The AHRQ mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable ( Kroth, & Young, 2018). 44) 1989 Health Plan Employer Data and Information Set (HEDIS) The National Committee for Quality Assurance (NCQA) developed the HEDIS which created standards to assess managed care systems using data elements that are collected, evaluated, and published to compare the performance of managed health care plans (Kroth, & 4

Young, 2018). 45) 1991 Standardized Evaluation and Management Codes (Physician Office Visit CPT Codes) The AMA and CMS implement major revision of CPT, creating a new section called Evaluation and Management (E/M), which describes patient encounters were the physician must document for quality purpose, Past, Family and Social History (PFSH), Physical Exam (PE) and Medical Decision Making (MDM) (AMA, 1991). 46) 1991 National Committee for Quality Assurance (NCQA) The NCQA ensures the quality of managed care plans by providing standard and objective information about HMOs (Marjoua, & Bozic, 2012). 47) 1992 Resource-Based Relative Value Scale (RBRVS) system Cost-based fee schedule for physicians under Omnibus Reconciliation Acts (OBRA) was created. Each CPT code is assigned a relative value unit (RVU) and multiply with an annual conversion factor to reimburse the physician more cost effectively based on their work, overhead and risk of malpractice (McCormack & Burge, 1994). 48) 1993 Clinton proposed the Health Security Act of 1993 Based on six guiding principles of security, simplicity, savings, choice, quality, and personal responsibility (Kroth, & Young, 2018). 49) 1996 National Correct Coding Initiative (NCCI) The NCCI was created to promote correct coding initiatives and to eliminate improper medical coding. NCCI edits are developed based on coding conventions defined in the American Medical Association’s Current Procedural Terminology (CPT) manual (CMS, 2021c). 50) 1996 Health Insurance Portability and Accountability Act of 1996 (HIPAA) The HIPAA established regulations that govern privacy, security, and electronic transactions standards for health care information. It also created portability of health insurance when an employee terms from their job. The primary intent of HIPAA is to provide better access to health insurance, limit fraud and abuse, and reduce administrative costs (Kroth, & Young, 2018). 51) 1997 Balanced Budget Act (BBA); Children’s Health Insurance Plan (CHIP); OIG Fraud & Abuse Audits Title XXI, State Children’s Health Insurance Program (SCHIP) established to provide uninsured, low-income children health insurance under state Medicaid programs. The Balanced Budget Act of 1997 (BBA) addresses health care fraud and abuse issues. The DHHS Office of the Inspector General (OIG) provides investigative and audit services in health care fraud cases (Kroth, & Young, 2018). 52) 1999 Center for Improvement in Healthcare Quality (CIHQ) The CIHQ is a membership-based organization comprised primarily of acute care and critical access hospitals, for which is provides accreditation services (CIHQ, 2021). 53) 1999 Omnibus Consolidated and Emergency Supplemental Appropriations Act (OCE- SAA) amended the BBA of 1997 to require the development and implementation of a Home Health Prospective Payment System (HHPPS) The OCE- SAA required the development and implementation of a Home Health Prospective Payment System (HHPPS), which reimburses home health agencies at a predetermined rate for health care services provided to patients. The HH PPS was implemented October 1, 2000 and uses the Outcomes and Assessment Information Set (OASIS), a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (McCall et al., 2013). 54) 2000 Outpatient Prospective Payment System (OPPS) Medicare’s OPPS is used to pay hospital outpatient services. Ambulatory Payment Classifications (APCs) are used to calculate reimbursement and is for hospital-based outpatient claims. It is a cost-based system that uses CPT codes and 5

caps on benefits and extends coverage of college students to age 26 (Kroth, & Young, 2018). 66) 2014 National Coordinator for Health Information Technology (ONC) The ONC is office that supports the administration's healthIT.gov efforts. It is a primary resource to the entire health system to support the adoption of health information technology and the promotion of nationwide, standards-based health information exchange (HealthIT, 2021). 67) 2015 Hospital Quality Reporting (HQR) and Initiative (H.Q.I.) The HQR began in 2003, mandated by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. Failure to successfully report resulted in a 0.4 percentage point reduction in the annual market basket used in the reimbursement. This increased to a 2.0 percent reduction under the Deficit Reduction Act of 2005. Under the American Recovery and Reinvestment Act of 2009 and the Affordable Care Act of 2010 the reduction is one-quarter of the hospitals applicable annual payment rate in 2015 and beyond if all Hospital Inpatient Quality Reporting Program requirements are not met (CMS, 2021b). 68) 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS) Repeals the Sustainable Growth Rate (PDF) formula, Value- Based purchasing. Implements MIPS, which combines he former PQRS reporting system with ePrescribe, and meaningful use into the one program with four (4) components. The reporting components are Quality Measures (QM), Promoting Interoperability (PI), Improvement Activities (IA) and Costs. For larger integrated delivery systems and Accountable Care Organizations (ACOs) a new Advanced Payment Models (QPP, 2021). 69) 2021 American Rescue Plan Act The American Rescue Plan Act of 2021, also called the COVID-19 Stimulus Package or American Rescue Plan The ARPA Expands A.C.A. health insurance subsidies and lowers costs (CMS, 2021). 70) 2021 Medicare Care Compare Medicare search engines that allow Medicare recipients to sign up, log in and find and compare nursing homes, hospitals, physicians other providers of care. There is also a lookup externally for non-Medicare patients, but the data is limited. The compare data compares from the quality measures and cost data submitted through the quality reporting programs. The data provides transparency and was initiated by the consumerism movement in healthcare (Medicare, 2021). 71) 2030-2000 Healthy People 2000, 2010, 2020, 2030 Healthy People 2030 is the 5 th decade of the program. Healthy People 1990 began a ten-year population health initiative. Every ten years since its inception goals have been set, population health data is measured, and outcomes are analyzed. The 1990 to 2000 was the baseline of the program. For Healthy People 2000, the second iteration of the initiative, was guided by 3 broad goals, a) increase the span of healthy life, b) reduce health disparities and c) achieve access to preventive services for all. For Healthy People 2010, the focus increased on improving quality of life. The one significant overarching goals was to eliminate health disparities and not just simply reduce them. For Healthy People 2020 there were four goals, i.e., a) attain a high-quality of life, b) live longer without preventable disease, disability, injury or premature death, c) achieve health equity and eliminate disparities, and d) improve all 7

groups in regard to health status. Finally, for Healthy People 2030, the fifth iteration rolled out in August 2021, there is and increased emphasis on the lessons learned over the last 4 decades to improve health equity, health literacy and a new concentration on well-being (Health, 2021; Kroth, & Young, 2018). References Achermann, J. (2009). Small gifts and big trouble: Clarifying the Taft Hartley act. University of San Francisco Law Review , 44(1), 63-94. American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). (2021). We maintain the highest standards for outpatient accreditation. [website]. Retrieved from https://www.aaaasf.org/who-we-are/ Center for Improvement in Healthcare Quality (CIHQ). (2021). Welcome to CIHQ. [website]. Retrieved from https://www.cihq.org/ Centers for Medicare and Medicaid (CMS). (2021). Physician Fee Schedule Proposed Rule with Comment Period. [website]. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/PhysicianFeeSched Centers for Medicare and Medicaid (CMS). (2021a). Clinical Laboratory Improvement Amendments (CLIA). [website]. Retrieved from https://www.cms.gov/Regulations-and- Guidance/Legislation/CLIA Centers for Medicare and Medicaid (CMS). (2021b). Hospital Inpatient Quality Reporting Program. [website]. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HospitalQualityInits/HospitalRHQDAPU Centers for Medicare and Medicaid (CMS). (2021c). National Correct Coding Initiative Edits. [website]. Retrieved from https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd Centers for Medicare and Medicaid (CMS). (2021d). Hospital Outpatient Prospective Payment System (OPPS). [website]. Retrieved from https://www.cms.gov/Research-Statistics-Data-and- Systems/Files-for-Order/LimitedDataSets/HospitalOPPS Centers for Medicare and Medicaid (CMS). (2021e). Acute Inpatient Perspective Payment System. [website]. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AcuteInpatientPPS Chaudhry, H.J. (2010). The Important Role of Medical Licensure in the United States. Academic Medicine : November 2010 - Volume 85 - Issue 11 - p 1657 Doi: 10.1097/ACM.0b013e3181f557ed Department of Health and Human Services (DHHS). (2021). Historical Highlights. [website]. Retrieved from https://www.hhs.gov/about/historical-highlights/index.html Derickson A. (2002). "Health for three-thirds of the nation": public health advocacy of universal access to medical care in the United States. American Journal of Public Health , 92(2), 180–190. https://doi.org/10.2105/ajph.92.2.180 Dotson P. (2013). CPT® Codes: What Are They, Why Are They Necessary, and How Are They Developed?. Advances in Wound Care, 2(10), 583–587. https://doi.org/10.1089/wound.2013.0483 Gabay M. (2013). The federal controlled substances act: schedules and pharmacy registration. Hospital pharmacy , 48(6), 473–474. https://doi.org/10.1310/hpj4806-473 Health. (2021). History of Healthy People. [website]. Retrieved from https://health.gov/our-work/healthy- people/about-healthy-people/history-healthy-people HealthIT. (2021). At the forefront of health IT, our vision is high-quality care, lower costs, healthy population, and engaged people. News. [website]. Retrieved from https://www.healthit.gov/ Kroth, P.J., Young, K.M. (2018). Shultz & Young's Health Care USA Understanding Its Organization and Delivery . 9th Edition. Jones & Bartlett. Marjoua, Y., & Bozic, K. J. (2012). Brief history of quality movement in US healthcare. Current reviews in Musculoskeletal Medicine , 5(4), 265–273. https://doi.org/10.1007/s12178-012-9137-8 8