| 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 license, discipline, and regulate physicians and other health care 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 Pennsylvania School of Nursing, n.d.). |
| 7) 1908 Workers’ compensation legislation |
President Theodore Roosevelt signed legislation to provide workers’ compensation (WC) for certain federal employees in unusually hazardous jobs (U.S. Department of Labor, n.d.). |
| 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 (U.S. Department of Labor, n.d.). |
| 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 (Young & Kroth, 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 health care 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). |
| 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 (Young & Kroth, 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 (Young & Kroth, 2018). |
| 15) 1930 Blue Shield (BS) Plans |
Blue Shield (BS) 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 (Young & Kroth, 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 (Young & Kroth, 2018; FDA, n.d.). |
| 17) 1939 Wagner National Health Act (S.1620) |
The bill would have allowed the states to implement mandatory and universal health care but did not pass due to WWII (United States national health program: Wagner, bill, S. 1620, 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 (Young & Kroth, 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 (Young & Kroth, 2018). |
| 21) 1950 Major medical insurance |
Birth of the major medical insurance for catastrophic and prolonged illness, with deductibles and lifetime maximum benefit amounts (Young & Kroth, 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 (Young & Kroth, 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) (Young & Kroth, 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 (Young & Kroth, 2018). |
| 25) 1966 Current Procedural Terminology (CPT) |
The Current Procedural Terminology (CPT) codes were developed by the AMA in 1966 as a way to describe and track physician and other professional medical services. The CPT Code book is updated annually, and changes go into effect on January 1 of each new year (Dotson, 2013). |
| 26) 1970 Controlled Substances Act (CSA); Drug Enforcement Agency (DEA): Controlled substances |
Controlled Substances Act (CSA) was created to improve the manufacturing, importation and exportation, distribution, and dispensing of controlled substances. Manufacturers, distributors, and dispensers of controlled substances must be registered with the Drug Enforcement Administration (DEA) (Gabay, 2013). |
| 27) 1970 Occupational Safety and Health Administration Act OSHA) |
The Occupational Safety and Health Administration Act (OSHA) was designed to protect all employees against injuries from occupational hazards in the workplace (Young & Kroth, 2018). |
| 28) 1972 Professional Standards Review Organizations (PSROs) |
Created as part of Title XI of the Social Security Amendments Act of 1972 were Professional Standards Review Organizations (PSROs), which were physician-controlled nonprofit organizations that contracted with CMS to provide for the review of hospital inpatient resource utilization, quality of care, and medical necessity. The PSROs were replaced with Peer Review Organizations (PROs), as a result of the Tax Equity and Fiscal Responsibility Act of 1982, or TEFRA (Young & Kroth, 2018). |
| 29) 1973 Health Maintenance Organization Act |
The Health Maintenance Organization Assistance Act of 1973 authorized federal grants and loans to private organizations that wished to develop health maintenance organizations (HMOs), which are responsible for providing health care services to subscribers in a given geographic area for a fixed fee (Young & Kroth, 2018). |
| 30) 1974 Employee Retirement Income Security Act of 1974 (ERISA) |
ERISA is a federal law that sets minimum standards for most voluntarily established retirement and health plans in private industry to provide protection for individuals in these plans. This law allows employers to be self-insured (Young & Kroth, 2018). |
| 31) 1975 U.S. Nuclear Regulatory Commission (NRC) |
The NRC is a federal agency that ensures safe use of radioactive materials. They license and regulate the nation’s civilian use of radioactive materials to provide reasonable assurance of adequate safety for people and the environment. In health care this would include all diagnostic medical use, therapeutic medical use, and medical research use (United States Nuclear Regulatory Commission, 2020). |
| 32) 1976 Food and Drug Administration (F.D.A.): Medical Equipment |
FDA: Medical Device Amendments passed to ensure safety and effectiveness of medical devices, including diagnostic products (FDA, n.d.). |
| 33) 1977 Health Care Financing Administration (HCFA) |
The DHHS combine health care financing and quality assurance programs into one agency, HCFA. Medicare and Medicaid programs were transferred to HCFA, which is now CMS (Young & Kroth, 2018). |
| 34) 1980 American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) |
The AAAASF was established to standardize and improve the quality of health care in outpatient facilities. AAAASF accredits thousands of facilities worldwide including clinics, surgery centers, and state/federal health agencies, and patients acknowledge that AAAASF sets the “Gold Standard in Accreditation” (American Association for Accreditation of Ambulatory Surgery Facilities, n.d.). |
| 35) 1980 Department of Health and Human Services (DHHS) |
The Office of Education and the Department of Health, Education and Welfare (HEW) became the Department of Health and Human Services (DHHS) (U.S. Department of Health & Human Services, n.d.). |
| 36) 1981 Omnibus Budget Reconciliation Act (OBRA) |
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) (Young & Kroth, 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 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 (Young & Kroth, 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 (Young & Kroth, 2018; Centers for Medicare & Medicaid Services, 2021a). |
| 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-41500) 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 (Young & Kroth, 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 (Young & Kroth, 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 (Centers for Medicare & Medicaid Services, 2021b). |
| 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 (Young & Kroth, 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 (Young & Kroth, 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 where 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 multiplied 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 (Young & Kroth, 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 (Centers for Medicare & Medicaid Services, 2021f). |
| 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 (Young & Kroth, 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 (Young & Kroth, 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 it provides accreditation services (Center for Improvement in Healthcare Quality, n.d.). |
| 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 HHPPS 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 payment classifications to pay for similar services under group flat fee payments (Centers for Medicare & Medicaid Services, 2021e). |
| 55) 2000 Benefits Improvement and Protection Act of 2000 (BIPA) |
The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) requires implementation of a $400 billion prescription drug benefit, improved Medicare Advantage (formerly called Medicare+Choice) benefits, faster Medicare appeals decisions, and more (Young & Kroth, 2018). |
| 56) 2000 Managed Market Competition; Consumer-driven health plans |
Markets were consolidating and managed care was accelerating, and consumer were driving the insurance market-driven health plans. Consumers want the best health care at the lowest cost. Consumer-driving plans were, for example, employer-paid with high-deductible insurance plans with medical savings accounts used by employees to cover deductibles and other medical costs when covered amounts are exceeded (Well, 2002). |
| 57) 2001 Administrative Simplification Compliance Act (ASCA) |
The ASCA establishes the compliance date (October 16, 2003) for modifications to the Electronic Transaction Standards and Code Sets as required by HIPAA. Covered entities must submit Medicare claims electronically unless the Secretary of DHHS grants a waiver (Centers for Medicare & Medicaid Services, 2021c). |
| 58) 2002 announced that quality improvement organizations (QIOs) |
CMS OIOs perform utilization and quality control review of health care furnished, or to be furnished, to Medicare beneficiaries. QIOs replaced peer review organizations (PROs), which previously performed this function (Young & Kroth, 2018). |
| 59) 2005 National Provider Identifier, NPI |
The Standard Unique Health Identifier for Health Care Providers (or National Provider Identifier, NPI) is implemented (Centers for Medicare & Medicaid Services, 2021c). |
| 60) 2005 Patient Safety and Quality Improvement Act of 2005 |
Amends Title IX of the Public Health Service Act to provide for improved patient safety and reduced incidence of events adversely affecting patient safety. It encourages the reporting of health care mistakes to patient safety organizations by making the reports confidential and shielding them from use in civil and criminal proceedings (Centers for Medicare & Medicaid Services, 2021c). |
| 61) 2005 Deficit Reduction Act of 2005 |
Created the Medicaid Integrity Program (MIP), which is a fraud and abuse detection initiative and program (Young & Kroth, 2018). |
| 62) 2006 Physician Quality Reporting Initiative (PQRI) or System (PQRS) |
The Tax Relief and Health Care Act of 2006 (TRHCA) authorized implementation of a physician quality reporting system that establishes a financial incentive for eligible professionals who participate in a voluntary quality reporting program (Young & Kroth, 2018). |
| 63) 2009 American Recovery and Reinvestment Act of 2009 |
The American Recovery and Reinvestment Act (ARRA) authorized an expenditure of $1.5 billion for grants for construction, renovation and equipment, and the acquisition of health information technology systems (Young & Kroth, 2018). |
| 64) 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act |
The Health Information Technology for Economic and Clinical Health (HITECH) Act provides DHHS with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange (Young & Kroth, 2018). |
| 65) 2010 Patient Protection and Affordable Care Act (2010) |
The PPACA (2010) provides quality affordable access to health insurance for Americans. The Act provides a broader range of mandated prevention services, where patients are not to be charged copayments or deductibles on those services to incent them to get the preventive services. The Act eliminates lifetime caps on benefits and extends coverage of college students to age 26 (Young & Kroth, 2018). |
| 66) 2014 National Coordinator for Health Information Technology (ONC) |
The ONC is the 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.gov, 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 hospital’s applicable annual payment rate in 2015 and beyond if all Hospital Inpatient Quality Reporting Program requirements are not met (Centers for Medicare & Medicaid Services, 2021d). |
| 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 the former PQRS reporting system with ePrescribe and meaningful use into the one program with four (4) components (Quality Payment Program, n.d.). |
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69) 2021 American Rescue Plan Act (ARPA) |
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 (Centers for Medicare & Medicaid Services, 2021c). |
| 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 look up 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 health care (Medicare.gov, 2021). |
| 71) 2030-2000 Healthy People 2000, 2010, 2020, 2030 |
Healthy People 2030 is the fifth 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 span of time 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 goal was to eliminate health disparities and not just simply reduce them. For Healthy People 2020 there were four goals: 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 groups in regard to health status. Finally, for Healthy People 2030, the fifth iteration rolled out in August 2021, there is 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.gov, n.d.; Kroth, & Young, 2018). |
