HEALTH REFORM The Patient Protection and Affordable Care Act

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HEALTH REFORM The Patient Protection and Affordable Care Act. PPACA: THE REAL STORY. The Great Dealmaker The Obama Administration made a series of deals to pass PPACA:.
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HEALTH REFORM The Patient Protection and Affordable Care Act PPACA:THE REAL STORY The Great DealmakerThe Obama Administration made a series of deals to pass PPACA:
  • The insurance industry: Assured that everyone would be required to buy their product -- and there would be no public option
  • The drug industry: No negotiation on prices
  • The AMA: No cut in physician fees
  • Hospitals: No cut in reimbursements, only slower growth in payments
  • Employers: Continued control of health benefits
  • Nervous members of the public: “You can keep what you have”
  • Starting in 2014: The Insurance Mandate
  • Citizens and legal immigrants required to be insured. Penalties up to 2.5% of income.
  • Insurers required to take everyone.
  • State-based insurance “exchanges” for individuals and small employers
  • Subsidies up to 400% Federal poverty level so premium (only) is less than 9.5% of income
  • “Hardship waiver” if premium greater than 8% of income  Can remain uninsured.
  • Medicaid for all below 133% poverty level
  • Exhibit 2. System Improvement Provisions of Affordable Care Act of 2010 Note: ACO = accountable care organization; PCP = primary care physician; AHRQ = Agency for Healthcare Research and Quality. HHS = Department of Health and Human Services Source: Commonwealth Fund analysis. Health Reform Provisions That Took Effect September 23, 2010: Emergency Room Patient Protections: No prior authorization or higher cost sharing Lifetime/Annual Limits: Phases in elimination of lifetime limits on healthcare benefits. OB/GYN Patient Protections: Prohibits requiring a referral to see an obstetrician or gynecologist. Preventive Health Services: Requires no copayment or deductible for certain preventive services. Dependent Coverage: Allows adult children under the age of 26 to stay in a parent's health plan.. Pre-existing Condition Exclusions for Children: Prohibits denying coverage to individuals under the age of 19 based on a preexisting condition. Rescission:Prohibits insurers from rescinding coverage Appealing Insurance Company Decisions: Provides consumers a way to appeal coverage determinations Health Reform Provisions That Took Effect January 1, 2011 Establishes State and Federal Preexisting Condition Insurance Programs: Minimum Loss Ratio for Insurers: 85% for large group and 80% for small group insurance. Closing the Medicare Drug Gap: Drug makers give a 50% discount in the donut hole. Medicare Primary Care Payments: 10% bonus to primary care docs and shortage area surgeons. Medicare Prevention Benefits: Co-pays and deductibles eliminated. Center for Medicare and Medicaid Innovation: Established and funded. Medicare Premiums: Raised for higher income beneficiaries. Medicare Advantage Plan Payments: Restructure to decrease federal subsidy. Medicaid Health Homes: Starts innovation to restructure care. CLASS Program: Starts voluntary insurance program for community living support services National Quality Strategy: Program established. Overall Consequences of PPACA
  • Continued reliance on private insurance
  • Employment-based insurance unchanged
  • Market competition will determine what health care costs (insurance premiums, co-pays, deductibles) and how it works (payment and denial practices)
  • Nothing but experimental pilot programs to try and reduce system costs, so there will be no likely reduction in costs or waste Result: The program will make very little difference in the lives of most people. Why? Because there’s no change in the way we will be paying for health care. The price problem that health-care reform failed to cure By Alec MacGillis The Washington Post October 24, 2010 [T]he Democrats' effort to sell the law to the public may be undermined by what even some ardent supporters consider its biggest shortfall. The overhaul left virtually untouched one big element of our health-care dilemma: the price problem.There is no government "single payer" on the other side of the table…. The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay…. The main reason for this is politics. So there was no price fight. It is one of those fine political ironies: The law derided as socialism may have had an easier time winning favor from a skeptical public if it was, well, a little more socialist.
  • By 2012 'Obamacare' In California: President's Affordable Care Act Has Been 'Lifesaving' For Golden State **About 8,600 Californians with pre-existing medical conditions have gained access to affordable health insurance. Patients who have illnesses such as cancer or multiple sclerosis - who face high costs or denials on the open market - can buy insurance through the program. **More than 350,000 young adults have been able to stay on their parents' health insurance plans until they are 26. **More than 370,000 low-income people have been covered by an expansion of Medi-Cal, the health insurer for low-income Californians, that is part of the state's "bridge to reform" waiver to alter the state-federal program. ** Consumers saved more than 100 million dollars when health insurance rate increases were rolled back or withdrawn as a result of increased regulatory power to review those increases. ** Seniors saved171 million dollars in prescription drug costs in a plan to close the Medicare limits in coverage. **12 million people who currently have health insurance no longer face a cap on coverage in case of a catastrophic illness.  One of the major flaws of the Affordable Care Act is that underinsurance will become the new standard for health insurance in the United States. The most common plans that will be purchased in the state insurance exchanges will fall well below the coverage that most people have today. The cheapest plans in the exchanges - bronze plans with an actuarial value of 60% (patient pays an average of 40% of covered costs) - will have deductibles of $4,375 for an individual ($8,750 for families) with coinsurance of 20% (the patient pays 20% of the amount over the deductible). The deductible can be reduced to $3,475 for an individual but then the patient faces a staggering coinsurance of 40%. Because of the availability of income-indexed subsidies, it is likely that silver plans with an actuarial value of 70% will be the most commonly selected plans. These are still well below the typical employer-sponsored plans which have an average actuarial value of 82%. The deductible for the silver plans would be $2,050 for an individual with a 20% coinsurance rate. The deductible could be reduced to $650 but, again, the coinsurance rate would increase to 40%. The 2014 limit for maximum out-of-pocket spending will be $6,350 for an individual or $12,700 for a family (on top of the portion of the premium that that must also be paid). These income-adjusted increases in cost sharing will still be excessive for most individuals and families with significant health problems and with all of the other financial problems that often are associated with ill health. Defining Essential Health Benefits — The View from the IOM Committee John K. Iglehart October 7, 2011 (10.1056/NEJMp1109982) When Congress enacted the Affordable Care Act (ACA), it mandated that a broad package of “essential health benefits” (EHBs) equivalent to that of a “typical employer plan” be offered by qualified health plans participating in newly created state-based insurance exchanges, as well as by new plans offered to individuals and small employers outside these exchanges. Congress directed the Department of Health and Human Services (DHHS) to flesh out the details. The DHHS, in turn, asked the Institute of Medicine (IOM) to recommend a process for defining and updating the EHB package — but notably, not to develop a specific list of benefits. In a report released on October 7, the IOM recommended that the initial EHB package be equivalent in scope to what could be purchased by the average premium that a small business would pay on behalf of an employee…Over time, under the ACA, an estimated 30 million uninsured individuals and employees of small businesses (fewer than 100 workers) with low-to-moderate incomes will become eligible for federally subsidized coverage through insurance exchanges or expansions of Medicaid programs…. The IOM report acknowledges that “the determination of the EHB is a politically and socially charged endeavor.” The report said the cost trend will not be moderated only by the definition of EHBs and added: “The committee considered whether complementary Medicare-only or federal-only approaches to reducing rising health costs would be sufficient and concluded they would not be. An all stakeholder strategy is required across the public and private sectors,” and the ACA-created independent payment advisory board, even if it survives strong opposition to its creation, will not include formal engagement of the private sector. By expressing its concern over health care costs whose annual increases outstrip the growth of the economy, the committee has issued a wake-up call for policymakers, clarifying how this spending pattern squeezes out other important competing needs, particularly in a no-growth economy. However, such previous warnings, as often as they have been issued, have largely fallen on deaf ears. TEN WAYS INSURANCE COMPANIES CAN GAME THE SYSTEM 1. Raising premiums There is no prohibition on companies raising premiums until 2014. 2. Denying or revoking coverage for people with pre-existing conditions (EXCEPT FOR CHILDREN) until 2014.3. Changing your insurance plan Raising premiums, shutting down or restricting access to less costly care plans like HMOs and pushing current customers into high-deductible plans, where customers have to pay significant expenses out of pocket before the insurance company picks up a dime. 4. Making life more difficult for doctorsReducing insurance payouts by expanding prior authorization barriers, lowering provider payment rates, and making it more difficult to file claims. 5. Selling across state lines Allowing insurance to escape oversight by the most competent state regulators. 6. Marketing only to healthy people Making certain drugs hard (or impossible) to find on pharmaceutical formularies, limiting access to certain hospitals or centers of excellence for certain chronic diseases or putting up physical barriers at enrollment meetings will keep sicker people from applying for their insurance. 7. Re-label current overhead expenses as health care When the reform finally takes full effect in 2014, insurance companies will have to spend 80 percent of their premiums on care for their customers. Thus, in order to make more money, they’ll have to increase the money you spend on care, or figure out a way to classify expenses currently deemed “overhead” as “health care for you.” 8. Taking full advantage of the unhealthy behavior premium In the reform, insurers are allowed to makes premiums 50 percent more expensive for consumers who engage in “unhealthy” behaviors, which was intended to allow them to continue charging smokers higher premiums. But there are lots of behaviors which can be deemed “unhealthy,” such as unprotected sex, eating fast foods, drunk driving. 9. Charging older people as much as they can The law allows insurers to charge people between 55 and 65 (the current age of Medicare eligibility) three times more than people 54 and under. 10. Increasing otherwise unregulated copayments and deductibles for medical services and pharmaceuticals. Impact of Health Reform on:Health Care Costs (Expansions) All figures reflect spending through 2019 Impact of Health Reform on:Health Care Costs (Savings) All figures reflect spending through 2019 Clinical Care Transformation Model Accountable Care Organization
  • Medical Groups
  • Enterprise Level Activities
  • PC-MH Functions
  • Hospitals
  • Service Line Integration
  • Medical Staff Alignment
  • Incentives for Efficiency & Lean Six Sigma
  • Quality (SCIP, Leap Frog)
  • Safety
  • Skilled Nursing Facilities
  • SNFists
  • On-site Case Management
  • Efficiency Rating Systems “Preferred Facilities”
  • Outcomes & Evidence Based Medicine
  • Call Coverage
  • Consult Services (Stroke, STEMI)
  • Ancillary Services
  • Free-Standing ASC & Diagnostic Testing Centers
  • Medical Group Enterprise Level Activities
  • ER Avoidance Programs
  • Urgent Care
  • End of Life (Palliative Care)
  • Patient Satisfaction & Loyalty
  • PCP/SCP Incentives & Clinical Guidelines
  • Pay for Performance Initiatives
  • Hospitalists, Post Discharge Follow-Up Programs
  • Home Care
  • Home Safety Visits
  • Post Discharge Visits
  • Home Health Coordinator of Services
  • DME
  • Integration & Oversight with Care Management
  • Care management (Acute, Chronic, Inpatient, SNF)
  • Health Coaching (Shared Decision Making)
  • Transition of Care
  • Provider Satisfaction
  • Behavioral & Mental Health
  • Advanced Primary Care Under Patient-Centered Medical Home
  • Hospice
  • Transitions (CHF, COPD, Frailty Syndrome, Dementia)
  • Cost Effective Medical Management & Utilization of Services (SCP, Ancillary)
  • Access, Same Day Appointments, e-Visits
  • Patient Satisfaction & Loyalty
  • Provider & Office Staff Satisfaction
  • Prevention & Wellness
  • Point of Care Analytics & Clinical Decision Support
  • Gaps in Care
  • Population Management & Chronic Care Registries
  • Home Visiting Teams
  • Generic Prescribing
  • Program
  • Patient
  • Personal Health Record
  • Patient Portal
  • Health Risk Assessment
  • Patient Engagement & Activation
  • ACOs and HMOs:Faith-Based Solutions Capitation as magic bullet Consolidation among providers cuts costs Prevention, care management & EMR/ computers save money P-4-P encourages global quality Risk adjustment can overcome gaming (cherry picking & upcoding of diagnoses) Lessons from the Physician Group Practice Demonstration — A Sobering Reflection Gail R. Wilensky, Ph.D., N Engl J Med 2011; 365:1659-1661 November 3, 2011 In early August, the Center for Medicare and Medicaid Services (CMS) announced the results of the Physician Group Practice (PGP) Demonstration project. Although the headline of the press release was glowing — “Physician Group Practice Demonstration Succeeds in Improving Quality and Reducing Costs” — the reported information suggests more mixed results.1These results should dampen unreasonable expectations, particularly in terms of potential savings, for accountable care organizations (ACOs), which were modeled after the PGP demo…. The demo began in 2005 (the first sobering fact is that it took so many years to get it started) and included 10 large PGPs. All were multispecialty groups, many with well-known names, such as the Marshfield Clinic, Geisinger, Park Nicollet, and Billings; two were associated with academic medical centers — the University of Michigan and Dartmouth. Physician groups in the demo received their regular Medicare payments for services provided to beneficiaries but could also share in the savings generated as long as they met certain quality metrics and exceeded a savings threshold of 2%. Thirty-two quality goals were used, most of them process measures related to coronary artery disease, diabetes, heart failure, hypertension, and preventive care. The savings threshold was calculated by using the per capita expenditures for a comparator group in the same geographic area and adjusting for the case mix and severity of illness.2The PGPs did very well on the quality metrics during all 5 years of the demo. In the fourth year, all 10 groups met at least 29 of the 32 quality goals. The savings are another matter. Even with all their experience, only two of the PGP participants were able to exceed a 2% savings threshold the first year of the demo, and only half managed to surpass that threshold after 3 years…. only half of these 10 experienced PGPs were able to achieve the 2% savings threshold — these results are unexpected and, more important, they suggest (doubts) about the likelihood of success for ACOs. The minimum savings threshold that CMS has proposed for ACOs is also 2% (or 3.9% for plans with fewer patients), but plans will have to share losses as well as gains by year 3. Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries - 15 Randomized Trials Deborah Peikes, PhD; Arnold Chen, MD, MSc; Jennifer Schore, MS, MSW; Randall Brown, PhD JAMA. 2009;301(6):603-618. ObjectiveTo determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. Design, Setting, and Patients Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. InterventionsNurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. Main Outcome Measures Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. ResultsThirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], −0.283 to −0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (−$84; 90% CI, −$171 to $4; P=.12; −$358; 90% CI, −$934 to $218; P=.31; and −$112; 90% CI, −$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. Conclusions Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. The Long-Term Effect of Premier Pay for Performance on Patient Outcomes Ashish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D. March 28, 2012 (10.1056/NEJMsa1112351) Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes. We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality a
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