aupha/hap editorial board for graduate studies · the guide to healthcare reform : readings and...
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AUPHA/HAP Editorial Board for Graduate Studies
Thomas J. Stranova Jr., ScD, Chairman Tulane University
LTC Lee W. Bewley, PhD, FACHE Army Baylor University
José A. Capriles, MD University of Puerto Rico
Dolores G. Clement, DrPH, FACHE Virginia Commonwealth University
Michael Counte, PhD St. Louis University
Jonathan P. DeShazo, PhD Virginia Commonwealth University
Mark L. Diana, PhD Tulane University
Blair D. Gifford, PhD University of Colorado
James W. Henderson, PhD Baylor University
Suzanne Hobbs, DrPH University of North Carolina at Chapel Hill
Pamela R. McCoy Loyola University Chicago
Nir Menachemi, PhD University of Alabama at Birmingham
Mary S. O’Shaughnessey, DHA University of Detroit Mercy
Andrea G. Sodano, PhD Boston University School of Management
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Library of Congress Cataloging-in-Publication Data
The guide to healthcare reform : readings and commentary / Daniel B. McLaughlin, editor. pages cm Includes index. ISBN 978-1-56793-694-0 1. National health insurance—Law and legislation—United States. 2. United States. Patient Protection and Afford-able Care Act. 3. Health insurance—Law and legislation—United States. 4. Health care reform—United States. 5. Medical care—Law and legislation—United States. 6. Health services accessibility—United States. 7. Medical policy—United States. I. McLaughlin, Daniel B., 1945– editor. II. Title: Guide to healthcare reform. KF3605.G85 2015 346.73'086382—dc23 2014030723
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To my family—Sharon, Kelly, Katie, and Paul
v i i
BRIEF CONTENTS
Preface ......................................................................................................................xv
Acknowledgments ................................................................................................xix
Chapter 1 Introduction ........................................................................................... 1
Chapter 2 The Affordable Care Act ......................................................................... 5
Additional Readings .....................................................................16
Chapter 3 Prevention, Wellness, and Population Health ....................................... 22
Additional Readings .....................................................................31
Chapter 4 Chronic Disease Management and Primary Care ............................... 102
Additional Readings ...................................................................112
Chapter 5 Productivity and Quality .................................................................... 170
Additional Readings ...................................................................179
v i i i B r i e f C o n t e n t s
Chapter 6 Payment Incentives ............................................................................ 226
Additional Readings ...................................................................240
Chapter 7 The Safety Net .................................................................................... 301
Additional Readings ...................................................................309
Chapter 8 The Perfect Market: Health Insurance Reform ................................... 315
Additional Readings ...................................................................326
Chapter 9 Health Policy and Advocacy ............................................................... 349
Additional Readings ...................................................................354
Chapter 10 The Future ......................................................................................... 406
Appendix ............................................................................................................... 415
i x
DETAILED CONTENTS
Preface ......................................................................................................................xv
Acknowledgments ................................................................................................xix
Chapter 1 Introduction ........................................................................................... 1The Journey ............................................................................................ 1Purpose of This Book ............................................................................. 1How the Book Is Organized ................................................................... 3Objectives .............................................................................................. 3Summary ................................................................................................ 4Applications: Discussion and Research ................................................... 4References .............................................................................................. 4
Chapter 2 The Affordable Care Act ......................................................................... 5The Groundwork Is Laid ........................................................................ 5The Three Theories ................................................................................. 6Legal Challenges to the ACA ................................................................ 13How to Use This Book ......................................................................... 14Summary .............................................................................................. 14Applications: Discussion and Research ................................................. 14References ............................................................................................ 15
x D e t a i l e d C o n t e n t s
Additional Reading .......................................................................16Reading 2A: Legal Issues in Health Insurance and
Health Reform (excerpt) .............................................................. 16Dean M. Harris
Chapter 3 Prevention, Wellness, and Population Health ....................................... 22Clinical Prevention ............................................................................... 22Wellness ............................................................................................... 25Community Building ........................................................................... 26Summary .............................................................................................. 28Applications: Discussion and Research ................................................. 29References ............................................................................................ 29
Additional Readings .....................................................................31Reading 3A: Introduction/Population Health Management ................ 31
Ann S. McAlearneyReading 3B: Population Health: Practicing Population Health
Management and Measuring Its Success ....................................... 57David B. Nash
Reading 3C: Community Health: A Measurable Management Task ............................................................................................. 64
Connie J. EvashwickReading 3D: ACA Integration Initiatives That Promote
Collaboration ............................................................................... 73Connie J. Evashwick
Reading 3E: Population Health Improvement: A Community Health Business Model That Engages Partners in All Sectors ........ 80
David A. Kindig and George Isham
Chapter 4 Chronic Disease Management And Primary Care............................... 102The Chronic Care Model ................................................................... 102The HITECH Act and Meaningful Use ............................................. 104Policies to Support Chronic Care in the ACA .................................... 104Summary ............................................................................................ 109Notes ................................................................................................. 110Applications: Discussion and Research ............................................... 110References .......................................................................................... 111
Additional Readings ...................................................................112Reading 4A: Government Policy and Healthcare Reform ................. 112
Gerald L. Glandon, Detlev H. Smaltz, and Donna J. Slovensky
x i D e t a i l e d C o n t e n t s
Reading 4B: Coordinating Care to Provide Effective Population Health Management .................................................................. 144
Heather Jorna and Stephen A. Martin, Jr.Reading 4C: The Patient-Centered Medical Home Solution to
the Cost-Quality Conundrum .................................................... 151Michael Ewing
Reading 4D: Primary Care ................................................................ 161Phoebe Lindsey Barton
Chapter 5 Productivity and Quality .................................................................... 170Productivity ....................................................................................... 170Quality ............................................................................................... 173Health Plan Quality Rating System .................................................... 175Summary ............................................................................................ 177Applications: Discussion and Research ............................................... 177Note .................................................................................................. 178References .......................................................................................... 178
Additional Readings ...................................................................179Reading 5A: How Purchasers Select and Pay for Value: The
Movement to Value-Based Purchasing ....................................... 179François de Brantes
Reading 5B: The Quality Improvement Landscape ............................ 194Kimberly D. Acquaviva and Jean E. Johnson
Chapter 6 Payment Incentives ............................................................................ 226Incentives: The Carrots ....................................................................... 228Penalties: The Stick ............................................................................ 231Fraud and Abuse: The Big Stick ......................................................... 232The Backup Plans ............................................................................... 233Affordability ....................................................................................... 234Structure ............................................................................................ 235Healthcare Inflation Today ................................................................ 235Summary ............................................................................................ 235Applications: Discussion and Research ............................................... 236References .......................................................................................... 237
Additional Readings ...................................................................240Reading 6A: The Accountable Care Organization .............................. 240
Marc Bard and Mike Nugent
x i i D e t a i l e d C o n t e n t s
Reading 6B: What Every CEO Should Know About Medicare’s Recovery Audit Contractor Program. ......................................... 272
Alan J. Goldberg and Linda M. YoungReading 6C: The Quest for Affordability in Healthcare ..................... 277
Bernard J. TysonReading 6D: The Medicare Hospital Payment Update ...................... 283
Daniel B. McLaughlinReading 6E: Post-Acute Care and Vertical Integration After
the Patient Protection and Affordable Care Act. ......................... 286Patrick D. Shay and Stephen S. Mick
Chapter 7 The Safety Net .................................................................................... 301Eligibility ........................................................................................... 302Navigators .......................................................................................... 302Dual-Eligible Beneficiaries .................................................................. 303Hospitals ............................................................................................ 303Rural Healthcare ................................................................................ 304Community Clinics ............................................................................ 305Healthcare Disparities ........................................................................ 305Summary ............................................................................................ 306Notes ................................................................................................. 306Applications: Discussion and Research ............................................... 307References .......................................................................................... 307
Additional Reading .....................................................................309Reading 7A: Equity of Care—Eliminating Healthcare
Disparities: The Call to Action. .................................................. 309Richard J. Umbdenstock
Chapter 8 The Perfect Market: Health Insurance Reform ................................... 315Universal Coverage ............................................................................. 315Health Insurance Exchanges .............................................................. 316Standard Benefits ............................................................................... 320Increased Government Regulation...................................................... 321Summary ............................................................................................ 323Applications: Discussion and Research ............................................... 323Note .................................................................................................. 324References .......................................................................................... 324
Additional Reading .....................................................................326Reading 8A: Health Insurance Exchanges .......................................... 326
Michael A. Morrisey
x i i i D e t a i l e d C o n t e n t s
Chapter 9 Health Policy and Advocacy ............................................................... 349Health Policy Process ......................................................................... 349The States ........................................................................................... 350Health Policy and Advocacy ............................................................... 350Summary ............................................................................................ 352Applications: Discussion and Research ............................................... 353Reference............................................................................................ 353
Additional Readings ...................................................................354Reading 9A: The Context and Process of Health
Policymaking ............................................................................. 354Buford B. Longest, Jr.
Reading 9B: Health Policymaking at the State and Local Levels and in the Private Sector ............................................................ 386
Leiyu Shi
Chapter 10 The Future ......................................................................................... 406Making Changes: The Process ............................................................ 406Potential Targets for Change .............................................................. 407Good Ideas Likely To Remain ............................................................ 410What About a Repeal? ........................................................................ 411System Changes ................................................................................. 411Summary ............................................................................................ 412Conclusion ......................................................................................... 413Applications: Discussion and Research ............................................... 413References .......................................................................................... 413
Appendix ............................................................................................................... 415