Download - Health Care Reform 101
22 May 2012HEALTH CARE REFORM
101
The Patient Protection and Affordable Care Act (ACA) was signed into law in March of 2010
A governmental policy that changes the delivery of health care services in a given place
Major Changes: All Americans must have health insurance by 2014 More emphasis on community-based services and less
reliance on institutional careDisease prevention and wellness are major themes
WHAT IS THE ACA?
Broaden the population that receives health care coverage through employment, or public sector insurance companies (e.g. DPW)
Increase the number of health care providers people may choose from
Improve the referral process and the right to be seen by a specialist
Mandate health insurance by reducing the cost and making it affordable for everyone
REFORMS IN THE ACA ATTEMPT TO:
A NEW VOCABULARY
Accountable care organization (ACO)
Basic health programsCarve-outCenters for Medicare and
Medicaid ServicesCommunity health centersFederally Qualified Health
CenterElectronic Health Record
(EHR)Health care homesHealth information
technology (HIT)
Health information privacy and security
Health Insurance Portability and Accountability Act (HIPAA)
Home and Community-Based Services
Information transparencyMeaningful UserMedicaidMedical homePatient Protection and
Affordable Care Act
Insurance Reform (Jan 2014)Coverage Reform (Sept 2010)Quality Reform (Jan 2011 – Dec 2013)
Payment Reform (Mar 2010 – Mar 2020)
HIT Reform (Jan 2011 – Dec 2013)
KEY COMPONENTS
Core feature of the ACAIncludes:
Individual Mandate provisionExpanding Medicaid eligibilityEstablishing Health Insurance ExchangesEstablishing the Essential Health Benefits package
Providing tax incentives to purchase insurance
An estimated 32 million individuals will become insured by 2019
INSURANCE REFORM
Most controversial provision of the ACARequires individuals to obtain health
insurance or pay a penaltyPenalties increase each year Exemptions include:
ReligiousIncarcerationUndocumented status
INDIVIDUAL MANDATE
Individuals and families with incomes up to 133% of the Federal Poverty Level (FPL) will be eligible Appx. $14,850 for an individualAppx. $30,650 for a family of four
Expected to enroll 11.6 million people in 2014
MEDICAID EXPANSION
States must establish by January 2014 or default to the Federal government
Several requirements:User Friendly Must screen and enroll public & private coverageMust establish “navigators”TransparencySelf-financing by 2015
HEALTH INSURANCE EXCHANGE
Ambulatory patient services
Emergency servicesHospitalization Maternity and newborn care
Mental health and substance use disorder services, including behavioral health treatment
Rehabilitative and habilitative services and devices
Laboratory servicesPreventive and
wellness services and chronic disease management
Pediatric services, including oral and vision care
Prescription drugs
ESSENTIAL HEALTH BENEFITSWHAT IS ESSENTIAL?
Many provisions are already in effect:Pre-Existing Condition Coverage to age 19Family Coverage to age 26No Annual or Lifetime LimitsClosing the Medicare Donut HoleNo co-pays/deductibles for prevention/ promotion interventions
Medical loss ratios now at 85 and 80 %
COVERAGE REFORM
QUALITY REFORM
Patient Centered Medical Homes (PCMH) and Health Homes
Accountable Care Organizations
Establishment of National Quality Measures
ACCOUNTABLE CARE ORGANIZATIONS (ACO)
Providers collectively take responsibility for the quality and costs of treatment
If providers can reduce costs while providing high quality care they receive a share of the cost savings
Can be operated by health systems, health plans, hospitals, large physician practices or other medical service organizations
Population health approach = not just taking care of the sick but keeping people healthy
PAYMENT REFORM
Payment reform involves moving whole sectors of the health care field from encounter payment systems to case and capitation systems
Lead work in this area will be done by the Center for Medicare & Medicaid Innovation: Medicare ACO Pioneer project
CMMI Innovation Challenge
Medicaid Emergency Psychiatric Demonstration
This is a 10 year undertaking
HIT is the use of computers as a means of exchanging medical information from doctor to doctor, or provider to provider
Currently, behavioral healthcare is not receiving financial incentives to implement needed EHRs for the field
The Behavioral Health Information Technology Act of 2011, S.B.39, is currently in CongressWould expand Federal incentives to implement HIT in physical health care to behavioral health care
HEALTH INFORMATION TECHNOLOGY REFORM
§10334: Elevates Office of Minority Health (OMH) to HHS and requires six HHS agencies to establish offices of minority health
§4302: Mandates federal health care programs to collect and report data on sex, race, ethnicity, language and disability status
§5306: Behavioral health workforce development grants
§5313: Community health workforce grants to promote culturally and linguistically appropriate services
§3509: Establishes an Office of Women’s Health
HEALTH EQUITY PROVISIONS
CONSTITUTIONAL CHALLENGES
Kaiser Family Foundation. Available at: http://www.kaiserhealthnews.org/Supreme-Court-Decides-Health-Law.aspx
ACA BENEFITS TO PENNSYLVANIANS
Insurance Reform 7.7 million residents are without lifetime limits on
coverage 32,100 young adults received coverage through
parent’s plans 657,000 children can not be denied coverage due to
pre-existing conditions
Medicare Provisions 2.3 million Medicare beneficiaries receiving primary care
services with no copay Currently, Medicare beneficiaries receiving 50% discount on
brand name drugs in donut hole By 2020 donut hole will be closed
ADVOCACY OPPORTUNITIES
Essential Health Benefits inclusion of behavioral health services HHS has given States the discretion to craft the EHB
Package While Mental Health/Substance Use is defined as an
essential health benefit, state determines at what levelHealth Insurance Exchange Design & Implementation
Transparency & Governance Use of Navigators
Other State Legislation S.B. 10: Amending the PA Constitution Maintenance of Effort (MOE) Waiver Request
QUESTIONS?