22 May 2012HEALTH CARE REFORM

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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?