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Health Care Reform 101


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Health Care Reform 101

  1. 1. HEALTH CARE REFORM 101 22 May 2012
  2. 2. WHAT IS THE ACA?  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 care  Disease prevention and wellness are major themes
  3. 3. REFORMS IN THE ACA ATTEMPT TO:  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
  4. 4. A NEW VOCABULARY  Accountable care organization (ACO)  Basic health programs  Carve-out  Centers for Medicare and Medicaid Services  Community health centers  Federally Qualified Health Center  Electronic Health Record (EHR)  Health care homes  Health information technology (HIT)  Health information privacy and security   Health Insurance Portability and Accountability Act (HIPAA)  Home and Community-Based Services  Information transparency  Meaningful User  Medicaid  Medical home  Patient Protection and Affordable Care Act
  5. 5. KEY COMPONENTS 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)
  6. 6. INSURANCE REFORM Core feature of the ACA Includes:  Individual Mandate provision  Expanding Medicaid eligibility  Establishing Health Insurance Exchanges  Establishing the Essential Health Benefits package  Providing tax incentives to purchase insurance An estimated 32 million individuals will become insured by 2019
  7. 7. INDIVIDUAL MANDATE Most controversial provision of the ACA Requires individuals to obtain health insurance or pay a penalty Penalties increase each year  Exemptions include:  Religious  Incarceration  Undocumented status
  8. 8. MEDICAID EXPANSION Individuals and families with incomes up to 133% of the Federal Poverty Level (FPL) will be eligible  Appx. $14,850 for an individual  Appx. $30,650 for a family of four Expected to enroll 11.6 million people in 2014
  9. 9. HEALTH INSURANCE EXCHANGE States must establish by January 2014 or default to the Federal government Several requirements:  User Friendly  Must screen and enroll public & private coverage  Must establish “navigators”  Transparency  Self-financing by 2015
  10. 10. ESSENTIAL HEALTH BENEFITS WHAT IS ESSENTIAL? Ambulatory patient services  Emergency services Hospitalization  Maternity and newborn care  Mental health and substance use disorder services, including behavioral health treatment Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care Prescription drugs
  11. 11. COVERAGE REFORM Many provisions are already in effect:  Pre-Existing Condition Coverage to age 19  Family Coverage to age 26  No Annual or Lifetime Limits  Closing the Medicare Donut Hole  No co-pays/deductibles for prevention/ promotion interventions  Medical loss ratios now at 85 and 80 %
  12. 12. QUALITY REFORM Patient Centered Medical Homes (PCMH) and Health Homes Accountable Care Organizations Establishment of National Quality Measures
  13. 13. 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
  14. 14. 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
  15. 15. HEALTH INFORMATION TECHNOLOGY REFORM 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 Congress  Would expand Federal incentives to implement HIT in physical health care to behavioral health care
  16. 16. HEALTH EQUITY PROVISIONS §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
  17. 17. CONSTITUTIONAL CHALLENGES Kaiser Family Foundation. Available at:
  18. 18. 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 preexisting 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
  19. 19. 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 level  Health 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
  20. 20. QUESTIONS?