Health care reform 101 22 may 2012 smm


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Health care reform 101 22 may 2012 smm

  1. 1. 22 May 2012HEALTH CARE REFORM101
  2. 2.  The Patient Protection and Affordable Care Act (ACA) wassigned into law in March of 2010 A governmental policy that changes the delivery of healthcare services in a given place Major Changes: All Americans must have health insurance by 2014 More emphasis on community-based services and lessreliance on institutional care Disease prevention and wellness are major themesWHAT IS THE ACA?
  3. 3.  Broaden the population that receives health care coveragethrough employment, or public sector insurance companies(e.g. DPW) Increase the number of health care providers people maychoose from Improve the referral process and the right to be seen by aspecialist Mandate health insurance by reducing the cost and making itaffordable for everyoneREFORMS IN THE ACA ATTEMPT TO:
  4. 4. A NEW VOCABULARY Accountable careorganization (ACO) Basic health programs Carve-out Centers for Medicare andMedicaid Services Community health centers Federally Qualified HealthCenter Electronic Health Record(EHR) Health care homes Health informationtechnology (HIT) Health information privacyand security Health Insurance Portabilityand Accountability Act(HIPAA) Home and Community-Based Services Information transparency Meaningful User Medicaid Medical home Patient Protection andAffordable Care Act
  5. 5. 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
  6. 6. 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 willbecome insured by 2019INSURANCE REFORM
  7. 7. Most controversial provision of the ACARequires individuals to obtain healthinsurance or pay a penaltyPenalties increase each year Exemptions include:ReligiousIncarcerationUndocumented statusINDIVIDUAL MANDATE
  8. 8. Individuals and families with incomes up to133% of the Federal Poverty Level (FPL) willbe eligibleAppx. $14,850 for an individualAppx. $30,650 for a family of fourExpected to enroll 11.6 million people in 2014MEDICAID EXPANSION
  9. 9.  States must establish by January 2014 or default tothe Federal government Several requirements:User FriendlyMust screen and enroll public & private coverageMust establish “navigators”TransparencySelf-financing by 2015HEALTH INSURANCE EXCHANGE
  10. 10. Ambulatory patientservices Emergency servicesHospitalization Maternity andnewborn care Mental health andsubstance usedisorder services,including behavioralhealth treatmentRehabilitative andhabilitative servicesand devicesLaboratory servicesPreventive andwellness services andchronic diseasemanagementPediatric services,including oral andvision carePrescription drugsESSENTIAL HEALTH BENEFITSWHAT IS ESSENTIAL?
  11. 11. 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 %COVERAGE REFORM
  12. 12. QUALITY REFORMPatient Centered MedicalHomes (PCMH) and HealthHomesAccountable CareOrganizationsEstablishment of NationalQuality Measures
  13. 13. ACCOUNTABLE CARE ORGANIZATIONS(ACO) Providers collectively takeresponsibility for the quality andcosts of treatment If providers can reduce costswhile providing high quality carethey receive a share of the costsavings Can be operated by healthsystems, health plans, hospitals,large physician practices orother medical serviceorganizations Population health approach = notjust taking care of the sick butkeeping people healthy
  14. 14. PAYMENT REFORM Payment reform involves moving wholesectors of the health care field fromencounter payment systems to case andcapitation systems Lead work in this area will be done bythe Center for Medicare & MedicaidInnovation: Medicare ACO Pioneer project CMMI Innovation Challenge Medicaid Emergency PsychiatricDemonstration This is a 10 year undertaking
  15. 15.  HIT is the use of computers as a means ofexchanging medical information from doctor todoctor, or provider to provider Currently, behavioral healthcare is not receivingfinancial incentives to implement needed EHRs forthe field The Behavioral Health Information Technology Act of2011, S.B.39, is currently in CongressWould expand Federal incentives to implement HIT inphysical health care to behavioral health careHEALTH INFORMATION TECHNOLOGYREFORM
  16. 16. §10334: ElevatesOffice of MinorityHealth (OMH) to HHSand requires six HHSagencies to establishoffices of minorityhealth§4302: Mandatesfederal health careprograms to collectand report data onsex, race, ethnicity,language anddisability status§5306: Behavioralhealth workforcedevelopment grants§5313: Communityhealth workforcegrants to promoteculturally andlinguisticallyappropriate services§3509: Establishes anOffice of Women’sHealthHEALTH EQUITY PROVISIONS
  17. 17. CONSTITUTIONAL CHALLENGESKaiser Family Foundation. Available at:
  18. 18. ACA BENEFITS TO PENNSYLVANIANSInsurance Reform 7.7 million residents are without lifetime limits oncoverage 32,100 young adults received coverage through parent’splans 657,000 children can not be denied coverage due to pre-existing conditionsMedicare Provisions 2.3 million Medicare beneficiaries receiving primary care serviceswith no copay Currently, Medicare beneficiaries receiving 50% discount on brandname drugs in donut hole By 2020 donut hole will be closed
  19. 19. ADVOCACY OPPORTUNITIES Essential Health Benefits inclusion of behavioral healthservices HHS has given States the discretion to craft the EHB Package While Mental Health/Substance Use is defined as an essentialhealth 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?