Ten Things You May Not Know About The Accountable Care Act

Ten Things Health Care Consumers May Not Know About the Accountable Care Act

The Accountable Care Act is perhaps the most meaningful of the 2010 health care reform mandates and a number of health care organizations have completed their first year in the program. This article highlights some of the consumer protection and cost cutting mandates and reveals the impetus for each element.

1-Application of evidence-based medical care, as a means to evaluate and pay for health services  

One of the results of the fifty-state, private payer national health care panorama is there are a lot of differences in patient care patterns, with some doctors ignoring the evidence based recommendations of national organizations, which result in disparate clinical outcomes. This means significant variances in patient deaths, re-admission rates for hospitalizations following treatment, and medical complications. An example of this phenomenon is in cardiac care, which has expanded the application of the very expensive cardiac pacemaker devices from the initial 1984 list of fifty-six diagnosis to the 2008 guidelines now at eighty- eight.[1]The problem with this robust expansion is scope-creep because only 5% of these recommendations are backed by the findings of “gold standard” randomized double-blind studies, which control for bias and are subject to rigorous scientific controls. To put it bluntly, many patients have received pacemakers for which the clinical research shows were not justified.

Cardiac device manufacturers like St. Jude Medical and Medtronic earn a tidy sum, roughly $7,500 for each pacemaker device, regardless of what the hospital receives in compensation and Medicare pays for most of these devices.[2]The medical device companies have earned between 48% and 20% net profits for years, meanwhile many hospitals  serving Medicare and Medicaid patients are starved for cash, as the current Medicare reimbursement model rewards the device makers and the cardiac specialist more than the hospital or the primary care doctor.

 The creation of the Patient Centered Outcomes Research Institute is an attempt to have an independent third party entity audit and recommend treatment practices based on scientific studies, especially for government funded health care programs. Many health care companies are outraged about this new agency oversight, but it is directly due to the opportunistic behavior of medical suppliers, specialists, and some hospitals at the expense of the health care system.

2-Creation of the Medical Home Criteria due to the over emphasis on specialty care while ignoring primary care

Facts of life in American health care include a plethora of specialists swarming over a patient in an acute care setting, but no one coordinating patient health over the care continuum. Medical schools produce more specialists than primary care providers now and the specialists earn a lot more money, which means political power in hospitals, medical associations, and in the beltway. By way of comparison, the mean income of cardiologists in 1987 was $271,555 versus less than $100,000 for primary care doctors, including family practitioners and pediatricians. Medicare is primarily to blame for this discrepancy as its reimbursement for clinical care has favored procedures and not time spent with patients. Ergo the doctor who spends the most time with the patient and may be the better practitioner will make less money.

3- Improved integration of patient care by observing key diagnosis and patient outcomes and paying people more for improved clinical performance

The Accountable Care Act links reimbursement payments from Medicare and Medicaid to clinical outcomes, in an attempt by the government to provide better stewardship of what we are getting for our health care investment. Specific conditions that the Accountable Care Act Shared Savings Program includes are: Chronic obstructive pulmonary disease (adult asthma), high blood pressure, heart failure, stroke, and diabetes. The ACO mandates attempt to assess clinical performance through a risk standardized assessment of chronic medical conditions, by reviewing hospital data, with the goal being the reduction in hospital admissions. In order to be eligible for the enhanced savings program the Centers for Medicare and Medicaid require hospitals which participate to report on the following metrics: patient caregiver experience, care coordination and patient safety, preventive health, and patient management for the at-risk population.

4-Accountable Care Act creates bundled payments for renal or kidney dialysis which is a cost containment measurement for this $78,000 per patient per year treatment, which is almost entirely paid for by Medicare.  

5-The Sunshine Act mandates disclosure of financial payments from medical device manufacturers and the pharmaceutical industry to health care providers.

The Sunshine Act, which is part of the Accountable Care Act mandates disclosure of financial payments from medical device manufactures (aka cardiac devices and orthopedic joints) and from the pharmaceutical industry to health care providers, including doctors and hospitals.[3]The highly profitable medical device industry has a practice of offering on-site bonuses for using their lucrative devices, which are now being prescribed for treatments which are not in compliance with evidence based treatment protocols.  So to assist the consumer, the government is attempting, through this mandate to shine a bit of light on conflicts of interest for treatment practices, so that you can make an informed decision on your procedure and where you have it done.

6-CMS, the government agency overseeing Medicare and Medicaid has established national performance metrics for key medical conditions which impact 80% of the national population.These benchmarks will establish a performance and reporting standard for all organizations, regardless of whether they choose to participate in the ACO Shared Savings Program. This new level of transparency will increase patient safety as better information becomes available to health care consumers.

7-ACO attempts to improve care for diabetes and heart disease patients

 By requiring 100% compliance with the six measures of clinical care, in order to achieve the increase in reimbursement under the Accountable Care Shared Savings Program, CMS hopes to stem the tide of these costly medical conditions. The measures of clinical care include; health status, health promotion and education, caregiver to patient communication, timely care, patient safety, and care coordination. This level of scrutiny is based on the drastic increase in disease prevalence and the need for the country to create a national intervention.

8-Establishment of the Independent Payment Advisory Board to reign-in health care overcharging

The Accountable Care Act has created the Independent Payment Advisory Board, which has broad authority to review and make recommendations for payment changes for health care services under Medicare. This is actually an aspect of the law that has great potential for cost containment authority, if congress will not capitulate to the powerful medical industrial lobby by refusing to deploy recommended changes. For example, why should cardiac device manufacturers continue to receive such exorbitant reimbursements at the expense of primary care services, so a realignment of payment could occur there. The point of the IPAB is to slow the growth of Medicare, which is presently escalating in an unsustainable fashion and everyone in Congress is in agreement on this factoid.

9-Savings Generated from the Accountable Care Act Will Shore-up the Medicare Trust Fund

The focus of the ACO mandates is to deliver better clinical outcomes and to reduce the long term trajectory of Medicare costs. Since Medicare is funded by payroll taxes and general funds, it is of concern to us all.

10-Accountable Care Act Increases Funding for More Fraud Auditors

Medicare fraud has been a problem since inception, because of entrepreneurial health care suppliers, clinicians, and hospitals. FYI the current Governor of Florida was at the helm of HMA, a large hospital chain when it was convicted of fraudulent Medicare billing, and he was asked to step down.[4]The Office of the Inspector General has found that for every dollar invested in fraud detection seventeen are recovered, yet a budget request for this in 2005, was denied by Congress(medical industrial lobbyists at work again).[5]

So the next time you are forced to listen to the grousing about the health care reforms and Obama care, just remember there are many consumer protection elements  which have the potential to transform the health care paradigm in this country and that is precisely what we need.

Feel free to share this article, written by Roberta E. Winter, MHA, MPA, and the author of Unraveling U.S. Health Care-A Personal Guide. http://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

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[1]Knocking on Heaven’s Door, Katy Butler, Scribner, a division of Simon & Schuster, 2013, chapter 12, p. 177, 2008 American College of Cardiology, Heart Rhythm Society, and the American Heart Association update for treatment guidelines.

[2]Knocking on Heaven’s Door, Katy Butler, Scribner, a division of Simon & Schuster, 2013, chapter 4, p. 64

[3] http://www.theatlantic.com/health/archive/2013/02/what-the-sunshine-act-means-for-health-care-transparency/272926/

[4] http://www.healthinsurance.org/blog/2013/06/13/medicare-fraud-and-for-profit-hospitals/

[5]It’s Enough To Make You Sick-The Failure of American Health Care and a Prescription for the Cure,  Jeffrey Lobosky, MD, Rowman & Littlefield, 2012, chapter 13, page 208

Medicaid Changes from the Accountable Care Act-Whether or Not Your State Adopted the Revised Eligibility Guidelines

What State Medicaid Expansions May look like in 2014

This article reviews the draft model for one state’s answer to the Medicaid Expansion under the Accountable Care Act. Washington State has posted the preliminary benchmarks and plan design for accommodating this act.[1]Warning to readers-this article may contain acronyms which are mind numbing, but part of the lumbering vernacular, and wherever possible the full name is cited.

Medicaid Eligibility

 To start with there are a dozen categories of “fast track” exemptions for Medicaid applicants and here is that list:

1. Health care for disabled workers
2. Family planning extension (more on this later)
3. Take charge family planning (whoa Nelly)
4. Psychologically indigent inpatient program (example-homeless folks)
5. Involuntary treatment act (hopefully this will apply to some of the nut-jobs who manage to obtain machine guns)
6. Kidney disease program (for those on dialysis)
7. ADATSA(Alcohol Drug Addiction Treatment Support Act)
8. Social Security Income qualifiers based on their low income status
9. Basic Health Plan qualifiers (subsidized medical insurance program for WA state residents with incomes no more than 200% of the Federal Poverty Level)
10. Medical Care Services Program (This is a managed care program run by the WA State Health Care Authority)
11. Medicaid qualifiers by virtue of low-income status
12. Children’s Health Insurance Plan Enrollees (CHIP)

Benchmark Plan Coverage

Next up are the definitions of the benchmark plan for insurance coverage mandates and here are those potential confounders:

1. Essential health benefits,
2. Essential health benefits reference plan
3. Base benchmark plan, benchmark
4. Alternative benefits plans

The benchmark plan must cover the following criteria in the benefit design:

1. BCBS-This refers to the bench mark equivalent coverage based on Blue Cross/Blue Shield plans
2. EPSTD-Early and Periodic Screening, Diagnosis, and Treatment Program which applies to children under 21 who are covered by the state Medicaid program
3. Non emergency transportation-What is this, a taxi to town?
4. Family planning services & supplies-AKA birth control options

People who are Exempt from the Benchmark Criteria and Eligible for Standard Medicaid Benefits include:

1. Pregnant women 
2.  Individuals who qualify for Medicaid based on being blind or disabled
3. Dual eligible enrollees, which is a category of people on both Medicare and Medicaid plans 
4.  Terminally ill hospice patients
5. Inpatients in hospitals, nursing home and ICF (assisted living facilities) who must spend all but a minimal amount of their income for the cost of medical care 
6.  TANF/Section 1931 enrollees, which is for parents and caretakers of incapacitated persons
7. Medically frail individuals, including those with disabilities that impair ability in one or more activities of daily living
8. Children in foster care 
9.  Individuals who qualify for LTC (long term care) services based on their medical condition
10. Individuals who only qualify for emergency care (?) 
11.  Individuals who qualify based on the  “spend down” of their total resources-such as senior citizens needing help with nursing home care.

Essential Health Benefits in 2014

The federal government has created ten essential health benefit plans for the states to adopt. Each state may have more than one benchmark Medicaid plan for eligible adults, which differs from the insurance exchange mandates, which are slated to have only one benchmark plan. Also, under current law, the mental-health-parity benefits for Medicaid only apply to Medicaid Managed Care Plans, and not the general Medicaid plans, but this is changing in 2014. According to federal mandates, essential health benefits must include the following insurance benefits:

1. Ambulatory services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services
6. Prescription drugs
7. Rehabilitative and habilitativeservices and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

With regard to the habilitative services and devices, this sounds like assistance for home living and a new word invented by the government order.

Benchmarking the New Medicaid Plan Design

Criteria which will be considered to establish a state benchmark for the Medicaid expansion plans include any of the following factors: the largest small group plan by enrollment (Blue Shield/Regence), the three largest state employee plans by enrollment, the largest three federal employee plans, and the largest commercial HMO in the state (Group Health Cooperative). The insurance companies will need to determine if their plans comply with the new criteria if they choose to participate in the Medicaid insurance offering, however, since so many of the state’s children are enrolled on the Children’s Health Insurance Plan (CHIP) it is expected that most carriers will. According to the Casey Foundation, 23% of the children in the United States live in poverty and in Washington State this metric was 18% in 2011.[2]In 2009, 57% of Washington’s Medicaid enrollees were children and this is true for other states as well.[3] The state with the most children living in poverty at that time was Mississippi at 32%.

Areas Not Affected by the Accountable Care Rules (ACO)

The ACA rules still allow Medicaid cost sharing in co-payments, deductibles, and contributions for services, which vary depending on the enrollee category. Medicaid does have the demonstration waiver provision under Section 1115, which allows states to petition for plan design changes which may have higher cost sharing provisions. Families with incomes equal to or less than the federal poverty level are allowed to have co-payments or cost sharing up to 5% of their income without any premium payments.  Allowable co-payments for 2012 are $3.80 for most services and $7.60 for none-life threatening-emergency room visits, as well as $3.80 for prescription drugs. There are also enrollees who are exempt from these co-payment requirements and they are as follows:

1. Pregnant women
2. Terminally ill people in hospice care
3. Medicaid enrollees who are already spending most of their income on health care costs during a hospitalization
4. Family Planning Services and supplies
5. Services provided by Indian Health Care entities for American Indians
6. Emergency services
7. All services are limited to one co-payment per service

Section 1115 Waiver Programs under Medicaid

Currently, forty states require some co-payment from parents enrolled on Medicaid and twenty-six states require co-payments for adults enrolled on their Section 1115 waiver programs. According to the Kaiser Commission Survey on Medicaid for the 2011 year, both Illinois and Wisconsin charge co-payments to Medicaid enrollees with incomes in excess of 150% of the federal level.

Bottom line, even for states not adopting the Affordable Care Act Medicaid expansion standards, there will still be an increase in their Medicaid enrollment for the following four reasons:

1. National insurance mandate requires insurance, so those who are of low income will become enrolled on Medicaid
2. Federal Subsidies through the insurance exchanges
3. Ease of enrollment process which integrates Medicaid and the insurance exchange offerings
4. In plain English, there will continue to be growth in Medicaid enrollment as long as there are so many people who are poor in this country

 And this is enough complexity and regulation analysis for a single setting so the healthpolicymaven is signing off.

This article was written by Roberta E. Winter, MHA, MPA and may be freely shared, with proper acknowledgement.

Additional sources for this article include the Center for Medicare and Medicaid- Medicaid Overview dated September 11, 2012 and the Kaiser Family Foundation Commission on Medicaid and the Uninsured report in November 2012.

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[1] http://www.hca.wa.gov/me/documents/Bnchmrk_Benefit_Cost_Sharing_December_2012.pdf

[2] http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?ind=43

[3] http://www.statehealthfacts.org/profileind.jsp?cat=4&sub=52&rgn=49

Supreme Court Reprieve for U.S. Health Care Reform

Despite the best efforts of health care reform detractors, the Supreme Court looks to have upheld the insurance mandate provisions as well as much of the rest of the edicts. A closer look at the impact on the Medicaid equalization will come after July 5th, when I return from holiday.
Bon Voyage!
healthpolicymaven

Congressional Wrangling Over Proposed Insurance Exchanges Takes A Nasty Turn

Wrangling Over Proposed Insurance Exchanges and Standard Health Care Benefits Takes a Nasty Turn

Barely recovering from the last congressional gaffe about redefining the rape of a woman in a transparent attempt to get out from under the federal Hyde Amendment criteria for Medicaid payments, the “powers-that-be” have made another mind blowing error in public engagement. In a nutshell and yes, I do mean all of these puns, here is the latest blunder by the Republicans controlling the house.

In a public hearing for testimony on the federal health insurance exchanges and standardized benefits for primary health care, which includes birth control options as benign as birth control pills, no women were allowed to testify at the hearing. It certainly is curious that those who are actually capable of pregnancy are excluded from the hearing. This refusal was despite vigorous opposition by female congresswomen. I actually listened to the hearing in order to believe it. And the woman they refused to allow to testify about the insurance exchange’s proposed standardized women’s health care was a college student. Yah, that is just what we want to discourage in this country, a woman with an education using prudence in reproductive matters.

And if that isn’t enough to befuddle a rational thinker, the reason the committee chairman gave for denying any woman the right to speak was because the meeting was about voting and safe guarding conscience in decision making. Interesting, I wasn’t aware that women lacked conscience, especially when you look at the violent crime statistics. But then again I guess these boys have turned their eyes away from those statistics. One wonders if they also were party to the move to redefine rape of an unconscious woman as a noncriminal event. If this is a matter of conscience, one wonders about theirs.

We are constantly assailed with Republican blather about fighting against big government, yet they seek to prevent birth control services from being covered on private insurance plans. As I have previously reported, several states already have enacted laws which prevent even private insurance plans from covering birth control services. Here are the members of this hall of shame: Kentucky, Missouri, Oklahoma, Idaho, and North Dakota. According to a 2003 Kaiser Foundation survey on contraceptive care, 87% of private employers provided coverage for birth control services, including abortion. So despite the anti-big-government talks, this smacks of big brother to me, or is it daddy?

For more straight talk on health care attend the Northwest Women’s Show on March 2nd, as the healthpolicymaven™ will present findings from her book, Unraveling U.S. Healthcare with my conscience intact.