November 16, 2018
The Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010. The idea behind the Act was to make health coverage available to everyone and attempt to lower the cost of healthcare. It keeps the Medicaid and Medicare programs but also allows commercial plans to participate in the exchange market selling individual plans to qualified applicants. There are exchanges in all fifty states where individuals and small businesses can buy private insurance plans online. Those payers participating in the exchanges must accept all participants, no matter what health conditions they may or may not have prior to applying for the coverage. They are also not allowed to charge higher rates based on a participant’s health status; everyone is to pay the same rate for the same coverage. At the time it was enacted, the ACA mandated that individuals have coverage or buy coverage through the exchange; this mandate has since been repealed. The ACA requires that the payers participating in the exchanges provide coverage for “essential health benefits, pre-existing conditions and preventive services”. The essential health benefits are ten services including doctor visits, inpatient and outpatient hospital services, prescription drug coverage, pregnancy and childbirth, mental health and others. CITATION hea18 l 1033 (healthcare.gov) The health exchange was rolled out in 2013 and had a lot of technical issues at the beginning. Because of the number of people trying to access and use the system, the system would stall and crash. CITATION Hiu13 l 1033 (Hiu) They had trouble for several weeks, even after making adjustment to improve access for users.
The ACA also allowed Medicaid expansion, increasing the income level people had to be under in order to qualify for Medicaid. However, in 2012 the Supreme Court decided to allow each state to decide if it would participate in the Medicaid expansion. West Virginia does participate in the expansion, so our Medicaid population has grown significantly. With that growth we have seen Medicaid move away from one traditional plan to different managed care plans with different companies. Medicaid allows participants in these plans jump from one managed care organization to another monthly, making it difficult for providers to know which plan to bill each time.
Lowering the cost of healthcare and improving quality are among the goals of the ACA. The American Recovery and Reinvestment Act through the HITECH Act gave providers incentive to implement EHR, with penalties to anyone not attesting and showing meaningful use by July 2014. The ACA allowed the implementation of Accountable Care Organizations (ACOs) which is a group including physicians, hospitals and other providers who will work together to coordinate care focusing on minimizing costs while providing better care. The ACO can receive bonus payments for succeeding in minimizing costs and meeting quality goals and benchmarks. They can also be penalized for failing to do so. We have a large ACO in Huntington, formed in 2018, consisting of Huntington Internal Medicine Group, Cabell Huntington Hospital and Marshall Health. CITATION mhc18 l 1033 (mhcaco.org) This ACO will be working toward coordinating care for over 13,500 Medicare beneficiaries in hopes to reduce duplication of services, reducing cost and providing better quality of care. CITATION Nas18 l 1033 (Nash)EHR is a necessary tool to facilitate the changes in healthcare in general, as well as the changes that are embedded in the ACA. CITATION Pra12 l 1033 (Practice Fusion) The EHR allows IT staff to pull data to help direct care. One of the goals of an ACO is to prevent illness or disease. One of the ways of doing this is through screenings. An EHR allows us to pull information like the last time a patient had their colonoscopy so those who are due for one can be identified and contacted. An EHR allows you to identify a diabetic patient who may have a high hemoglobin A1C to bring them in for education or to set them up with a nutrition appointment. Participating in an ACO would allow similar things to happen, but with access to the health data in the other participating providers’ electronic medical records. In the example of the MHC ACO in Huntington, a provider at HIMG would be able to see if a mutual patient had had a colonoscopy at Cabell Huntington Hospital, eliminating the need for a duplication of services.
Just having an EHR is not going to be enough to allow goals to be met. There are three categories that group the health IT capabilities that are needed to meet the needs of healthcare changes: a collaboration platform, clinical quality measures with clinical decision support and prompting, and robust data reporting. CITATION Pra121 l 1033 (Practice Fusion) This means EHRs need to talk to each other. In the case of an ACO, it may mean that everyone participating in the ACO is on the same EHR. For the clinical quality measures it would look like the previous example of being able to identify diabetic patients whose A1C is too high. Clinical decision support would look like an EHR that prompts the physician while the patient is in front of him that the patient is due for their screening colonoscopy. Robust reporting allows for data mining to give a practice or a facility a good look at how they are doing and where they can improve, not only with pre-made reports, but with the ability to customize or build reports more suited for the individual practice.
There have been several failed attempts to repeal the ACA; although there have been some provisions within the Act that were repealed before they were ever implemented. The mandate requiring individuals to have coverage was repealed in 2017, taking effect in 2019. The objection to the ACA seems to be based on partisanship. Conservatives don’t want government interfering in health care and liberals want government more involved, and felt the ACA gave too much power to private commercial payers. CITATION Rov17 l 1033 (Rovner) One of the biggest complaints about the ACA is that some people lost their coverage or ended up in networks that didn’t include their physicians and hospitals. Some employers dropped coverage for their employees, calculating that paying the penalty was cheaper than providing coverage. This forced employees to purchase coverage on the exchange, coverage that was not always equal to what they had with their employer’s plan. Working at HIMG, we have seen examples of people unknowingly purchasing coverage on the exchange that was in a network that didn’t include their physician. Being in a tri-state area, we see patients from Ohio, Kentucky and West Virginia. We have had several patients who obtained coverage through exchanges in Ohio and Kentucky only to find out later the network was a very small network, often with providers in a different part of the state, nowhere near where the patient actually lived. So, although the patient technically had “coverage”, they really had none when they went outside their network. As a provider, this created problems for us at HIMG because these patients would present to us with a card that indicated for example, “Aetna”, a plan we normally participate with. However, in very small print somewhere else on the card, it would indicate a network name that we were not a part of. Our registration staff had to be educated to watch for these network names on the cards so they could inform the patients prior to being seen that we were out of network with their plan. This was very frustrating for us and for those patients.
I don’t think we are going to see a repeal or replacement of the ACA anytime soon. In the 2018 elections the Democrats gained control of the House, but even without that, the margin of difference within the Republican party is so close, a repeal or replacement would not likely get voted in. Healthcare is a very large complex problem with no easy answers. It makes sense to focus on the quality of care provided to patients and to look to providers to help reduce cost; however, there is a lot of additional work and resources needed in administrating the tasks involved with making these things happen. There must be a balance with what is required and what is reasonable to ask of providers. It is an exciting time to be in healthcare, although not an easy one with all the changes one must keep up with to stay in the business!