by Wyn Staheli, Director of Research
February 3rd, 2015
Even though the health care system in the United States is one of the most expensive per capita in the world, we have a dismally low quality of care ranking. Healthcare reform (HCR) in its simplest terms is addressing these shortcomings in order to improve healthcare coverage, delivery, policies, or payment. According to Wikipedia, "healthcare reform typically attempts to:
- Broaden the population that receives health care coverage through either public sector insurance programs or private sector insurance companies
- Expand the array of health care providers consumers may choose among
- Improve the access to health care specialists
- Improve the quality of health care
- Give more care to citizens
- Decrease the cost of health care"
In an attempt to reach these goals, the Patient Protection and Affordable Care Act (PPACA - also known as Obamacare or ACA) and the Health Care and Education Reconciliation Act were both signed into law in 2010. The implementation of these acts has proven to be challenging for patients, providers, insurance carriers and even the federal government. It is important to understand that reform is not set in stone. Although portions of the law have been enacted, there are many components that are still 'in the works'. For example, some pilot programs are already underway, but there are others which are still in the design phase. As pilot programs are implemented and correspondingly evaluated, criteria is also likely to change.
CLICK HERE to review information by CMS regarding Administrative Simplification Provisions in the Patient Protection and Affordable Care Act of 2010 (ACA).
PROVIDER NON-DISCRIMINATION CLAUSE
The PPACA added a section to the Public Health Service Act, Section 2706(a), that states that an insurer "shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable state law." This clause could have far-reaching implications for numerous types of healthcare providers - including doctors of chiropractic. Does this mean that a health plan is now required to allow chiropractors to perform all services within their scope of practice? Will this create a battle in the scope of practice laws at the state level? Much of how this will play out is still unknown.
The following resources can be helpful to understand more:
PRIMARY CARE PHYSICIAN SHORTAGE PROPELS GROWTH
There is no disputing the fact that primary care physicians are in short supply. HHS has projected that by 2020, there will be a shortage of 20,400 PCPs. Since PCPs are the gatekeeper for PCMHs, there will be an increasing need to avoid the problems that have been plaguing the Veterans Administration. One solution is to include doctors of chiropractic as PCPs. The key to help ACOs and PCMHs understand that DCs have been trained as conservative PCPs. Dr Rick McMichael of the ACA's Health care Reform Task Force stated that "Many health care decision makers still do not know the comprehensive education of today's doctor of chiropractic. They don't realize that we are trained as conservative PCPs. We are well trained as port-of-entry, first-contact doctors."
Providers need to be able to demonstrate their ability to provide high quality low-cost care. We are experiencing a limited window of opportunity to demonstrate to these groups that DCs can and should be part of their new organizations. The time to be proactive is NOW.
PATIENT CARE MODELS
There are two patient care models of particular interest to doctors of chiropractic:
- Accountable Care Organizations (ACO)
- Patient Centered Medical Homes (PCMH) and Patient Centered Healthcare Homes (PCHCH)
Although these models have the same goals, they are not the same. For example, in a PCMH, a primary care physician (PCP) is in charge of the healthcare delivery team, whereas an ACO is more like a group of coordinated practices. Even though these entities may sound like they are a glorified HMO, there are some major differences. Provider compensation is based on quality standards and the overall health of their patients instead of compensation based on cutting costs and sheer volume of patients "processed".
1. Accountable Care Organizations (ACO)
An ACO is a network of healthcare providers and hospitals voluntarily joined together to provide high quality, coordinated patient care. Provider payment is typically tied to how well those goals are met. Payment models are varied and can be capitation, fee-for-service, shared-savings or some type of hybrid combination. Shared savings means that providers are paid a 'bonus' for providing quality care at low cost. According to the CMS website:
"The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program."
Currently there are nearly 500 ACOs established in the U.S. This includes both Medicare programs and the private sector. According to Kaiser Health News, an estimated 14 percent of the U.S. population is now served by an ACO. Medicare has three different ACO programs (Medicare Shared Savings Program, Advance Payment ACO Model and Pioneer ACO Model) which cover about four million Medicare beneficiaries.
Under the PPACA, the specific requirements for ACO contracts are determined by the Department of Health and Human Services (HHS) which means that ACOs will likely evolve over time as the effectiveness of these programs are evaluated.
The following resources can be helpful to understand more:
2. Patient Centered Medical Home (PCMH) and Patient Centered Healthcare Home (PCHCH)
According to the Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ), a PCMH is defined as:
"The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes:
"There are a host of groups that have specifically defined the components of a medical home. For example, the Patient Centered Primary Care Collaborative (PCPCC) offers many resources and the National Committee for Quality Assurance has created a program to recognize a patient-centered medical home."
According to the American Nurses Association, "Concern has been expressed that the term “medical home” conjures up a place, like a nursing home, rather than a model of care. It has been suggested that a “health care home” might signify a broader, more holistic approach. A number of government agencies and organizations, including Health Resources and Services Administration and the National Quality Forum, have used the term “health care home.” CMS has recently adopted “Advanced Primary Care model (APC).”
Note: The Health Resources and Services Administration (HRSA) is the governing body for regulations regarding Health Centers. The PPACA expanded funding for PCMHs which must meet accreditation standards and certain qualifications.
Back in the fall of 2013, there were some serious complaints lodged when people discovered that their plan that they were told they could keep was no longer available. As a result, in November and announcement was made to resolve the problem. There were some changes made to grandfathered plans. Grandfathered plans are those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increase costs for consumers. Insurers must notify consumers with these policies that they have a grandfathered plan.
So what are 'substantial changes"? There are many ways in which a plan may lose grandfathered status. For example, if benefits are significantly cut or reduced, the premium changes, or significantly raising the deductible or co-insurance.
- URAC announces partnership with Foundation for Chiropractic Progress by Chiroeco discusses special pilot project to determine whether chiropractic care models can achieve the principles of the PCHCH
- How to Create Accountable Care Organizations by the Center for Healthcare Quality & Payment Reform (CHQPR)
- ACO Toolkit by Accountable Care Organization Learning Network