Affordable Care Act Primer for Premeds (Part 3)

Quality Improvement in the Affordable Care Act

The next two sections of the Act focuses on Medicare quality metrics and higher-level public health efforts. It's kind of fun to see the Federal government take an edgy, shake-things-up approach. I'm not sure, however, how well large bureaucracies can effectively function as innovators.

Title III: Improving the Quality and Efficiency of Health Care

In my opinion, this section has the potential to profoundly shift the way care is given in the US. This Title of the Affordable Care Act (ACA) established the Center for Medicare and Medicaid Innovation. Keep in mind: these are innovations, not proven solutions. Basically, the Federal government has recognized that there are big problems in our current system of reimbursements based upon procedures without any regard to outcome. CMI was put in place to discover novel approaches that are effective by increasing accountability.

Innovations that are put in place by Medicare have the potential to cause a huge rippling affect within all health systems (e.g., hospital networks, insurance plans, clinics). You see, Medicare regulations are incredibly stringent. Approved providers have quite a few hoops to jump through for any health plan, and the lower-than-average reimbursement for Medicare just adds to the sting. But there can be an upside to all that regulation.

Here’s the general idea: Health systems will implement changes designed to improve clinically-measurable outcomes such as the percentage of their patients with good blood pressure or whose cholesterol is at an acceptable level. These changes might include using case manager to follow-up with patients over the telephone or getting patients into classes designed to help them manage their chronic conditions. These systems will essentially get a “bonus” from Medicare for population-based improvements. Over time, the carrot will turn into a stick, meaning the bonus will go away and a financial penalty will be put into place. That’s a pretty strong incentive to change. It is thought that system-level changes will not only affect patients with Medicare, but will change how care is given to all patients.

This section also includes details specific to Medicare plans, such as the “donut hole.” The “donut hole” refers to a prescription drug benefit that seemed to be designed to encourage patients to limit the number of medications they took. Patients were required to pay a $300 deductible before coverage kicked in. Above that amount, prescriptions were covered until the annual amount got close to $3,000. If a patient needed more than $3,000 in prescriptions, she would be required to cover the next $3,000 out of her own pocket before “catastrophic” coverage would be in effect. Essentially, it would be possible for a patient who used $7,000 worth of prescription medications to be responsible for about $4,000. (Dollar amounts of coverage varied depending upon the year.) The ACA gradually decreases the amount of out-of-pocket expenses an individual is responsible for.

Title IV: Prevention of Chronic Disease and Improving Public Health

Lots of people believe that the ACA will increase Americans’ health status because of its focus on prevention. While the Act does require insurers to cover preventive services at 100%, there may be a bit of disappointment over the care that is classified as preventive. If your insurance already gives you a no-out-of-pocket-cost annual exam, you will probably not notice much of a change. The services that are covered at 100% are those that have received an “A” or “B” rating from the US Preventive Services Task Force.

Title IV also sets out to create an environment of health promotion through efforts such as calorie labeling at restaurants and wellness programs for older adults. Having worked in health promotion for many years, I think that these environmental approaches can help us turn the tide in the obesity epidemic. There’s more to Title IV regarding improvement in public health, but my brief primer is already too lengthy.