Summary of the Affordable Care Act | The Henry J. Kaiser Family Foundation
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Previous work showed a modest outcome benefit for patients treated at high care intensity centers after general, vascular, and orthopedic surgical procedures. Studies set in the more immediate health care reform climate indicate that high-intensity care may reduce amputation rates in patients with peripheral vascular disease. Whether efforts to increase care intensity, particularly in the management of postoperative complications, will result in measureable outcome benefits remains unclear.
These data have the potential to improve our understanding of the relationship between intensity of care and surgical outcomes, with the possibility to better inform new payment structures for surgical episodes of care.
The Centers for Medicare and Medicaid Services maintains this database using claims submitted by hospitals where Medicare beneficiaries receive care.
We selected patients who underwent 7 common major surgical operations using International Classification of Diseases, Ninth Revision, Clinical Modification codes.
Quiz Ref ID For this analysis, we included the following procedures: We excluded patients younger than 65 years or those with incomplete clinical data in the registry. This study was approved by the University of Michigan institutional review board; patient consent was waived. Hospital Care Intensity and Resource Data The Dartmouth Atlas of Healthcare maintains an extensive data repository focusing on defining and understanding the wide variation of health care resource use in the United States.
Adjustment is accomplished using ordinary least squares regression.
Four models of the physician-patient relationship.
These data included hospital bed size and occupancy, annual surgical volumes, and staffing full-time—equivalent nursing and technician support. Outcomes Our primary outcomes for this analysis were day mortality, major complications, and failure to rescue. Overall complication rates were consistent with previously published work using similar patient populations and data sets. We defined failure to rescue as mortality in patients with at least 1 major complication ie, the case fatality rate for patients sustaining a major complicationas has been previously described.
We compared differences between HCI as a continuous variable and postoperative outcomes in bivariate analysis using Pearson correlation coefficient. Hospitals were compiled into 3 groups based on HCI: Effective January 1, Require all new policies except stand-alone dental, vision, and long-term care insurance plansincluding those offered through the Exchanges and those offered outside of the Exchanges, to comply with one of the four benefit categories.
Existing individual and employer-sponsored plans do not have to meet the new benefit standards. See description of benefit categories in Creation of insurance pooling mechanism. This deductible limit will not affect the actuarial value of any plans.
Effective January 1, Limit any waiting periods for coverage to 90 days.
The Association Between Hospital Care Intensity and Surgical Outcomes in Medicare Patients
Effective January 1, Create a temporary reinsurance program to collect payments from health insurers in the individual and group markets to provide payments to plans in the individual market that cover high-risk individuals.
Effective January 1, through December Allow states the option of merging the individual and small group markets. Effective January 1, Consumer protections Establish an internet website to help residents identify health coverage options effective July 1, and develop a standard format for presenting information on coverage options effective 60 days following enactment.
Develop standards for insurers to use in providing information on benefits and coverage. Compacts may only be approved if it is determined that the compact will provide coverage that is at least as comprehensive and affordable as coverage provided through the state Exchanges. Enroll newly eligible Medicaid beneficiaries into the Medicaid program no later than January states have the option to expand enrollment beginning incoordinate enrollment with the new Exchanges, and implement other specified changes to the Medicaid program.
Maintain current Medicaid and CHIP eligibility levels for children until and maintain current Medicaid eligibility levels for adults until the Exchange is fully operational. Establish an office of health insurance consumer assistance or an ombudsman program to serve as an advocate for people with private coverage in the individual and small group markets. Phase-in revised payments over 3 years beginning infor plans in most areas, with payments phased-in over longer periods 4 years and 6 years for plans in other areas.
Provide bonuses to plans receiving 4 or more stars, based on the current 5-star quality rating system for Medicare Advantage plans, beginning in ; qualifying plans in qualifying areas receive double bonuses.
Phase-in adjustments to plan payments for coding practices related to the health status of enrollees, with adjustments equaling 5. Cap total payments, including bonuses, at current payment levels. Reduce annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice and other Medicare providers, and adjust for productivity.
Effective January 1, Establish an Independent Payment Advisory Board comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate.
If so, beginning January 15,the Board will submit recommendations to achieve reductions in Medicare spending. Beginning Januarythe target is modified such that the board submits recommendations if Medicare per capita spending exceeds GDP per capita plus one percent.
The Board will submit proposals to the President and Congress for immediate consideration. The Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing including Parts A and B premiumsor would result in a change in the beneficiary premium percentage or low-income subsidies under Part D.
Hospitals and hospices through and clinical labs for one year will not be subject to cost reductions proposed by the Board. The Board must also submit recommendations every other year to slow the growth in national health expenditures while preserving quality of care by January 1, Effective upon enactment Allow providers organized as accountable care organizations ACOs that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program.
To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians, define processes to promote evidence-based medicine, report on quality and costs, and coordinate care. Shared savings program established January 1, Create an Innovation Center within the Centers for Medicare and Medicaid Services to test, evaluate, and expand in Medicare, Medicaid, and CHIP different payment structures and methodologies to reduce program expenditures while maintaining or improving quality of care.
Payment reform models that improve quality and reduce the rate of cost growth could be expanded throughout the Medicare, Medicaid, and CHIP programs. Effective January 1, Reduce Medicare payments that would otherwise be made to hospitals by specified percentages to account for excess preventable hospital readmissions. Effective fiscal year Medicaid Increase the Medicaid drug rebate percentage for brand name drugs to Effective January 1, Extend the drug rebate to Medicaid managed care plans.
Require the Secretary to develop a methodology to distribute the DSH reductions in a manner that imposes the largest reduction in DSH allotments for states with the lowest percentage of uninsured or those that do not target DSH payments, imposes smaller reductions for low-DSH states, and accounts for DSH allotments used for waivers.
Effective October 1, Prohibit federal payments to states for Medicaid services related to health care acquired conditions. Effective July 1, Prescription drugs Authorize the Food and Drug Administration to approve generic versions of biologic drugs and grant biologics manufacturers 12 years of exclusive use before generics can be developed. Effective upon enactment Waste, fraud, and abuse Reduce waste, fraud, and abuse in public programs by allowing provider screening, enhanced oversight periods for new providers and suppliers, including a day period of enhanced oversight for initial claims of DME suppliers, and enrollment moratoria in areas identified as being at elevated risk of fraud in all public programs, and by requiring Medicare and Medicaid program providers and suppliers to establish compliance programs.
Develop a database to capture and share data across federal and state programs, increase penalties for submitting false claims, strengthen standards for community mental health centers and increase funding for anti-fraud activities. The Institute will be overseen by an appointed multi-stakeholder Board of Governors and will be assisted by expert advisory panels.
Findings from comparative effectiveness research may not be construed as mandates, guidelines, or recommendations for payment, coverage, or treatment or used to deny coverage.
Effective upon enactment Medical malpractice Award five-year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigations.
Preference will be given to states that have developed alternatives in consultation with relevant stakeholders and that have proposals that are likely to enhance patient safety by reducing medical errors and adverse events and are likely to improve access to liability insurance.
Funding appropriated for five years beginning in fiscal year Medicare Establish a national Medicare pilot program to develop and evaluate paying a bundled payment for acute, inpatient hospital services, physician services, outpatient hospital services, and post-acute care services for an episode of care that begins three days prior to a hospitalization and spans 30 days following discharge. If the pilot program achieves stated goals of improving or not reducing quality and reducing spending, develop a plan for expanding the pilot program.
Establish pilot program by January 1, ; expand program, if appropriate, by January 1, Create the Independence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their home and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction.
Four Models of the Physician-Patient Relationship by Davis Hammond on Prezi
Effective January 1, Establish a hospital value-based purchasing program in Medicare to pay hospitals based on performance on quality measures and extend the Medicare physician quality reporting initiative beyond Reports to Congress due January 1, Dual eligibles Improve care coordination for dual eligibles by creating a new office within the Centers for Medicare and Medicaid services, the Federal Coordinated Health Care Office, to more effectively integrate Medicare and Medicaid benefits and improve coordination between the federal government and states in order to improve access to and quality of care and services for dual eligibles.
Effective March 1, Medicaid Create a new Medicaid state plan option to permit Medicaid enrollees with at least two chronic conditions, one condition and risk of developing another, or at least one serious and persistent mental health condition to designate a provider as a health home.
Effective January 1, Create new demonstration projects in Medicaid to pay bundled payments for episodes of care that include hospitalizations effective January 1, through December 31, ; to make global capitated payments to safety net hospital systems effective fiscal years through ; to allow pediatric medical providers organized as accountable care organizations to share in cost-savings effective January 1, through December 31, ; and to provide Medicaid payments to institutions of mental disease for adult enrollees who require stabilization of an emergency condition effective October 1, through December 31, Create processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs.
National strategy due to Congress by January 1, Establish the Community-based Collaborative Care Network Program to support consortiums of health care providers to coordinate and integrate health care services, for low-income uninsured and underinsured populations. Funds appropriated for five years beginning in FY Financial disclosure Require disclosure of financial relationships between health entities, including physicians, hospitals, pharmacists, other providers, and manufacturers and distributors of covered drugs, devices, biologicals, and medical supplies.
Four models of the physician-patient relationship.
Report due to Congress April 1, Disparities Require enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations.
Also require collection of access and treatment data for people with disabilities. Require the Secretary to analyze the data to monitor trends in disparities. Effective fiscal year Establish a grant program to support the delivery of evidence-based and community-based prevention and wellness services aimed at strengthening prevention activities, reducing chronic disease rates and addressing health disparities, especially in rural and frontier areas.
Funds appropriated for five years beginning in FY Coverage of preventive services Eliminate cost-sharing for Medicare covered preventive services that are recommended rated A or B by the U. Preventive Services Task Force and waive the Medicare deductible for colorectal cancer screening tests. Authorize the Secretary to modify or eliminate Medicare coverage of preventive services, based on recommendations of the U. Preventive Services Task Force. Preventive Services Task Force and recommended immunizations with a one percentage point increase in the federal medical assistance percentage FMAP for these services.
Effective January 1, Authorize Medicare coverage of personalized prevention plan services, including a comprehensive health risk assessment, annually. Require the Secretary to publish guidelines for the health risk assessment no later than March 23,and a health risk assessment model by no later than September 29, Effective January 1, Provide incentives to Medicare and Medicaid beneficiaries to complete behavior modification programs. Effective January 1, or when program criteria is developed, whichever is first Require Medicaid coverage for tobacco cessation services for pregnant women.
Effective October 1, Require qualified health plans to provide at a minimum coverage without cost-sharing for preventive services rated A or B by the U. Preventive Services Task Force, recommended immunizations, preventive care for infants, children, and adolescents, and additional preventive care and screenings for women. Effective six months following enactment Wellness programs Provide grants for up to five years to small employers that establish wellness programs.
Funds appropriated for five years beginning in fiscal year Provide technical assistance and other resources to evaluate employer-based wellness programs. Conduct a national worksite health policies and programs survey to assess employer-based health policies and programs. Employers must offer an alternative standard for individuals for whom it is unreasonably difficult or inadvisable to meet the standard.
Effective January 1, Establish state pilot programs by July to permit participating states to apply similar rewards for participating in wellness programs in the individual market and expand demonstrations in if effective.
Require a report on the effectiveness and impact of wellness programs.