Lecture 3: Healthcare Reform

Question 1

What aspects of the ACA help to improve patient access to healthcare

Answer 1

1. Create individual and employer mandate
2. Expand public programs (Medicaid)

Question 2

What are the 3 approaches of health care reform?

Answer 2

1. Single payer Approach: federal government pay all care
2. Private market approach: private insurance markey competition
3. Mixed approach: Expand public programs for uninsured (Medicaid) and expand employer-based insurance (ACA)

Question 3

What were the focuses of ACA?

Answer 3

1. Access: expand insurance coverage
2. Costs: control healthcare costs
3. Quality: improve quality/health system performance
4. Focus on prevention and wellness
5. Consumer protections: how do we give patients information that is digestible and understable

**similar to Managed Care organization

Question 4

In ACA, what was individual mandates? What happened in 2019?

Answer 4

Required most US citizens to have health insurance and if you didn’t you would have to pay a tax penalty
However, people were upset and did not want to be told they need health insurance and tax penalty was eliminated in 2019

Question 5

What Program helped give access to individuals without employer-based private insurance, Medicaid or Medicare and small businesses?

Answer 5

Health Insurance Exchanges (HIE)

Question 6

What are Health Insurance Exchanges (HIE)?

Answer 6

1. “Virtual marketplace” for individuals and small businesses to purchase health insurance
2. open to persons without employer-based insurance, medicaid or medicare
3. preventative health services are 100% covered and no patient cost sharing due to ACA
4. Allows individuals and small businesses to compare prices, benefits and performance of health plans
5. Premium tax credits and subsidies for enrollees based on income (premium help similar to LIS in Medicare Part D)
6. Open enrollment Nov.1st-Dec.18th (similar to Medicare and Part D)

Question 7

All plan in HIE must be a “qualified health plan” which means these 3 things:

Answer 7

1. Allows people to compare health plans and purchase insurance
2. Must cover “essential health benefits”
3. Limit patient cost sharing

Question 8

In HIE, what is the “essential health benefits” package?

Answer 8

Consists of 10 areas
* have to be in every HIE insurance package, very braod and comprehensive
* KNOW that: prescription drugs are covered!
* Access to healthcare services=better healthcare

Question 9

Have all states expanded Medicaid due to the ACA?

Answer 9

No, 10 states have not

Question 10

The HIE must provide 4 levels of covereage: bronze, silver, gold and platinum. Describe the bronze and platinum plan

Answer 10

• Bronze Plan: lowest premium and deductible/cost-sharing are higher
• Platinum plan: highest premium and deductible/cost-sharing are lower

Question 11

How does ACA give access through employer mandates/requirements?

Answer 11

• Employers with over 50 employees are assessed a fee per full time employeee if: not offered coverage and have at least 1 full time employee receiving a premium tax credit in the Exchange
• Employers less than 50 employees are exempt

Question 12

What was the Small Business Health Options (SHOP)?

Answer 12

ACA established SHOP exchanges for small businesses/employees to get health insurance

Question 13

How does ACA give access through expansion of public programs?

Answer 13

1. increased medicaid eligibility by broadening income eligibility range
2. States will receive federal funding to defray cost
3. states can decide whether to expand medicaid (voluntary to expand medicaid)

Question 14

What are examples of how the ACA has affected private health insurance?

Answer 14

1. Covers preventative healthcare with no patient cost-sharing
2. Extends dependent coverage up to age 26
3. Prohibit cancelling coverage
4. Prohibits pre-existing condition exclusions and discrimination based on health status
5. Prohibits lifetime money caps on insurance coverage
6. Process to review and justify increases in premiums (now have to answer why you are increasing premiums)

Question 15

What aspects of the ACA help to control healthcare costs?

Answer 15

1. Administrative simplification
2. oversight of health insurance premiums
3. emphasis on prevention and primary medical care
4. providing info so people can compare costs and quality when choosing health plans in the Exchanges
5. Changes to Medicare (reduce coverage gap or donut hole for Medicare part D; both the ACA and Inflation reduction act)
6. Reduce waste, fraud, and abuse in public programs

Question 16

How does the Center for Medicare and Medicaid Innovation (CMMI) improve quality?

Answer 16

test diffrent models of payment to reduce costs which increases quality

Question 17

What aspects of the ACA help to improve healthcare quality?

Answer 17

1. Essential health benefits package
2. Pay for Performance
3. Eliminate cost-sharing for medicare covered preventive services
4. Center for Medicare and Medicaid Innovation (CMMI): Stusy different payment structures and methods to reduce costs, while increasing quality

Question 18

How is the ACA financed?

Answer 18

1. Tax changes (changes to taxes on Medicare Parts A & D)
2. CMS: new payment models will be tested
3. Annual fees for pharma sector and health insurance sector

Question 19

. What are the goals of a Patient Centered Medical Home (PCMH)?

Answer 19

1. patient centered
2. Comprehensive
3. Coordinated
4. Accessible
5. Commited to quality and safety

PCMH (Patient-Centered Medical Home)

Focus: The PCMH model emphasizes primary care and providing comprehensive, patient-centered care by transforming primary care practices into “medical homes.” The primary goal is to improve individual patient outcomes through coordinated, continuous care, often led by a primary care provider.
Key Goals:
* Coordinating care across the healthcare system (specialists, hospitals, home care, etc.).
* Enhancing the patient-provider relationship by creating a personal connection and continuity of care.
* Focusing on preventive care and managing chronic conditions.

Question 20

What are other healthcare reforms in addition to ACA?

Answer 20

1. Patient-Centered Medical Homes (PCMH)
2. Accountable Care Organizations (ACOs)

Question 21

Accountable Care Organizations (ACOs)- Do we
see them in public health insurance programs? Private health insurance? Both?

Answer 21

Both;
Public: Medicare (CMMI) and Medicaid
Private: Private health insurance plans

Question 22

What are ACOs?

Answer 22

Accountable Care Organizations
* an approach to patient care delivery that includes a financial component
* holds a group of providers “accountable” for quality outcomes and costs to take care of a patient populations
* ACOs share risk and cost savings if yearly benchmarks are met

An Accountable Care Organization (ACO) is a group of healthcare providers that voluntarily come together to provide coordinated, high-quality care to Medicare patients. ACOs are designed to improve the efficiency of care and reduce unnecessary spending while maintaining or improving quality.
ACOs focus on broad, coordinated care across different types of healthcare providers (primary care, specialists, hospitals, etc.) to improve the health outcomes of a defined population of patients (often Medicare beneficiaries).
Key Goals:
* Coordinating care among multiple providers to improve population health outcomes.
* Reducing unnecessary medical services and avoiding duplication of services.
* Improving cost efficiency by sharing savings among providers if cost and quality goals are met.

Question 23

Which types of healthcare providers can be in an
ACO?

Answer 23

• Primary care physicians
• Specialists
• Hospitals
• Nurse practitioners, physician assistants, and clinical nurse specialists
• Skilled nursing facilities and home health agencies
• Pharmacists
• Behavioral health providers
• Laboratories and diagnostic services
• Other allied health providers (e.g., physical therapists, dietitians)

These providers collaborate to deliver coordinated, patient-centered care, aiming to improve outcomes and reduce costs for Medicare beneficiaries.

Question 24

Do providers share in risk and/or cost savings for not meeting/meeting quality benchmarks?

Answer 24

Yes, ACOs share in any cost savings they achieve for Medicare if they meet quality and efficiency targets, but they may also share in financial losses if they don’t meet those benchmarks.

Question 25

With the passage of the ACA, do all Americans have health insurance?

Answer 25

No; The ACA has resulted in increasing access to health insurance for many Americans BUT not all.

Question 26

What were the ACA goals to reduce healthcare costs?

Answer 26

1. Cuts to administrative costs and product reimbursement
2. Efficiencies in care delivery

Question 27

What were the ACA goals to improve healthcare quality?

Answer 27

1. New integrated care models (PCMH, ACOs)
2. Pay for Performance (P4P)

Question 28

Compare and contrast PCMHs and ACOs

Answer 28

Both the PCMH and ACO models aim to improve healthcare delivery by enhancing coordination, reducing costs, and improving patient outcomes. PCMHs focus on individual patient-centered care, particularly through primary care, whereas ACOs take a broader approach, involving multiple types of providers to manage care for entire populations, with a focus on cost savings and quality metrics.

Question 29

In what ways did the Inflation Reduction Act have an impact on Medicare Part D?

Answer 29

1. **Requires medicare drug price negotiation **
2. Limit on out-of-pocket drug costs: Eliminates 5% coinsurance for catastrophic coverage in Medicare Part D in 2024, 2k cap on Part D out-of-pocket spending in 2025 and limits annual increases in Part D premiums for 2024-30
   3.** Expands eligibility for Medicare Part D LIS full benefits **
3. Caps out-of-pocket insulin costs to $35/mo
4. **All vaccines are free **

Question 30

In what way did the Inflation Reduction Act impact the ACA?

Answer 30

Extends** federal premium subsidies** for people buying insurance in the healthcare marketplace thorugh 2025