Health care reform

attempts to contain costs

shift from fee-for-service to managed care
diagnosis related groups (DRG) - capitation for medicare (part A) hospital care -> adopted by all insurers
professional standard review orgs
peer review orgs
certificate of need requirements for capital improvements

attempt to improve access

HIPAA : health insurance companies must:
- not deny coverage due to preexisting medical conditions
- sell to small employer groups and individuals who lose coverage regardless of health history
- renew policies
- include patient privacy requirements in law

health savings account (HSA) - medical savings account (MSA)

tax free savings account used for out of pocket expenses for HDHP insurance plans, total out of pocket spending is capped, limit changes annually

flexible spending account (FSA) - employer based

used for any approved medical or child care expenses
use it or lose it annually

affordable care act original legislation

- outpatient visits
- emergency services
- hospitalization
- maternity care
- mental health and SUDs
- prescription drugs - essencial formulary
-rehabilitation
- labs
- preventative wellness and chronic disease management
- pediatrics

affordable care act expansion

funding for increased access
employer and individual tax penalties
tax on nonprofit hospitals failing to comply
annual fees for pharmaceutical manufacturing and health insurance companies
child coverage up to 26
benefits for women
holding insurance companies accountable

other aspects of ACA

national quality improvement strategy
patient centered outcomes research institute
medicare part D - eliminated gap in 202
pharmaceutical manufacturers - 50% discount on brand name RX (part D)

inflation reduction act 2022

negotiate RX prices within medicare part B and D
pharma pays rebates to medicare if prices increase exceed inflation
caps OOP spending-for medicare part D plans in 2024
caps monthly copayments for insulin to $35 for medicare
eliminates copays for adult vaccines covered in medicare part D
expands benefits for part D low income substidy

accountable care organizations ACO

initiated by medicare called Medicare shared saving program
organized group of providers all accountable for overall care of patient population and follow processes to promote evidence based, high quality and cost efficient care

ACo payment reform

shared shaving program - quality & cost reduction are met 1/2 of the savings become bonus to ACO
advanced payment model: upfront fixed payment , upfront variable payment based on # of beneficiaries, and variable monthly payment based on # of beneficiaries
eligibly - min 5,000 medicare beneficiaries at least 3 years

NYS reforms

- ACA mandated changes
- insurance exchange
- expanded access
= public outreach for already available plans
Medicaid reform:
- cost containment
- improved efficacy
- current ACA wavier - DSRIP program

DSRIP reform goals

reduced avoidable hospitalization by 25%
create performing provider systems (PPS)
value based payment structure
available data portal and analytics