by Michael Newell RN MSN~
The Patient Protection and Affordable Care Act (termed Obama Care by its detractors) is a complex but sweeping piece of legislation aimed at re-engineering the health financing of the American Health Care System so as to improve the quality and lower the cost. The ACA, along with mandated changes in the use of technology proscribed the HITECH Act1 also usher in new challenges and opportunities for those who practice Care Management.
The national discussion now occurring as provisions of the ACA become reality is also sparked by such facts as:
- An estimated 32 million new people will have access to health services starting in 2014 that did not have such access before.2
- With new influx of patients and not enough primary care providers, many people will have difficulty getting an appointment with their own PCP. In Massachusetts, this has led to Urgi-Centers or walk-in clinics to fill the gaps for non-emergent care. These clinics are usually placed on major highways near light industry and/or restaurants and use physician extenders such as Physician Assistants and Nurse Practitioner who can do diagnosis and drug prescriptions, simple x-rays and suturing. They do not take Medicaid, but specialize in those with commercial health insurance, worker’s compensation insurance and cash for such services as school/team physicals, drug screening, etc.3
- The advent of Electronic Health Records, including an individual person keeping their own Personal Health Record (PHR), along with the “Meaningful Use” provisions of the HITECH Act on EHRs. Part of the meaningful use criteria includes improved documentation presented to patients as they leave the office encounter. This documentation specifies the reason the patient presented themselves, the diagnosis, the Plan of Care, referrals, prescriptions, etc. that will assist patients and families to coordinate their own care.
- The support of “Patient Centered Care”. The Institute of Medicine (IOM) defines patient- centered care as “care that is respectful of and responsive to individual patient preferences, needs, and values” and that ensures “that patient values guide all clinical decisions4
The ACA includes a renewed focus on chronic care management. Chronic care costs 75% of all health care expenditures. One in two adults has at least one chronic illness.5 The renewed effort by the federal legislation to manage the “cost curve” in healthcare includes coordination of care and health advocacy for individuals as well as “population health”. Componentls of this effort include:
- Care innovations such as Accountable Care Organizations (ACOs) are expected to use a variety of methods motivated by a split of any savings that accrue from improvements in health delivery with the Medicare. Since these entities have no outreach ability in the community, Care Managers who are knowledgeable about the service area are in an ideal situation to assist these organizations.
- Enhanced Primary Care or the “Medical Home” model has already demonstrated significant savings, partially due to improved care coordination.6 Again, these organizations will need care coordination in the community to assist them in managing those high-risk individuals with three or more chronic conditions.
- Bundled Payments. In order to achieve meaningful savings in the inpatient setting, the Center for Medicare & Medicaid Innovation (CMMI) has introduced bundled payments,7 as a model for hospital payment and delivery reform. A bundled payment is a fixed payment for a comprehensive set of hospital and/or post-acute services, including services associated with readmissions. Moving from individual payments for different services to a bundled payment for a set of services across providers and care settings encourages integration and coordination of care that should raise care quality and reduce readmissions. Variants on bundled payments are being demonstrated and differ in the scope of services included in the bundle and whether payment is retrospective—based on shared Medicare savings—or prospective, which intensifies the financial risk and return to investing in changes to the efficiency and quality of care. Currently, 467 health care organizations across 46 states are engaged in the bundled payment initiative.
- Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act. This program tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The 112 participating organizations are paid an all-inclusive care management fee per eligible discharge that is based on the cost of providing care to the patient and implementing the systemic reforms at the hospital level8.
- Federally Qualified Health Centers (FQHCs) that provide Primary Care in a clinic setting with extensive use of ”physician extenders”, Nurse Practitioners and Physician Assistants are expected to perform care coordination activities for their constituents, including health coaching, wellness activities, community outreach9. These centers have been in existence for many years, and have focused on geographic areas such as inner city or the rural poor, those with Medicaid or those lacking any health coverage at all.
- Additional incentives are being created to coordinate primary care, mental health, and addiction services. The goal is enhanced community-based service options for individuals with a mental health and/or substance use conditions. Medicaid state plan changes and demonstration grants are already expanding these services for individuals who have long-term care needs (e.g., dual-eligible, high-risk Medicare beneficiaries, Money Follows the Person and other Medicaid Waiver changes that will evolve based on state applications). In addition, the CLASS Act (Community Living Assistance Services and Supports Act) creates a self-funding initiative for individuals who need home- and community-based services. Additional incentives to coordinate primary care, mental health, and addiction services.10
2 Health Reform’s Next Challenge: Who Will Care For The Newly Insured? http://www.amednews.com/article/20100412/profession/304129957/1/
4 Michael J. Barry, M.D., and Susan Edgman-Levitan, P.A (2012) Shared Decision Making — The Pinnacle of Patient-Centered Care. http://www.nejm.org/doi/full/10.1056/NEJMp1109283 5 Centers for Disease Control: http://www.cdc.gov/chronicdisease/resources/publications/aag/chronic.htm
6 Michael L. Paustian, Jeffrey A. Alexander, Darline K. El Reda,Chris G. Wise, Lee A. Green, and Michael D. Fettersm(2013) Partial and Incremental PCMH Practice: Transformation: Implications for Quality and Costs Health Services Research. Published online on 5 JUL 2013. DOI: 10.1111/1475-6773.120857 Centers for Medicare & Medicaid Services. Bundled Payments for Care Improvement Initiative. http://innovation.cms.gov/initiatives/bundled-payments/