Patient Protection and Affordable Care Act: An Analysis
In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law. One major provision of this law created Accountable Care Organizations to increase provider accountability. Under the ACO model, providers are awarded bonuses for decreasing costs and increasing quality of care. Unlike the managed care organizations of the 1990’s Accountable Care Organizations do not employ the use of primary care physician as gatekeepers to control access and referrals to specialists and other care. The ACO model gives the patient freedom to seek care from any provider and move relatively unrestricted through the health care system.It all sounds accurate from a consumer perspective ,but as you try to go deep and try to understand a little more.
This invites the question: how can a physician be held responsible for quality and cost of their patient’s care when that patient may be seen by multiple providers?
The solution is attribution, but this one-word answer is not as simple as it seems.
By using claims data, patients can be assigned to a provider or set of providers. While the patient may see multiple providers in multiple networks, only the attributed providers are responsible for the patient’s cost and quality of care.
A number of attribution strategies exist :
1.Patient-based vs Episode-based 2.Single Attribution vs Multiple Attribution 3.Prospective Attribution vs Retrospective Attribution
An ACO should use the method that best suits the specific needs of their organization.
Patient-based vs Episode-based:
Patient-based attribution assigns the cost of individual patients to a provider(s). This encompasses the entire spectrum of care for any given patient. Episode-based attribution assigns the cost of an “episode of care” to a provider. This includes all clinical services from onset of symptoms to completed treatment. Most Accountable Care Organizations are using patient-based attribution as the primary method of performance measurement.
Single Attribution vs Multiple Attribution:
Single attribution assigns the patient or episode to a single provider. Using a multiple attribution method allows providers to be accountable only for the proportion of care they provided per patient or episode.
Prospective Attribution vs Retrospective Attribution:
Prospective attribution is the practice of assigning patients to a provider or providers based on their historical claims data. Although patients may seek care from any provider, they are assigned to providers they have used most in the past. The CMS Pioneer program is an example of prospective attribution.
Conversely, retrospective attribution looks at past claims and attributes patients based on their utilization. This method of attribution is used by the Medicare Shared Savings Program (MSSP). The greatest strength of retrospective attribution is its accuracy, rather than predicting where patients will receive care, patients are assigned by their actual use of services.
Let's now see the some prudent changes that came in with the Affordable Care Act of 2010 or popularly known as Obama Care in bullet points below:
1.Doing away with life-time and annual dollar limits.
2.Stopping insurance companies from denying you coverage or charging you more based on health status or Requiring all insurers to cover people with pre-existing conditions
3.Stopping insurance companies from imposing unjustified rate hikes.
4.Letting young adults stay on their parents’ plan until 26.
5.Expanding Medicaid and expanding coverage to tens of millions by subsidizing health insurance costs through the Health Insurance Marketplaces (HealthCare.Gov and the state-run Marketplaces
6.Requiring large businesses to insure employees
7.Providing tax breaks to small businesses for offering health insurance to their employees
8.Ensuring all plans cover minimum benefits like limits on cost sharing and ten essential benefits including free preventive care, OB-GYN services with no referrals, free birth control, and coverage for emergency room visits out-of-network
9.Improving Medicare for seniors and introducing CHIP for kids.
The Patient Protection and Affordable Care Act (PPACA), couldn't prove to be a major break through and different people have different analysis . Without being taking any political sides we should try to tailor it to the needs and benefits of the people who look forward to lawmakers . So, what were the short comings ?
The primary cause of the insurance premium rate hikes under Obama Care is the requirement for insurers to cover high-risk consumers. Insurance companies can no longer deny Americans with pre-existing conditions and can’t charge higher rates based on health status or gender. Other parts of the law like the rate review provision and the creation of the health insurance marketplace help to reduce premium costs. These factors, along with a few other required benefits, rights and protections (like the elimination of lifetime and annual dollar limits) led to rate increases between 2010 and 2014.It’s increase is such that where premiums used to be 11% in 1999, now it has doubled to 22% in 2017. Moreover ,it is estimated to touch 25% by 2020.
FACT:
Some regions saw bigger premium hikes than others.
lower-income adults (under the 400% Federal Poverty Level) are the most likely to see a reduction in what they pay.
Those with high-end plans, who had been in exclusive groups due to being healthy, saw the biggest premium increase. So , in a way you have been charged of being healthy?!
To get reduced rates individuals will have to buy insurance from states health insurance market place, which has it’s own pros-cons.
(Link ( for detailed information please visit)
http://obamacarefacts.com/obamacare-health-insurance-premiums/)
Up till this point it feels good but Insurance companies especially private are not such an easy nut to crack ,so they found around other ways like increasing premiums and co-pays and eventually placing the burden on taxpayers . They were already under immense pressure of insignificant improvement in income for decades and inflation , increase in premiums and co-pays was a cherry on top!
So, let's now see in points where Obama Care could have improved :
1.Mandatory to purchase Health Insurance plan or pay penalty and those with employer coverage feel like they are seeing a rate hike (thus paying more for working!) .
2.Out of pocket costs; $6,850 for an individual plan and $13,700 for a family plan before marketplace subsidies. It's simply not affordable.
3.There are no rules for how much employer offered spousal or family coverage can cost. There are rules that say you can’t get cost assistance unless an employer offers coverage that costs more than 9.5% of MAGI per person.
4.Premiums have sky rocketed.
5.26 million remain uninsured and many under insured.
On the other hand Trump Care has the opportunity to mend these gaps . It's a team effort and people around him and his best advisors should take inputs from educators and intellectuals to come up with an appealing Healthcare Policy.