What's Driving Healthcare Reform?
Briefly describes eight legislative and regulatory forces now transforming healthcare services in the United States. These forces establish technological and regulatory incentives and requirements on insurance payers and healthcare providers. The purpose of healthcare reform is described.
Despite having the world’s most expensive health care system, the United States ranks last compared with six other industrialized nations based on measures of quality, efficiency, access, equality and healthy lives. The overall purpose of healthcare reform in the United States is to improve quality and outcomes through measurement, transparency and accountability.
The driving forces transforming healthcare in the United states are:
American Recovery and Reinvestment Act (ARRA) /HITECH) .
Patient Protection and Affordable Care Act (ACA)
Health Information Technology for Economic and Clinical Health Act (HITECH),.
U.S. Department of Health and Human Services National Strategy for Quality Improvement in Health Care (National Quality Strategy)
Health Insurance Portability and Accountability Act (HIPAA)
National Commission on Quality Assurance (NCQA)
Centers for Medicare and Medicaid (CMS)
As defined by the ACA, the “Triple Aim” of the ACA is to:
Ensure access to healthcare and patient satisfaction.
Improve group health and well-being.
Manage or reduce healthcare costs.
The ARRA requires providers (EPs) eligible for reimbursement to use certified electronic health record systems (EHRs). Mental health care providers are not currently defined as “eligible”.
The HITECH Act calls for voluntary adoption of health information technology (HIT) technology throughout the health care system. This new law substantially expands the federal government's effort to
Establish a national electronic patient records system.
Establish comprehensive privacy and security standards for records.
Establish incentives for healthcare providers (not including Mental Health) who adopt Meaningful Use (MU) criteria.
Meaningful Use (MU) is a set of criteria for the use of electronic health record systems (EHR) to improve patient care by healthcare providers. The concept of meaningful use was developed by the National Quality Forum (NQF). Their ideas included improved population health, coordination of care, improved safety, and promoting patient engagement by creating a common interoperable electronic health record system that supports information exchange and provides information to providers that supports data informed practice decision making. Physicians are given financial incentives to adopt EHRs that are certified by the Federal government and support MU. Behavioral and mental health care providers are not eligible.
The U.S. National Quality Strategy includes:
Promoting better health and health care delivery focusing on engagement.
Attending to the health needs of all patients.
Eliminating disparities in care.
Aligning public and private sectors.
Supporting innovation, evaluation and rapid-cycle learning and dissemination of evidence.
Utilizing consistent national standards and measures.
Focusing on primary care and coordinating and integrating care across the health care system and community.
Providing clear information so constituents can make informed decisions.
HIPAA rules were enacted by the U.S. Congress that requires formal notices must be sent to patients for any data breach when private Protected Health Information (PHI) is revealed to the public and it allows for fines. The rules are specific concerning how and under what circumstances PHI can be shared in the operation of healthcare services. HIPAA provides for a complaint process, investigation and enforcement of penalties.
NCQA is a not-for-profit corporation that serves individual healthcare providers, provider groups, health plans and organizations offering:
Accreditation, Certification and Recognition programs for healthcare providers and organizations.
Performance Measurement and Report Cards
Educational programs designed to improve health care by disseminating best practices.
Recommendations for Public Policy
NCQA promotes Primary Care Medical Home (PCMH) and provider Tier designation criteria derived from measures of quality that have value to healthcare payers and that can be used as a basis to negotiate reimbursement rates based on anticipated outcomes.
CMS is the largest insurance payer in the United States, is funded by the Federal government through the Center for Medicare, Medicaid and CHIP. Nearly 50% of all healthcare services are paid for and administered by CMS, making it the largest health plan and market force in the US. CMS’ role in the larger health care arena has been expanded to support affordable health care and make the U.S. health care system more outcome-driven and cost-effective.
The ACA requires CMS to:
Expand Medicaid.
Regulate private health insurance plans.
Create high quality care and better health outcomes at lower costs through improvement to health care for all Americans.
Promote health care innovation.
Reduce disparities in healthcare.
Coordinate with States to set up Health Insurance Marketplaces,
Establish Affordable Insurance Marketplaces.
Integrate the Center for Consumer Information and Insurance Oversight to oversee market reforms and consumer protections in the private health insurance market.
Promote the adoption and use of health information technology in the nation’s health care system.
Michael G. Conner, PsyD is a psychologist in private practice and an owner of Private Practice Cloud, LLC a healthcare operation support business. His business currently supports The American Mental Health Alliance Oregon (AMHA-OR). Dr. Conner is a member of the Board of Directors of Mentor Research Institute (MRI). He acknowledges Michaele P. Dunlap, PsyD, Board Secretary of AMHA-OR, and President of MRI, as co-author of this article.