Healthcare in the USA – Highlights as of July 2013

Healthcare Reform, ICD 10, Meaningful Use, ACOs (Accountable Care Organizations), HIPAA Omnibus Rule, EHRs, Health Information Exchange (HIE), Medicaid Expansion and on goes the terms and acronyms affecting both the consumer and the healthcare professional. The learning curve alone to understand what is going on and how it affects each segment of the population is staggering. The fact that there is a significant gap in terms of knowledge of the facts and interpretation of the same by multiple parties is so wide that the same ferments more uneasiness and doubt.

So let’s see if we can share some light based on the recent facts:

1. WASHINGTON — As of Tuesday, July 2, 2013, the Obama administration announced that one of the key provisions of the healthcare reform will be delayed until 2015. This provision required businesses with more than 50 employees to provide health insurance for their workers.
Prior to this extension Companies would have had to pay the Internal Revenue Service (IRS) $2,000 for each full-time employee who didn’t get coverage after the January 1st 2014 dateline.
The question that remains is if the Administration will also provide similar relief to individuals who face a penalty if they do not have health insurance by 2014. The individual mandate calls for a “tax” of $95, or 1% of taxable household income, and rise in phases to $695 per person, with a cap of 2.5% of household income, by 2016.

Let’s pause and do a quick comparison:

Company Individual
Monthly Insurance Cost $ 500 $ 350
Annual Cost $6,000 $4,200
Penalty/tax $2,000 $ 695
Difference $4,000 $3,505

Of course I’m oversimplifying the facts but in the most basic scenario it will be better for me to pay the tax and forget about the law altogether.

2. The Centers for Medicare & Medicaid Services confirmed the potential loss of 28% of their Pioneer accountable care organizations.

Accountable Care Organizations (ACOs) are groups of healthcare professionals and hospitals that join forces under this model to provide services to the Medicare Population. Medicare ACOs are another component of the Healthcare Reform and the basic idea is that eventually this model will assume risk for patients well being and in the process save money to the Government.

Incentives for the ACOs are based on meeting 31 quality measures established by the Centers for Medicare and Medicaid Services (CMS). Regretfully these quality measures were established without any historical data to justify the same which in turn may result on these ACO’s being unable to provide services and remain financially stable.

If you are a healthcare professional this information is important and should be considered as part of your business plan. If you are a Medicare recipient it means little to you at this time even though in the future your choices of care may be limited by the ACO. As a business there is little relevancy unless you decide to receive coverage by the ACO network which in a way it will be no different than any other insurance.

3. Medicaid Expansion. This is another key component of the Healthcare Reform whose future is uncertain in some states. The basic preamble of the Medicaid expansion is offer healthcare services under the Medicaid program to individuals below 138 percent of the federal poverty line, about $31,800 for a family of four. During the first three years of the program the Federal Government will assist those states with additional funding in order to cover these expenses.

While the Medicaid Expansion seems to be a great idea the reality may be otherwise. As it is some States are having a hard time funding the program with the current enrollment, hence an increase in their rosters is not financially sound. The fact that the Federal Government will provide additional funding for the first three years is great but what will happen after that time?

Another point to consider is which Physicians and facilities accept Medicaid. For the last couple of years more doctors and facilities have been migrating out of the Medicaid program due to their lower reimbursement. There have been an initiative to increase Medicaid fees to Medicare levels, yet even Medicare fees are been questioned as fair and reasonable.

The significance of the Medicaid Expansion program depends on the interest group. For example for the individual no Medicaid Expansion results in no individual mandate under Health Care Reform. For the healthcare professional is a little more difficult as an expansion may result in more potential clients but not necessarily more take home pay. For businesses is also important as Medicaid expansion could take a little pressure regarding the health insurance mandate.

There are no straight answers as we are embarking in new territories. There is also no question that the Healthcare Reform is facing tough challenges. The only thing we can count on is “change”.