Health Care Decoded v2
Health Care, Decoded
At midnight on January 1, several new parts of the Patient Protection and Affordable Care Act (PPACA, or ACA, for short) kick in, one of which is designed to improve the way insurers treat women: If you've ever had a cesarean section, reproductive cancer, or one of many other female-only medical problems, you'll no longer risk being denied coverage or paying more for your health insurance. And yes, it happens. "We've heard stories where women who had C-sections were denied coverage unless they could provide a note from their doctor saying that they'd been sterilized," says Judy Waxman, vice president of health and reproductive rights at the National Women's Law Center, a nonpartisan, nonprofit women's advocacy organization in Washington, DC.
[sidebar]Here's what else the ACA will change.
No longer can insurance companies stop paying claims once you hit an arbitrary annual or lifetime limit on essential health care services. This is particularly important for women, because we typically have higher costs than men. "We have more complex health needs and conditions, and we live longer, all of which contribute to those higher costs," says Laura Cohen, senior health policy analyst at the Connors Center for Women's Health and Gender Biology at Brigham and Women's Hospital in Boston. Case in point: Women make 58% more visits a year to primary care physicians and use more prescription drugs than men do.
Higher premiums for women
Until the advent of the ACA, 92% of the best-selling health insurance plans in the individual market determined premiums based on gender. That meant that women paid 60% more, on average, for health insurance than men did. Since insurers can no longer consider gender when pricing health insurance, many women will see their costs drop.
Asking about pre-existing conditions
If you've ever had a C-section, filled a prescription for an antidepressant, or been a victim of domestic violence, then it's likely that you pay more for individual health insurance—if you can find it. Those have all been considered preexisting conditions, and basing coverage on those types of issues has long had a disproportional impact on women, given our higher rates of chronic conditions such as depression and autoimmune disease, Cohen says.
In addition to the changes that will affect women directly, the ACA will address two of the biggest problems in our health care system—cost and quality—by:
Providing financial incentivesfor doctors and other providers to join forces to deliver more patient-centered, coordinated care, which studies find can improve quality and reduce costs.
This encourages doctors to see you as a person, rather than as a single disease or condition, and to treat the causes of your health problems as well as your symptoms. For example, researchers at Joslin Diabetes Center in Boston recently completed a study of hundreds of diabetes-related hospital admissions.
Turns out that readmission rates within 30 days of discharge were dramatically lower for patients treated by a diabetes team than for those who were treated by regular hospital staff. What's more, the folks seen by these teams (consisting of an endocrinologist, a diabetes educator, and maybe a dietitian and fitness coach) were much more likely to see their doctors for regular visits and follow treatment plans after discharge than the control group.
Paying doctors and hospitals bonusesfor meeting certain quality criteria for Medicare patients. It's called value-based reimbursement, and studies find that it translates into better care and outcomes, particularly for people with chronic conditions such as diabetes
One way of looking at this: Doctors who provide the best care, rather than those who perform the most procedures, will reap rewards.
Creating the Patient-Centered Outcomes Research Institute, a nonprofit organization that will produce and promote research to determine what works best in medicine.
Penalizing hospitalsif Medicare patients with certain medical conditions are readmitted within 30 days of discharge. That means you'll see a better level of follow-up care. You'll be asked to schedule follow-up appointments with your doc before discharge, you'll leave with the right medications and precise instructions, and you may even get a monitor to track you at home or have a visiting nurse check in on you.
Requiring that criteriafor hospitals and physicians be available online. Visit medicare.gov/hospitalcompare.
Encouraging "patient-centered care,"which the Institute of Medicine defines as "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions." Here's how that works: Say your doctor recommends a drug for your depression. Instead of just writing out a prescription, she now has incentive to ask, for example: What are your goals for managing your depression? How do you feel about taking drugs? What side effects are you willing to accept to feel better? Would you be OK with gaining weight or having libido issues, which are common side effects of some antidepressants?
Creating the Partnership for Patients programto reduce preventable hospital-acquired conditions, injuries, and deaths. Fact: Right now, nearly one out of every 20 hospitalized patients picks up an infection related to health care, which contributes to some 100,000 deaths a year. (See what other hospital mistakes you can avoid.)
So if you're wondering why a country with world-class medical care needs all these changes, the answer is simple: Despite what many of us think, our system ranks last overall among seven leading industrialized countries in terms of health care-related quality and accessibility, yet we spend more per person than any other industrialized nation. Will the ACA change all that? It's much too soon to tell. But the experts we consulted for this story suggest that it's a start.
"The Affordable Care Act makes an effort to significantly enhance the quality of health care services delivered in the United States," says Kevin C. "Casey" Nolan, an associate professor at Johns Hopkins Bloomberg School of Public Health.
Experts agree that quality health care systems should have three core goals:
- Improve the health of the population
- Enhance the patient experience of care (including quality, access, and reliability)
- Reduce, or at least control, the per capita cost of care
This is what the Affordable Care Act was designed to do. The legislation will tie payment for health care providers to quality, not quantity, "so health care providers who document that they deliver high quality at an affordable cost will be the winners," says Nolan. "Today, providers are paid based on what they do, be it a procedure or an office visit. That's changing." Now, he says, providers' pay will be tied to the quality of care given and its cost.
The Institute of Medicine, a nongovernmental, nonprofit agency, is the health arm of the 150-year-old National Academy of Sciences. Here's how the IOM visualizes the current state of our health care system:
- Our health care system is so disorganized that if banking were like health care, ATM transactions would take not seconds but days or longer, thanks to unavailable or misplaced medical records.
- Our current system provides such uncoordinated services that if home building were like health care, carpenters, electricians, and plumbers would all work with different blueprints and wouldn't cooperate with each other.
- The costs of medical services are so hidden and capricious that if shopping were like health care, you wouldn't see the price till you checked out—and it would vary widely within the same store, depending on how you paid.
- The quality of care is so spotty that if automobile manufacturing were like health care, warranties requiring manufacturers to fix or pay for defects wouldn't exist, and factories wouldn't monitor or improve product quality.
- Our system is so uncoordinated that if airline travel were like health care, pilots could design their own preflight safety checks or opt not to perform them at all.
Your ACA questions, answered
Q: Will the Affordable Care Act result in higher health insurance costs?
A:That depends. Estimates are that women, as well as adults ages 55 to 65, are likely to see lower premiums, while young men's may increase. That's only in the individual state marketplaces, however. Employer health insurance costs have been rising for years because of rising health care costs, and Milliman, an actuarial consulting firm, estimates a 9% increase in premiums in 2014, despite the ACA. However, the law's requirement that insurance plans cover an essential set of health benefits and provide preventive and screening services with no co-payments may increase premium costs, Milliman notes.
Q: Is it true that some employers are cutting jobs or hiring only part-time employees to avoid providing health insurance?
A:The ACA requires that beginning in January 2015, employers with 50 or more employees provide affordable health insurance for all employees who work 30 hours a week or more, or these employers may have to pay significant financial penalties. There have been a few news reports that some large employers, particularly restaurant chains, have threatened to hire fewer full-time employees so they can avoid the mandate. In Massachusetts, however, which implemented mandated health coverage in 2006, the percentage of employers offering health insurance actually increased, even through the recession. And remember, 92% of large employers (97% of those with 101 or more employees) already offer health insurance to their full-time employees.
Q: My employer offers health insurance, and while I can afford it for myself, the family policy is too expensive. Will that change?
A:That depends. Due to a "glitch" in the ACA, the affordability of employer-provided health plans is determined based on an individual policy, not a family policy. If, however, you can afford to cover only yourself, the rest of your family can obtain coverage through your state's marketplace. Single mothers will be able to purchase insurance just for their children in state marketplaces; some children may also qualify for Medicaid, depending on household income.
Video: Decoded: US healthcare
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