Less Visible Important Benefits of the ACA
Published Friday 13 of July, 2012
Just as the media has focused on the Peter Higgs part of the Higgs Boson particle, with scant attention to the “boson” part, named after the eminent Indian physicist Satyendranath Bose, so with the Affordable Care Act . With the AC the primary focus has been on the mandate and Medicaid, with scant attention to two potentially life-changing health reforms, likely to have major positive consequences for you and your family.
These two benefits are coordinated care and parity. They have the potential to have a huge impact on our health and our pocketbook.
Under the ACA, primary care settings, where most of us get our healthcare, that become high quality practices, i.e. can demonstrate, via hard data, sustained better health outcomes for their patients, and at lowered costs, will be financially rewarded by the government (e.g. via Medicare or Medicaid) or by private insurers.
These transformed practices, whether hospitals, doctors offices, health centers, or some combination thereof, are becoming known as “accountable care organizations” or “patient-centered health homes.” They are called this because they are networks of hospital and doctors agreeing to take responsibility and accountability for their population of patients. They are accountable for keeping patients healthy and for keeping costs down. If they can demonstrate over time better quality of care in terms of patients better health outcomes, while also managing to keep costs down for their patients by avoiding unnecessary tests and procedures and emphasizing preventive services, then those medical providers get to keep a share of the resulting health delivery savings. An example would be where patients with diabetes or high blood pressure receive quality and preventive care that keeps them out of the hospital. Quality care, lowered costs.
A core element of accountable, high-value is medicine is coordinated care. Coordinated care means first and foremost addressing patients’ medical and behavioral health needs together, in a coordinated, collaborative fashion. It entails health care teams, comprised of both medical doctors and behavioral health professionals and their staffs, working in unison, utilizing a common patient treatment plan. It includes a “care manger,” usually a RN or nurse practitioner, following-up with patients on a regular basis to monitor and track appointments, medication management, referrals follow-through, etc, under the supervision of the health care team. It means setting up patient registries where patients’ treatment progress (or lack thereof) doesn’t fall through the cracks, and where cumulative data can be gathered that will be vital to assessing practice performance, and seeing what works on a population-wide basis, helping the larger community stay healthy.
For years now, national surveys have shown that most patients would prefer an integrated approach to their healthcare, in which primary care and mental health providers work together to address medical and behavioral health needs. Despite this strong wish, we patients have had to cope as best we could with a fragmented healthcare delivery system, in which medical and behavioral treatment services have been delivered in separate geographic and functional silos, with little or no collaboration among doctors. Now, finally, with the ACA’s coordinated care reform, we will start to receive mental health services along with our medical treatments in a coordinated, collaborative, prevention-focused fashion.
How will coordinated care save costs for patients? According to the respected, impartial Institute of Medicine, many healthcare providers, policymakers and others have in the past not recognized that mental health problems don’t exist in isolation. Frequently they run parallel to the patient’s other medical issues and, if those mental health conditions are ignored or poorly treated, often lead to worse overall health outcomes for the patient and higher costs for all of us.
Unaddressed co-existing behavioral issues hamper patients from being able to engage in self-care, take medications, stay engaged in healthy behaviors, etc and thus impede their recovery from their medical problems. Cost-wise, the 10% of the total U.S. patient population with both co-occurring medical and behavioral conditions account for 90% of total health expenditure in this country! Treating both behavioral and medical conditions together in a coordinated way is the low-hanging fruit on the healthcare cost savings tree. It’s a no-brainer. But sadly, it hasn’t been possible until now.
The second unheralded but vital benefit the ACA provides is parity. This refers to a federal law enacted in 2008 that requires insurance companies to offer mental health/substance use serviced benefits in their health insurance plans on an equal basis with the medical/surgical benefit services offered. The ACA requires parity – that the financial and treatment limitations placed on mental health and substance use not be more restrictive than those for medical and surgical benefits – must be part of the new health exchanges (or health plan supermarkets, if you will) and also be part of Medicaid expansion program services. The ACA makes parity a basic requirement for more than just large company insurance plans.
In sum, as you take stock of what the ACA means for you and your family, remember these two innovations, coordinated care and parity. They could make all the difference for you in the future.
Florence C. Fee
“Complex health” patients are defined as those with co-existing medical and psychiatric conditions.