Individual Mandate Repeal: Impact on the Affordable Care Act

Individual Mandate Repeal: Impact on the Affordable Care Act

                   The Patient Protection and Affordable Care Act, commonly known as the Affordable Care Act (ACA), was passed into law in 2010.  Implementation of the law was spread out over four years, with every citizen required to carry a minimum level of health insurance by March 31^st, 2014.  Those failing to submit proof of health insurance coverage with tax returns faced an income tax surcharge.  The intent of this requirement, often referred to as the individual mandate, was to help lower overall spending on healthcare by the federal government.  

                   In 2017, a new tax reform bill was passed that included a repeal of the individual mandate required by the ACA.  Starting in 2019, citizens will no longer be required to provide proof of health insurance with their tax returns (Mukherjee, 2017).  The impact of the removal of the individual mandate is not yet known, but speculations and estimations indicate that premiums will increase and fewer citizens will carry health insurance, which could have consequences on cost and quality of care available.

                   One of the main goals of the ACA was to reduce the number of emergency room visits by focusing on preventative care. Researchers at John’s Hopkins published a paper in the Annals of Emergency Medicine on this topic.  Their study took place in Maryland over an 18-month period. During that period, access to health insurance increased by 20 percent, but visits to emergency departments only decreased by one percent.  It was estimated by the authors that patients who newly obtained health insurance continued to use the healthcare services to which they were accustomed, rather than seeking out a primary care physician and preventative care (Xu, 2017).

                   An article published by the Washington Examiner written by Robert King (2018) investigated the potential changes that could result from the repeal of the individual mandate.  In the article, King outlines several potential outcomes including the raising of health insurance premiums.  In the article, he states the Congressional Budget Office predicts that up to 4 million people will choose to forgo insurance in 2019 and up to 13 million people will loose coverage.  This could result in a 10 percent premium raise every year, starting in 2019.  One of driving factors for premium increase will be linked to the population most likely to forgo coverage – the young and healthy.  Without a penalty or fine, this population will lack an incentive to obtain health insurance.  The loss of their contribution negatively impacts the risk pool (King, 2018).  

Another potential problem is the closure of federal exchanges, which were created to

meet a need in states that did not expand their Medicaid programs.  Without the individual mandate, there might not be enough interest in the federal exchanges, especially in states with lower populations.  Many states already only have one federal exchange option, and those signing up are usually in a higher risk population than is possible to sustain the insurance offerings (King, 2018).

                   In addition to the removal of the individual mandate, the tax reform bill also allows for the return of short-term insurance plans, as well as plans that do not include ten key requirements for a health insurance plan to qualify under the ACA, such as maternity care (King, 2018).  These short term and lower-risk plans might attract individuals looking for coverage with a lower premium, drawing more customers away from the federal exchanges.

                   Fortune magazine also published an article regarding the future of the ACA in light of the tax reform bill (Mukherjee, 2017).  In that review, it is estimated that Americans will not be largely impacted by the removal of the individual mandate.  They propose that a majority of American citizens already have health insurance coverage through their employer, Medicare, Medicaid, or the military, so will not greatly be affected by the tax reform bill.  Options to purchase health insurance increased with the passage and implementation of the Affordable Care Act and these options are likely to stay in place, regardless of the removal of the individual mandate.  They did predict that premiums would go up, on average, by 10%, but for some individuals, increased federal subsidies will offset those increases.  It is estimated that by 2027, 13 million fewer Americans will have health insurance due to the removal of the individual mandate (Mukherjee, 2017).

In FindLaw (2018), the same potential outcomes are outlined.  However, the authors point out that many aspects of the ACA will stay the same, which comes with advantages and disadvantages.  There will continue to be options available to those who are not covered by their employer, Medicare, Medicaid, or the military, however as long as individuals cannot be denied insurance coverage due to pre-existing conditions, the removal of the individual mandate might encourage citizens to wait until they have a health emergency before signing up for coverage.

                   As mentioned above, the true outcome of the repeal of the individual mandate will not likely be known until 2020 or beyond.  However, based on the literature review, the following implications are most likely:

                   1.  Premium rate increases, by as much as ten percent each year.

                   2.  A loss of health insurance coverage by up to 13 million individuals.

                   3.  A reduction in federal exchange options due to loss of enrollment.

                   4.  Continued access to health insurance options, with new options becoming available                             in the form of short-term policies with reduced coverage.

                   5.  Overuse of emergent care will likely still continue as more individuals lose                                           health insurance coverage.

                    

References

FindLaw (2018).  Obamacare basics: What is the Affordable Care Act?  Retrieved from

https://healthcare.findlaw.com/patient-rights/obamacare-basics-understanding-the affordable-care-act.htm.

King, R. (2018, January 14).  The Obamacare individual mandate is repealed.  Here’s what’s

           next.  Washington Examiner.  Retrieved from https://www.washingtonexaminer.com/the

           obamacare-individual-mandate-is-repealed-heres-whats-next

Mukherjee, S. (2017, December 20).  Tax bill individual mandate.  Fortune.  Retrieved from

           http://fortune.com/2017/12/20/tax-bill-individual-mandate-obamacare/

Xu, T. (2017, July 24).  Research shows one aspect of the affordable care act has no significant

          impact on emergency department patient visits.  John Hopkins Medicine.  Retrieved from

          https://www.hopkinsmedicine.org/news/media/releases/research

Opioid Mortality Rates in States with Medical Cannabis Laws

Opioid Mortality Rates in States with Medical Cannabis Laws

                  

Opioids are frequently used in the United States to treat acute and chronic pain.  In the 1990’s, pharmaceutical companies assured the medical community that opioids were not commonly associated with addiction.  This led healthcare providers to prescribe opioids as a common treatment for pain related issues.  It soon became apparent that opioids were in fact addictive to many, and by the mid 2010’s, the rate of people addicted to opioids became a public health crisis.  The Health and Humans Services (HHS) department of the United States Federal Government declared opioid addiction a public health emergency in 2017 (U.S. Department of Health and Human Services, 2018).  In 2016, opioid overdoses were the cause of more than 42,000 deaths in the United States.  Opioid overdoses increased by 30% in 45 states from 2016 to 2017.  In the Midwestern states, that increase was more than 70% (NIH, 2018).  Both the HHS and the National Institute of Health are looking for alternative methods to treat acute and chronic pain.  One of the suggested alternatives is to consider safe and effective non-addictive drugs, such as medical marijuana, to help manage pain. 

                    

Marijuana is labeled a Schedule I drug by the United State’s Drug Enforcement Agency.  Schedule I drugs are considered not to have any medicinal purposes and are not legal to sell or carry across state lines (DEA, 2018).  In November of 1996, California passed Proposition 215, which allowed for the harvest and utilization of marijuana for medical purposes.  This opened the door for other states to do the same.  By 2013, 19 other states and the District of Columbia had passed similar legislation.  The Supreme Court and the federal government fought these laws until 2013 when the Justice Department announced it would no longer attempt to block any states from implementation of medical marijuana laws.  Currently, 30 states and the District of Columbia allow marijuana to be used for medical purposes (New York Times, 2013).  It is still illegal to carry cannabis across state lines or sell it for recreational uses in most states, however it is commonly used for various medical purposes.

                    

One of the first studies to look at medical cannabis laws and opioid overdose mortality rates was completed in 2014 (Bachhuber, 2014). Results of the study indicate that states with medical cannabis laws had a lower average number of deaths associated with opioid overdose. In his study, Bachhuber (2014) indicated that there was a correlation of lower opioid overdose mortality rates, but no established causation.  In addition, the increased access to cannabis for medical purposes could influence opioid misuse in either direction, which indicates a need for further study.  A few limitations were noted, as well; the study was limited to a specific time period, not all opioid overdose mortalities are properly identified on death certificates, and the study does not take into account characteristics of the individuals within the different states (Bacchuber, 2014).

                     

Bradford (2018) conducted a longitudinal analysis of daily doses of opioid prescriptions filled by patients who utilize Medicare Part D.  The primary outcome of the study focused on the total number of daily opioid doses prescribed.  Results from this study indicate that from 2010 to 2015, 23.08 million daily doses of opioids were dispensed per year under Medicare Part D.  States with medical marijuana laws had fewer doses filled than those without.  Specifically, states with active dispensaries had 3.7 million fewer doses filled on a daily basis.  In addition, hydrocodone prescriptions decreased by 2.3 million and morphine decreased by .3 million.  In this study, the author concluded that medical marijuana laws are associated with a significant reduction in opioid prescriptions in the Medicare Part D population, especially in states with active dispensaries (Bradford, 2018).

                    

Hockenberry (2018) conducted a cross-sectional study using quasi-experimental difference-in-difference design comparing opioid prescribing trends between states with and without medical marijuana laws from 2011 to 2016.  This study found that states with medical marijuana laws were associated with a 5.88% lower rate of opioid prescriptions.  States that allowed adult use of marijuana, without or without medical reasons, found a reduction of 6.38%.  The authors of this study concluded that medical marijuana laws have the potential of reducing opioid use, which could also reduce mortality rates. 

As opioid addiction has been declared a national public health emergency, it is important to consider viable options to reduce the use of opioids as a method to control and manage both acute and chronic pain.  The studies outlined in this literature review are not conclusive, but they do point to an overall decrease of opioid use in states with medical marijuana laws.  While these studies do not provide causation, the correlation is enough to consider the benefits of alternative pain reducing methods, including the use of medical marijuana.  

Suggestions for future studies would include an updated study similar to the one conducted by Bachhuber (2014).  Doctors have reduced access to opioid painkillers since that time, which has led some patients to seek similar drugs in the open market.  Some states, such as Colorado, have more strongly regulated access to medical marijuana since the 2014 study, as well (Ingold, 2018).  This tighter control has made it more difficult for patients to obtain cannabis as an alternative to opioids.  Finally, more states have legalized marijuana use, which would also provide greater opportunity for obtaining new data.

References

Bachhuber, M.A. (2014). Medical cannabis laws and opioid analgesic overdose mortality

in the United States.  JAMA Internal Medicine 174(10) 1668-1673. Doi:

0.1001/jamainternmed.2014.4005

Bradford, A.C. (2018).  Association between US state medical cannabis laws and opioid

prescribing in the Medicare Part D population.  JAMA Internal Medicine 178(5):

667672. Doi:10.1001/jamainternmed.2018.0266

DEA (2018).  Drug scheduling.  Retrieved from https://www.dea.gov/druginfo/ds.shtml

Hockenberry, W.H. (2018).  Association of medical and adult-use marijuana laws with

opioid prescribing for Medicaid enrollees.  JAMA Internal Medicine 178(5); 67

679.Doi:10.1001/jamainternmed.2018.1007

Ingold, J. (2018, February 22).  Do medical marijuana laws reduce opioid overdoses?  A

new study adds a layer of nuance.  Denver Post.  Retrieved from

https://www.denverpost.com/2018/02/22/medical-marijuana-laws-reduce-opioid

overdoses/

NIH (2018).  Opioid overdose crisis.  Retrieved from https://www.drugabuse.gov/drugs

abuse/opioids/opioid-overdose-crisis

U.S. Department of Health and Human Services (2018).  What is the U.S. opioid

epidemic? Retrieved from https://www.hhs.gov/opioids/about-the

epidemic/index.html

Hierarchical Condition Category (HCC) coding

Hierarchical Condition Category (HCC) coding is an adjustment tool that is used to calculate risk scores and to predict future health costs for populations. CMS talks about risk adjustments associating practices, or they use Tax Identification Numbers or TINs, to describe providers that my deliver care to populations that are now well and other TINs that provide care to those populations that are more well than others.

The critical element of this measurement is the ratio of actual-to-expected performance and then taking into account the National Average. This measurement can take two providers and measure the performance of the two based on clinical complexity. CMS takes an example of one practice treating a very sick population that has higher costs. When you look to compare a provider of a healthy population to this one who treats a sicker population, the one treating the sicker population looks like they may not be as efficient. However, if you compare the practice that is treating a sicker population to another same or similar practice, you may find that they are actually more efficient and have much lower costs than the other practice treating the same population type.

Some of the measures that are looked at in the risk adjustment are as follows:

30-day All-Cause Hospital Readmission Measure

Calculates the percentage of qualifying hospital admissions that result in unplanned readmissions within 30 days of discharge

Hospital admissions for Acute and Chronic ACSC Composite measures

Represents distinct conditions for hospital admissions are potentially avoidable with using the services of ambulatory care delivery options

Per Capita Costs for all attributed beneficiaries and per capita costs for beneficiaries with specific conditions

Calculates per capita costs through HCC and generates a risk score that identifies potential per capita costs attributed to the beneficiaries measured

MSPB measure

A measurement of Part A and Part B total expenditures before, during, and after a qualified hospital stay

Consumer Assessment of Healthcare Providers (CAHPS) for Physician Quality Reporting System (PQRS) measures

CMS uses other data for measurement such as age, education, overall health and mental health indicators

This process takes into account several methodologies, but the one that stands out is expected performance vs. actual performance.

Overall, HCC coding has a great many variables both in the provider scope and the population served. A good Healthcare Administrator that is working in the primary practice arena or Accountable Care Organizations will need to familiarize themselves with the HCC coding concepts and how they may impact your facility and the population that is served. Not monitoring this process can cost the practice or ACO a considerable amount of resources without adequate measures to recoup costs.

Submitted by Kevin Harrington, MATS, MSHA, RHIA, CHP

Assistant Program Director, Health Administration, Saint Joseph's College

Family Financial Responsibility for Senior Care

Several recent items got me thinking about how American society is planning for senior care needs as Boomers age and start accessing LTPAC services. 

 ·        A New York Times article titled “The New Retirement: Near the Kids”  (hhtps:nyti.ms/2HNJ1j5) details a discussion of retirees moving away from the “sunbelts” and in to senior communities near their children. The article discusses the importance of family contacts, isolation, and nutritional needs as we age. While news articles and anecdotal stories do provide some interesting examples, they are limited in their scope and might not reflect the trends in society as a whole. 

 ·        Another article reported from the life insurance company (Northwestern Mutual) reported that 21% of Americans have no retirement savings and 33% of Boomers have less than $25,000 in savings. Those savings amounts are considerable less than the cost of a year in any senior care settings.

 ·        Another article in the Wall Street Journal was a question in their “Market Watch” section from someone asking about children’s responsibility to support aging parents. The author reports that about two dozen states have laws that have “filial” responsibility or “piety” laws, which require that families have a duty to support parents of adult children. While these have rarely been used and date back to colonial times, they are enforced on an occasional basis.

 ·        The final article (The Investment News Adviser Center) reported that two-thirds of financial fraud against the elderly was perpetrated by those closest to the victim. (ie. family, friends or trusted individual).

 All of the articles are concerning individually, as they have broad public policy issues on how to provide, support, and finance senior care needs into the future. Taken together, the potential for seniors and their families to be able to find and afford quality senior care is very concerning. The demographics of American society are very well known and should be used by public policy makers to prepare society for the coming challenges of aging Americans. Doing nothing to change the service delivery and financing for seniors has grave potential for taxpayers and families of seniors.

Written by Steve Chies, Program Manager, Long-Term Care Administration, Saint Joseph’s College

Great Article!

One of our graduates has written a terrific article!  I have linked it here!

Why I Chose to Join the Nursing Home Profession

Annual Wellness Visits

With Health Administrators changing place of service/employment and organizations expanding their presence in Primary Care Practices (PCP), there are many areas of focus for the PCP, of which one of them is Annual Wellness Visits.

An Annual Wellness Visit (AWV) has the following characteristics:

• It is an enhanced visit that lasts 45-60 minutes, at no-cost to the patient, including preventive labs
• The goal is to see every Medicare patient every year and for this service to be billed once per calendar year
• The benefit refreshes January 1 of every year. There is no need for the PCP to wait 365 calendar days between visits
• In addition to the traditional AWV CPT codes G0438 and G0439, some insurance plans offer the ability for the PCP to submit additional codes for reimbursement.  Check your local plans for details.
• AWVs need to be performed by a primary care physician, contracted nurse practitioner, or PA

 During an Enhanced Annual Wellness Visit the practitioner must

• Document patient’s current chronic conditions and ongoing treatment plans
• Conduct preventive screenings for conditions such as high blood pressure, diabetes, depression, and heart disease
• Review medications
• Schedule preventative treatments: colonoscopy, blood work, mammogram, etc.
• Complete lab work as necessary
• Use a pre-populated template based on the requirements of the specific payer

Benefits of an Enhanced Annual Wellness Visit

• Allows for accurate reporting/submission of patient’s chronic conditions to Medicare in the current year
• Maintains best practice of seeing your patients at least once a year
• Allows opportunity to identify care gaps and create a plan of care for the year
• Ensures acceptable medical record documentation in the case of a Risk Adjustment Data Validation (RADV) audit.
• Compliance with Star Measures is also required by CMS.
• Other considerations:  

CMS measures outcomes in multiple domains, including measures focused on your efforts to manage chronic conditions/issues in the Medicare population:

                                          i.    Osteoporosis

                                        ii.    Diabetes (retinopathy, nephropathy, HgbA1c, and cholesterol control)

                                       iii.    Hypertension

                                       iv.    Rheumatoid arthritis

v.  Bladder control

This is just a quick overview of the Annual Wellness Visit. If you find yourself or your organization getting more involved in Primary Care Practice Management, this is one of several areas that you as a Healthcare Administrator can find areas of efficiency for both the practice, and most importantly, the patient.

Submitted by Kevin Harrington, MATS, MSHA, RHIA, CHP, Full-Time Faculty, SJC

Cultural Agility & Long-Term Care Settings

In my opinion, in the service industry, whether it is elder care or kinder care, cultural competence is the nexus that can determine success and satisfaction in any service business. I learned this fact early in my education as a recreation therapist. I had to understand the specific cultural interests of each population so that I could engage clients in meaningful activities in which they felt connected. For example, my Hispanic students wanted to learn the salsa and liked the upbeat tempo of that genre. My African American students wanted to listen to hip-hop and dance like Michael Jackson. We all compromised and had fun and a lot of laughs learning the various styles of dance and music.

Likewise, as a recreation therapist in a nursing home, I had to provide a variety of activities which would connect to a multitude of cultural interests. The religious activities were where I saw the most distinguishable segregation in cultures. The African American religious groups were more robust, loud, and lasted hours. Whereas, the non-Hispanic white religious activities were conservative and quick. The Catholics preferred to take Mass in their room. We had both an English-speaking priest and a Spanish-speaking priest who would visit the Catholic residents in their room.

I have always worked in very culturally rich locations and have been mindful of cultural differences both in the client population and the workforce. In fact, in the Northern Virginia market, a common complaint among patients is that they don’t understand the staff. In our demographic area, many African workers from Sierra Leona have a strong dialect and speak broken English. We also have many Hispanic workers and Filipino workers. There exist language barriers between staff and residents who are of not a minority background. Equally, many of our workforces are Muslim, and employers have had to adjust workflow to accommodate Muslim traditions and religious observances. So, as a health administrator, I have had many experiences with implementing cultural competencies to serve minority elders effectively.  I equally have had to apply cultural appreciation and diversity training to my non-minority elders and workforce to get along with and accept the cultural differences of our minority workforce.

Competencies Needed in Skilled Nursing Facilities

            There are three competencies that I believe skilled nursing facilities in culturally rich areas could do more to integrate into their healthcare settings. These include coordinating with traditional healers, incorporating culture-specific attitudes and values into health promotion tools, and locating clinics in geographic areas that are easily accessible for specific populations.

            Many years ago, I contracted with a massage therapy school to provide therapeutic massage to our bedridden and chronic pain residents. For me, massage is healing to the body and mind and works much better for my aches and pains than pain medication. Traditional healing methods offer a holistic approach to healing. Common traditional healing methods include acupuncture, sauna and steam baths, herbal teas, and herbal or mineral body scrubs. When I think of traditional healing and the elderly, I think of the power of touch and the power of spirituality. Sometimes, a hug or sharing a prayer is all that is needed to ease some pain and suffering of our fragile elders. Bearing in mind the variances in cultures where touch or eye contact may be offensive or an untoward expression.

            In the context of meeting a specific cultural need, there are practicing traditional healers for the African populations, the Chinese populations, and Native American populations. In my opinion, skilled nursing facilities should consult with residents and families to see if they have these specific preferences and make the accommodations, as feasible, to provide traditional healing to these residents.

            Preventive medicine, healthy lifestyle choices, and chronic disease management are how we will help the influx of the older population age well. The use of health promotion tools such as educational seminars and workshops, published literature, e-health, m-health, telemedicine, and health screenings are all useful tools to manage our aging population. However, if we don’t implement cultural sensitivity into the tools, the message will be lost on the minority elder population.

            Something as simple as the standard rehab ladder could reflect cultural sensitivity. How difficult would it be to ask the patient what their rehab goals are and establish a personal ladder of achievement? Maybe there is a grandchild’s graduation in the future? Perhaps there is a 50^th wedding anniversary party? Maybe it is to golf or possibly swim? I use this as a simple example of a complicated issue. However, awareness is half the battle.

            As a skilled nursing facility provider, I would like to see more referrals being made to outpatient therapies, home-health agencies, physicians and specialists, and social workers who share not only the demographics of the discharged patient but also the culture. Most insurance companies include in their directory of providers the languages that the provider speaks. I think the same should be included in a list of home health agencies, outpatient therapy clinics, and enrichment programs for the elderly.

Cultural Sensitivity & Patient-Centered Care

            To conclude the discussion of cultural competencies, I would be remiss not to parallel cultural sensitivity to patient-centered care. Both models aim to improve healthcare.  Whereas, 

“the primary aim of the cultural competence movement has been to balance quality, to improve equity and reduce disparities by specifically improving care for people of color and other disadvantaged populations. [And] the primary aim of patient-centeredness has been to individualize quality, to complement the healthcare quality movement’s focus on process measures and performance benchmarks with a return to an emphasis on personal relationships and customer service. As such, patient-centeredness aims to elevate quality for all patients” (Saha, Beach, & Cooper, 2010, p. 9).

About the Author

References

Saha, S., Beach, M.C. & Cooper, L.A. (2010, February 18). Patient centeredness, cultural            competence and healthcare quality. Retrieved from          https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2824588/

Contributed by Donna Rein, Graduate Student, MHA Program, Saint Joseph's College

Aging and Dehydration

What is dehydration? Simply put “Dehydration occurs when more water and fluids leave the body than enter it” (Crosta, 2017).  Studies show that even mild dehydration (1-3% of body weight) can impair many aspects of brain function (Leech, 2017).

Research has also shown that between 6-30% of people over age 65 are hospitalized for some form of dehydration.  The major cause is the lack of fluid intake.  This is often attributed to patients not having the sensation of “thirst”, and not recognizing the signs/symptoms of dehydration such as a sense of dizziness, dry mouth, headache, or a feeling of tiredness.  Another reason noted by patients is their desire to avoid frequent, inconvenient trips to the bathroom, and lastly a fear associated with spontaneous incontinence or loss of bladder control.  (Konings, F., Mathijssen, J., Schellingerhout, J., Kroesbergen, I., Goede de, J., & Goor de, I. (2015).

The benefits of proper hydration aid the body in getting rid of waste - through urination, perspiration and bowel movements.  Proper hydration also keeps body temperature normal, lubricates and cushions joints, and assists in protecting sensitive tissues.

How much fluid should adults drink per day? About 15.5 cups (3.7 liters) of fluids for men and about 11.5 cups (2.7 liters) of fluids a day for women (Mayo Clinic Staff,1998-2018).   Tips to encourage/increase hydration are as follows:  make it a game/encourage the use of colored drinking glasses, incorporate more fluids into other foods such as soups and less sugary beverages like vegetable juices and non-caffeinated beverages such as herbal teas and fruit juices, and making fluids easily accessible.

References

Crosta, P (2017, December 20). What you should know about dehydration. Retrieved from https://www.medicalnewstoday.com/articles/153363.php

Konings, F., Mathijssen, J., Schellingerhout, J., Kroesbergen, I., Goede de, J., & Goorde, I. (2015).  Prevention of dehydration in independently living elderly people    at risk: A study protocol of a randomized controlled trial. International Journal    of Preventive Medicine, 6103. doi:10.4103/2008-7802.167617

Leech, J. (2017, June 4). 7 Science-based health benefits of drinking enough water.  Retrieved from https://www.healthline.com/nutrition/7-health-benefits-of-water  
Mayo Clinic Staff. (2018). Water: How much should you drink per day? Retrieved from https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/water/art-20044256

The author, Patricia M. Cuddy, is a student currently enrolled in the Master of Health Administration program at St. Joseph’s College.  Ms. Cuddy has worked in healthcare for 24 years as a registered, licensed Radiology Technologist, Clinical Manager of Radiology, and is currently working in Human Resources.