Question

In 2010, the Affordable Care Act refreshed this initiative and offered the States the opportunity to bid on Duals Demonstration Pilots. Describe what do the components of these demonstration pilot programs tell you about the general state of care coordination in the U.S

Answer 1

On March 23, 2010, President Obama signed the Affordable Care Act. The law puts in place comprehensive health insurance reforms that will roll out over 4 years and beyond

2010

NEW CONSUMER PROTECTIONS

• Putting Information for Consumers Online. The law provides for where consumers can compare health insurance coverage options and pick the coverage that works for them. Effective July 1, 2010.
• Prohibiting Denying Coverage of Children Based on PreExisting Conditions. The health care law includes new rules to prevent insurance companies from denying coverage to children under the age of 19 due to a pre-existing condition. Effective for health plan years beginning on or after September 23, 2010, for new plans and existing group plans.
• Prohibiting Insurance Companies from Rescinding Coverage. In the past, insurance companies could search for an error, or other technical mistake, on a customer's application and use this error to deny payment for services when he or she got sick. The health care law makes this illegal. After media reports cited incidents of breast cancer patients losing coverage, insurance companies agreed to end this practice immediately. Effective for health plan years beginning on or after September 23, 2010.
• Eliminating Lifetime Limits on Insurance Coverage. Under the law, insurance companies will be prohibited from imposing lifetime dollar limits on essential benefits, like hospital stays. Effective for health plan years beginning on or after September 23, 2010.
• Regulating Annual Limits on Insurance Coverage. Under the law, insurance companies' use of annual dollar limits on the amount of insurance coverage a patient may receive will be restricted for new plans in the individual market and all group plans. In 2014, the use of annual dollar limits on essential benefits like hospital stays will be banned for new plans in the individual market and all group plans. Effective for health plan years beginning on or after September 23, 2010.
• Appealing Insurance Company Decisions. The law provides consumers with a way to appeal coverage determinations or claims to their insurance company, and establishes an external review process. Effective for new plans beginning on or after September 23, 2010.
• Establishing Consumer Assistance Programs in the States. Under the law, states that apply receive federal grants to help set up or expand independent offices to help consumers navigate the private health insurance system. These programs help consumers file complaints and appeals; enroll in health coverage; and get educated about their rights and responsibilities in group health plans or individual health insurance policies. The programs will also collect data on the types of problems consumers have, and file reports with the U.S. Department of Health and Human Services to identify trouble spots that need further oversight. Grants awarded October 2010.

IMPROVING QUALITY AND LOWERING COSTS

• Providing Small Business Health Insurance Tax Credits. Up to 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. The first phase of this provision provides a credit worth up to 35 percent of the employer's contribution to the employees' health insurance. Small non-profit organizations may receive up to a 25 percent credit. Effective now.
• Offering Relief for 4 Million Seniors Who Hit the Medicare Prescription Drug “Donut Hole.” An estimated 4 million seniors will reach the gap in Medicare prescription drug coverage known as the “donut hole” this year. Each eligible senior will receive a one-time, tax free $250 rebate check. First checks mailed in June 2010, and will continue monthly throughout 2010 as seniors hit the coverage gap.
• Providing Free Preventive Care. All new plans must cover certain preventive services such as mammograms and colonoscopies without charging a deductible, co-pay, or coinsurance. Effective for health plan years beginning on or after September 23, 2010.
• Preventing Disease and Illness. A new $15 billion Prevention and Public Health Fund will invest in proven prevention and public health programs that can help keep Americans healthy—from smoking cessation to combating obesity. Funding begins in 2010.
• Cracking Down on Health Care Fraud. Current efforts to fight fraud have returned more than $2.5 billion to the Medicare Trust Fund in fiscal year 2009 alone. The new law invests new resources and requires new screening procedures for health care providers to boost these efforts and reduce fraud and waste in Medicare, Medicaid, and CHIP [Children's Health Insurance Program]. Many provisions effective now.

INCREASING ACCESS TO AFFORDABLE CARE

• Providing Access to Insurance for Uninsured Americans with Pre-Existing Conditions. The Pre-Existing Condition Insurance Plan provides new coverage options to individuals who have been uninsured for at least 6 months because of a preexisting condition. States have the option of running this program in their state. If a state chooses not to do so, a plan will be established by the Department of Health and Human Services in that state. National program effective July 1, 2010.
• Extending Coverage for Young Adults. Under the law, young adults will be allowed to stay on their parents' plan until they turn 26 years old (in the case of existing group health plans, this right does not apply if the young adult is offered insurance at work). Check with your insurance company or employer to see if you qualify. Effective for health plan years beginning on or after September 23.
• Expanding Coverage for Early Retirees. Too often, Americans who retire without employer-sponsored insurance and before they are eligible for Medicare see their life savings disappear because of high rates in the individual market. To preserve employer coverage for early retirees until more affordable coverage is available through the new Exchanges by 2014, the new law creates a $5 billion program to provide needed financial help for employment-based plans to continue to provide valuable coverage to people who retire between the ages of 55 and 65, as well as their spouses and dependents. Applications for employers to participate in the program available June 1, 2010. For more information on the Early Retiree Reinsurance Program.
• Rebuilding the Primary Care Workforce. To strengthen the availability of primary care, there are new incentives in the law to expand the number of primary care doctors, nurses and physician assistants. These include funding for scholarships and loan repayments for primary care doctors and nurses working in underserved areas. Doctors and nurses receiving payments made under any state loan repayment or loan forgiveness program intended to increase the availability of health care services in underserved or health professional shortage areas will not have to pay taxes on those payments. Effective 2010.
• Holding Insurance Companies Accountable for Unreasonable Rate Hikes. The law allows states that have, or plan to implement, measures that require insurance companies to justify their premium increases to be eligible for $250 million in new grants. Insurance companies with excessive or unjustified premium exchanges may not be able to participate in the new health insurance Exchanges in 2014. Grants awarded beginning in 2010.
• Allowing States to Cover More People on Medicaid. States will be able to receive federal matching funds for covering some additional low-income individuals and families under Medicaid for whom federal funds were not previously available. This will make it easier for states that choose to do so to cover more of their residents. Effective April 1, 2010.
• Increasing Payments for Rural Health Care Providers. Today, 68 percent of medically underserved communities across the nation are in rural areas. These communities often have trouble attracting and retaining medical professionals. The law provides increased payment to rural health care providers to help them continue to serve their communities. Effective 2010.
• Strengthening Community Health Centers. The law includes new funding to support the construction of and expand services at community health centers, allowing these centers to serve some 20 million new patients across the country. Effective 2010.
• Given the fragmented nature of the U.S. healthcare system, healthcare providers have increasingly implemented programs aimed at coordinating the care patients receive. Although these programs vary widely in structure and style, the primary goals of care coordination programs—to improve disease outcomes while containing overall healthcare costs—tend to be consistent across organizations. Historically, most care coordination programs have targeted patients with chronic conditions, which are costly, especially if managed poorly. According to a 2004 Partnership for Solutions report, 48% of the U.S. population has one or more chronic conditions; all their care represents 83% of total healthcare spending.¹⁴ Patients with chronic conditions visit their health care providers, fill prescriptions, and are hospitalized more often than the general population.¹⁴ Furthermore, patients with chronic conditions are more likely to experience poorly coordinated care, which can lead to adverse drug interactions, unnecessary or duplicate tests or procedures, conflicting information from multiple providers, and increased health care costs

Our approach to collecting the information presented in this chapter relied on background literature searches for policy papers, Internet searches using care coordination and related terminology for ongoing care coordination programs and demonstration projects, searches for conference brochures, and personal contacts with professionals currently leading care coordination efforts. This search was not intended to be exhaustive or fully systematic.