Changes in Healthcare | The Connecticut Mirror

Almost everything about the health care you receive, from who you see when you visit your doctor's office to how your medical records are kept, is likely to change over the next several years. Some of these changes are the result of the federal health reform law passed in 2010. Others are attempts to improve the way care is delivered or how it's paid for. The guide will explain some key ideas and concepts behind these changes.

Federal Reform

The reform bill was passed by Congress and signed by President Obama in 2010. While it is still hotly debated, many decisions are still being made about how the new law will be implemented and how that will affect you. Here are some key areas being worked on:

Universal Coverage	Beginning in 2014, most Americans will be required to have health insurance. Coverage will be expanded primarily in two ways: Increased Medicaid eligibility for low-income children and adults, and ... more + Universal Coverage Beginning in 2014, most Americans will be required to have health insurance. Coverage will be expanded primarily in two ways: Increased Medicaid eligibility for low-income children and adults, and the creation of marketplaces known as health insurance exchanges that would offer insurance plans to individuals and small businesses, including those who qualify for federal subsidies to purchase coverage. Although the reform measure is commonly said to require universal coverage, there are exceptions. People who belong to faith-based health cooperatives, for example, won’t be required to buy coverage, and people who are in the country illegally won’t be allowed to participate.
Health Insurance Exchange	A health insurance exchange is a marketplace for individuals and small businesses to buy health insurance. Most or all of the health plans sold on the exchange are expected to be offered by ... more + Health Insurance Exchange A health insurance exchange is a marketplace for individuals and small businesses to buy health insurance. Most or all of the health plans sold on the exchange are expected to be offered by private insurance carriers. The plans will be subject to more regulation than the existing insurance market requires. The exchange will have a website, similar to travel sites like Orbitz, that allows people to compare insurance plans. Each plan offered on the exchange must have at least three benefit levels, ranging from lower premiums and higher costs at the time of service to higher premiums and lower costs when care is received. People who earn up to 400 percent of the poverty level and do not get insurance through their jobs will be eligible for tax credits to help cover the cost of buying insurance through the exchange. Each state must have an exchange in place by 2014, although states can work together to create regional exchanges and the federal government will develop an exchange for states that don’t do it themselves. In 2011, the Connecticut General Assembly passed and Gov. Dannel P. Malloy signed legislation establishing the exchange as a quasi-public agency.
Essential Health Benefits	Beginning in 2014, health plans must cover a set of “essential health benefits.” When the reform law passed, the federal government was expected to define what benefits are “essential.” But in ... more + Essential Health Benefits Beginning in 2014, health plans must cover a set of “essential health benefits.” When the reform law passed, the federal government was expected to define what benefits are “essential.” But in December 2011, the U.S. Department of Health and Human Services announced that it would allow state regulators to determine what benefits the plans in their states must cover, meaning there will be variation across the country about what benefits are considered “essential.” The choice isn’t completely open; state regulators must pick from four options, basing their benefits on those offered by either a state employee health plan, a federal employee health plan, an HMO plan offered in the state, or a small-group plan offered in the state. Those planning Connecticut’s health insurance exchange hope to make a decision about the state’s definition of “essential health benefits” in 2012 so insurers have time to develop products that include them by 2014.
Medical Loss Ratio	The medical loss ratio, sometimes called the medical care ratio, refers to the proportion of health insurance premium dollars spent on medical claims and activities related to improving the ... more + Medical Loss Ratio The medical loss ratio, sometimes called the medical care ratio, refers to the proportion of health insurance premium dollars spent on medical claims and activities related to improving the quality of medical care. A company with a medical loss ratio of 80 percent spends 80 cents of every premium dollar on claims and other medical care activities, while the other 20 cents go to overhead expenses including marketing, profits, salaries and administrative costs. The health reform law sets minimum medical loss ratios. Beginning in 2011, individual and small-group insurance plans must spend at least 80 cents of every premium dollar on health care and quality improvement, and large group plans must spend at least 85 percent of premium revenues on those things. Plans that don’t meet the requirements must provide rebates to consumers. Several states have sought exemptions to the requirement, but Connecticut has not.
Insurance Regulations	The health reform law imposed new requirements on health insurance plans,some of which take effect now and some that will be phased in over the next few years. Current changes include extending ... more + Insurance Regulations The health reform law imposed new requirements on health insurance plans,some of which take effect now and some that will be phased in over the next few years. Current changes include extending coverage for children under 26 on their parents' policies and prohibiting insurers from denying coverage to children with pre-existing conditions. (That change will apply to everyone in 2014.) Other changes include prohibiting insurers from putting dollar limits on “essential benefits” like doctor visits, hospitalizations and drugs and from denying payments because of an error or technical mistake on a customer’s insurance applications. Health plans must also cover preventive care with no out-of-pocket cost to members. Insurance companies must also spend at least 80 or 85 percent of premium dollars on health care or quality improvement efforts; those that don’t will have to issue rebates to customers.
Accountable Care Organizations	Under the federal reform law, health care providers could form networks, known as accountable care organizations, to provide coordinated care to Medicare patients across a continuum of care ... more + Accountable Care Organizations Under the federal reform law, health care providers could form networks, known as accountable care organizations, to provide coordinated care to Medicare patients across a continuum of care settings. An accountable care organization could include doctors, hospitals, home health agencies, nursing facilities and other types of providers. Each accountable care organization’s pay would be tied to meeting health care quality goals and producing outcomes that save money; if the ACO delivers quality care at reduced costs, its members could share in the savings. The idea is to move away from a system that pays providers to perform tests and procedures but doesn’t reward efforts to keep patients from needing them, toward a system that provides incentives for keeping patients well. The concept is one of the reasons behind an increased push by hospitals to build links with nursing facilities, home health care organizations and physician practices. Private insurers are embracing similar models. The federal government released the ACO regulations in October, drawing praise from doctors and hospitals, who had been critical of proposed regulations released in the spring.

Other Changes in Healthcare

Apart from federal reform, other changes are taking place in the health care system. Some are driver by advances in technology, others by a recognition that the current system is often inefficient and doesn't deliver the best care to patients. Here are some areas of change:

SustiNet	SustiNet was proposed as a state-run health insurance plan. Lawmakers did not pass the controversial bill that would have created a state-run insurance plan, but did create a SustiNet Health ... more + SustiNet SustiNet was proposed as a state-run health insurance plan. Lawmakers did not pass the controversial bill that would have created a state-run insurance plan, but did create a SustiNet Health Reform Cabinet in 2011 that would serve as an advisory board and make recommendations about health care policy. The cabinet will also develop a business plan for an alternative to private insurance. SustiNet was first proposed in 2009 by the Universal Health Care Foundation of Connecticut as a way to achieve universal coverage. After federal health reform passed in 2010, creating a way for most people in the country to get health insurance, supporters pitched SustiNet as a “public option” that would compete with private insurance. The concept has drawn opposition from insurers and some business groups, who have argued that it could threaten the state’s insurance industry and add to the state’s budget woes. The proposal before legislators in 2011 called for joining the state employee and retiree health plan with other state-funded health plans, such as Medicaid, under a quasi-public authority, which would then offer insurance to small businesses, municipalities, nonprofits and, ultimately, the public. That proposal stalled when Gov. Dannel P. Malloy raised concerns with it. The compromise bill that created the SustiNet cabinet also allowed municipalities and some nonprofits to buy insurance through the state, and created an Office of Health Reform and Innovation to coordinate state and federal reform efforts. Supporters say the state could still be on a path toward their original goal of a public option, but critics say the plan has been significantly watered down.
Patient-Centered Medical Homes	There’s no single definition, but the idea is that a team of health care providers work together to stay on top of their patients’ care. Rather than waiting for a diabetic patient to make an ... more + Patient-Centered Medical Homes There’s no single definition, but the idea is that a team of health care providers work together to stay on top of their patients’ care. Rather than waiting for a diabetic patient to make an appointment, for example, the medical team would keep track of patients’ blood sugar levels and call in those who fall outside the target range. They would also coordinate patients’ visits to specialists and play a role in managing the patient’s health whether the patient is at home, in the hospital or another care setting. Many physicians, insurance companies and patient advocates embrace the medical home concept as a way to ensure that patients get better care, at less cost. The Malloy administration has embraced the medical home concept, and has set a goal of having all Medicaid patients have access to a medical home in the coming years. Medical practices can be recognized as medical homes by the National Committee for Quality Assurance, which sets standards that include being accessible to patients outside office hours, prescribing electronically, following up on tests and procedures done at other facilities, and using data to track patients’ hospitalizations and emergency room visits. Only a small number of practices in Connecticut have achieved this designation, although some meet many of the requirements.
Electronic Medical Records	Chances are, at some point in the next few years, your doctor’s paper charts will be replaced with a computer. It’s part of a nationwide push toward electronic health records, which proponents say ... more + Electronic Medical Records Chances are, at some point in the next few years, your doctor’s paper charts will be replaced with a computer. It’s part of a nationwide push toward electronic health records, which proponents say could reduce the frequency of duplicated tests, reduce medical errors, improve care and make it easier for a patient’s multiple doctors to share information. The federal government is providing payments to health care providers who use electronic medical records, and beginning in 2015, will begin reducing Medicare payments to those who don’t. Many Connecticut doctors say electronic records have benefits, but some say the cost is daunting, particularly for small practices, as is the time required to adjust to them.

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May 14, 2012

Report: Babies, 18-year-olds still wrongly losing Medicaid coverage

By Arielle Levin Becker

One-year-olds and 18-year-olds are still wrongly losing Medicaid coverage because of administrative glitches and confusing notices, despite pledges from Department of Social Services officials to address the issues, according to the researchers who identified the problems.

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May 3, 2012

Labor proposal passes Senate, heads for Malloy's signature

By Arielle Levin Becker

A controversial proposal to give collective bargaining rights to certain home care workers and daycare providers is headed to the governor's desk, completing a process begun less than seven months ago with two executive orders.

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May 2, 2012

Privacy dominates debate on health care database

By Arielle Levin Becker

After a lengthy debate centered on patient privacy, the House of Representatives on Wednesday approved a proposal to develop a statewide database of medical, dental and pharmacy claims information aimed at getting a comprehensive view of health care usage, cost and quality.

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May 2, 2012

New budget figures make agreement on Medicaid changes likely

By Arielle Levin Becker

April 27, 2012

Caring, long term: A way of life for 1 in 8 Connecticut residents

By Arielle Levin Becker

April 20, 2012

House approves controversial collective bargaining proposal

By Arielle Levin Becker

Federal Reform

Other Changes in Healthcare

Health care costs

Health care legislation

Health reform

Insurance

Long-term care

Medicaid

Medicare

Mental Health

Patients

Providers and facilities

Research

SustiNet

Uninsured

Topics

Latest

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Federal Reform

Other Changes in Healthcare

Health care costs

Health care legislation

Health reform

Insurance

Long-term care

Medicaid

Medicare

Mental Health

Patients

Providers and facilities

Research

SustiNet

Uninsured

Topics

Latest

Quote / Unquote

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