Canon Medical Systems USA

The Affordable Care Act: What You Need To Know!

Tom Szostak - Healthcare Economics Manager, TAMS and Lainie Hardman | June 03, 2015



As we contemplate the 5th anniversary of the Patient Protection and Affordable Care Act (ACA) this year, there is still confusion over what the changes are, why they were deemed necessary, and how it will be fully implemented over time.  Toshiba America Medical Systems Senior Healthcare Economics Manager, Tom Szostak, reviews the ACA in a comprehensive 5-part series of articles. In this series, Mr. Szostak reviews the history of healthcare, the reason for reform, the changes under the ACA, and how this will shape healthcare in America.

Part I of the series addresses discovering value in a fee-for-service culture and explains the history of the healthcare system in the United States up to the implementation of the ACA.  One of the major themes of Part I is to illustrate how ultimately healthcare reform is an economical issue even though the focus has been in the political arena.  The role of healthcare on the economy is reviewed in relation to the aging population, the rising costs of healthcare, and its share of the US GDP.  Part I concludes with a review of the fee-for-service payment model and illustrates the need for change.
The United States Congress has voted to repeal the ACA 56 times and it continues to remain a talking point for electoral platforms.
Part II of the series addresses the legislation in depth and seeks to simplify the changes under the ACA.  This article speaks to the three tenants on which the ACA was built: access, quality and cost.  In detail: improving access to care for patients, increasing the quality of care from providers, and reducing the total cost of care to the federal government that will help to endure the Medicare program remains solvent for years to come.  Part II also reviews the two distinct categories of reform: insurance reform and delivery reform.  Alternative payment models are introduced: Accountable Care Organizations (ACOs), Hospital Inpatient Value Based Purchasing (HIVBP), Penalties for Excessive Readmissions, and Bundled Payments for Care Improvement (BPCI)


Part III of the series addresses new programs under delivery reforms.  The article opens with a review of the shortcomings of the fee-for-service payment models and the lack of incentives under this model for providers to communicate or coordinate patient care.  Additionally, this model incents providers to focus on volume and profitability and can include duplication of procedures.  The article also explains the history of The American Recovery and Reinvestment Act (ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act and how they played into establishing the electronic health record (EHR) and how the EHR will enable care coordination, transitions, and management of patient care.  Part III then moves on to a comprehensive review of the alternative payment models: ACO, HIVBP, Penalties for Excessive Readmissions Program, and BPCI.

Part IV of the series addresses medical imaging’s role in supporting clinical transformation.  This article reviews the case of medical imaging and how the reforms and new payment models creates a complete change from the previous paradigm.  An in-depth review is provided on how the payment structure can be redefined in the culture of ACOs.  A chart is provided that illustrates a list of imaging procedures is shown with the 2015 Hospital Outpatient Prospective Payment System (OPPS) rate versus the lower 2015 Medicare Free Schedule Payment Rates.  In light of the significant changes in final Medicare payments the article discusses the changing role of the radiologist and how they can transition from reading orders to partnering with physicians to determine the correct procedures at the diagnostic level.  Part IV also addresses the possible changes to medical imaging in hospital settings as opposed to free standing centers and the evolving role of patients as consumers.

Part V and the final article in the series builds upon the previous articles to tie everything together and discuss the future of the healthcare market.  This article reviews the upcoming “Cadillac tax” that will become effective in 2018 and what the ramifications will be to the insurance marketplace when a 40 percent excise tax is applied to excess benefit dollars.  This final article also deals with the reassignment of risk from employers to consumers and how that may drive price transparency and ultimately transition, making healthcare a retail product.  The conclusion proposes a possible future for the role of healthcare in the government.

The Affordable Health Care Act remains one of the most controversial topics on the political scene today.  The United States Congress has voted to repeal the ACA 56 times and it continues to remain a talking point for electoral platforms.   Considering the complexities of how healthcare reform fits in with the US economy, a repeal is no longer so simple, as Mr. Szostak states in Part V, “…changes within the healthcare sector will continue.  Health reform continues to gain momentum as the public and private sectors announce changes on a daily basis.”  If you are in the business of healthcare or a consumer, it’s important to know how these changes may affect you or your business.

All five articles in the series are available by clicking here.