patient gurneyToday’s guest blog post is courtesy of our board member, Tim Porter-O’Grady, DM, EdD, ScD, FAAN, FACCWS.  Tim brings a deep and informed perspective to the implications of the Affordable Care Act for workers, their employers and healthcare providers.  What’s your organization doing to get ready to comply with the Act?

The Patient Protection and Affordable Care Act (PPACA) is well on its way into the fourth year of implementation. Looking past the strident political machinations, human resource leaders need to now deepen their understanding of its components and characteristics and what it actually does to improve the lives of workers and how it addresses long-standing health concerns of management. For the first time in the history of American healthcare, there is a drive to achieve real health value and ultimately to change the health status of the American population.

This focus on value economics now means that there must be increasing evidence of impact in health services.  The longstanding dependence on a tertiary care model where we wait until employees get sick and then undertake a flurry of activity to address the problem leads us to higher levels of cost and a lower capacity for a sustainable positive health outcome.  Our primary care foundations or infrastructure is not yet so well developed to a level that we can focus on preventing the conditions and circumstances that lead to our highest priced illnesses and conditions. One need only look at the overwhelming problems we are now confronting with the challenges and cost of treating an uncontrolled level of diabetes directly related to obesity and the high sugar, high fat diet in the U.S. The costs associated with treating diabetes and its co-morbidities over a lifetime far outstrip the costs associated with early addressing the practices and behaviors that lead to them.

The PPACA now emphasizes efforts that directly address health concerns and issues that can prevent the later onset of illnesses. Regular screening for high risk health issues can now be incorporated into health plans in a way that addresses both illness prevention and related costs. In addition, free preventive services are provided for potentially high risk, high cost services such as abdominal aortic aneurysm, alcohol misuse, blood pressure, cholesterol, colorectal, depression, type II diabetes, HIV screenings, diet counseling and immunizations (hepatitis, herpes, papilloma virus flu, measles, mumps, rubella, pneumonia, tetanus, diphtheria, pertussis, and varicella). In addition, free counseling is available regarding obesity, sexually-transmitted diseases, and tobacco use. Since many if not most employee related sick days are the result of these identified health problems, there is a potential for significant cost benefit for employers to assure their employees participate in these free preventive services.

Provider performance now emphasizes those activities which prevent accelerating utilization of high intensity health services and repeated admission to health services because earlier services were inadequate or ineffective. Recidivistic health care will simply not be supported or funded if it represents poor provider practices or ineffective standards of care. The PPACA now requires that providers “get it right” by assuring the application of evidence-based protocols and best practices for defined episodes of care. Besides accelerating the potential for quality care, the impact on the cost of that care of more effective provider practices will be significant.

Providers will now be incented not only by price but also by quality.  Competition between plans and providers now include measures of impact especially as it relates to comparable measures of quality of service.  Quality measures will now include clinical comparative effectiveness and user evaluation of service satisfaction. Imbedded in health reform is the intent that the system must ultimately produce a healthy population, not simply treat its ails and illnesses. In fact, the notion that admission to a hospital bed is evidence of the failure of the system to better address the health needs of the person plays out as a theme throughout the PPACA.  Beginning January 1st, 2015, physicians and other providers will begin to be paid for value not for volume. The question in this climate for the provider is not how much did I do for persons but rather did I make any difference for individuals in what together we chose to do in their best interests.  Those providers than can advance the quality of service and care at the same time as carefully managing its costs will be positioned to reap value-based rewards.

For employers and their health plans, the net aggregate value of this shift in design, delivery and outcome in the PPACA provides one of the strongest efforts to date to get at real issues of health-driven care and service. It is now time for employers who have a large stake in a healthy workforce to reinvigorate their own efforts to partner with their health plans in the pursuit of early engagement health services, primary care health interventions, and the pursuit of healthier life choices. The impact of such an effort will accrue to both healthy workers and a healthier bottom line.

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