Listening to some of the law makers you would think the healthcare reform bill, signed by President Obama was an apocalypse now, rather than a process, albeit a messy one, of change in our democracy. Certainly lots of things are missing from the single biggest healthcare reform (cost containment) since the initiation of Medicare in the sixties, but this article reviews how the current Public Health Services Act impacts hospital systems. And you can thank-me-in-advance for compressing the 153-page bill into only 4 pages for you to digest.
Medicare Changes
Medicare changes will have an impact on hospitals, as the majority of their patients are typically Medicare eligible.
1. Closure of the prescription drug "donut hole" exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs. Also, the difference in cost sharing between generic and name brand drugs will continue at 7% until 2020 when it will increase to 25% for Medicare participants.
2. Changes in Medicare Advantage (HMO) payments
There is a planned phase out of indirect costs associated with medical education for medical plans with capitated rates (HMO’s) and replaced by modified benchmarks. This is an extremely complicated calculation, which I won’t cover, except to say that qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Changes in Medicare Administration
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government. This provision applies to insurance companies or health systems that include sponsored health plans.
5. Market Basket Update for reimbursements
The Medicare Market Basket is a reimbursement adjustment category and under this act, the percentage point adjustment will be as follows: .03 in 2014, .02 in 2015 &2016, and .75 in 2017-2019. Have fun with that you svengallis of finance & accounting.
6.Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status, but for hospitals that have a high proportion of Medicaid patients, implementation has been delayed until December 31, 2010.
7. Changes in Imaging Payments
This is a modification to the current schedule of reimbursement for imaging services, beginning 2011, a 75% utilization rate will be assumed for this service for Medicare patients. Department managers in laboratory and X-ray units will want to review this to assess the impact on revenues and budget.
8. Repeal of Medicare prepayment medical review limitations.
Disproportionate Share Funding
For hospitals that serve indigent populations, making them eligible for Disproportionate Share Funding from the federal government, the current reduction is 1.5% and this will become 1% in 2014 and then increase to 2% in 2017. Though it appears that states with heavy indigent and Medicaid populations will feel this DPS reduction less than wealthier states, because of a complex modification formula. Hospitals with a low percentage of uninsured patients will experience a reduction in this reimbursement. Everybody has to share the pain I guess.
Medicaid Changes
Medicaid changes are a bright spot for hospitals as more people will be eligible for Medicaid, versus having no insurance now. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans. This is for the calculation of reimbursement for primary care physician services, which will benefit clinics especially. The formula for the FMAP change is as follows:
2014-50%
2015-60%
2016-70%
2017-80%
2018-90%
2019-100%
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Tax Subsidies and Funding of Insurance Mandates
The healthcare reform bill uses health insurance as one of the means to improve access to healthcare services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums. Here is the schedule for tax credits to finance health insurance purchasing:
Federal Poverty/ Level Premium Assistance/ Final Assistance %
Up to 133%/ 2%/ 2%
133% to150%/ 3%/ 4%
200% to 250%/ 6.3%/ 8.05%
250% to 300%/ 8.05%/ 9.5%
300% to 400%/ 9.5%/ 9.5%
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for healthcare. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008.
Health Insurance Luxury Tax
High cost or "luxury" health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor?
Individual Penalties
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels.
The combination of tax subsidies, employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast at this time. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive.
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts, lets just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.
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