IN THE UNITED STATES, a unique government-sponsored healthcare system gives many individuals access to health insurance via Medicare at age 65, or Medicaid based on physical, psychological, or economic need. Historically, the working class has accessed health insurance via employer-sponsored insurance plans or private insurance. In order to address private health insurance coverage gaps and bring affordable healthcare to all Americans, legislators designed a bill to reform the healthcare system primarily through health insurance revisions. On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA) into law, introducing a cascade of events that reshaped the way healthcare is delivered and financed.1 This article synthesizes the ACA evolution, discusses encompassed programs, and illustrates the impact of the ACA on the nursing profession with an emphasis on geriatric care. It also addresses changes to the ACA enacted over the past year and their effect on care delivery.
Evolution of the ACA
The three main objectives of the ACA were improving access for patients, elevating the quality of care, and reducing healthcare expenditures.2 Initially, the primary goal for this healthcare change was for all Americans to have greater access to care. On June 22, 2010, a new patient's bill of rights was established that expanded coverage for minors, provided for out-of-network emergency services, extended insurance coverage to the age of 26 under a parent's plan, and provided the right to appeal a payment denial. In addition, many health promotion and preventive services were provided to most citizens free at the point of care.1
Next, the government sought to standardize access to insurance and coverage, giving consumers the ability to compare insurance plans. In October 2013, the Health Insurance Marketplace offered open enrollments, facilitating access to health insurance for all families. In 2014, tax credits were extended to middle- and low-income families who invested in health insurance.1 As of January 2014, the ACA lifted lifetime coverage caps and provided essential health coverage for preexisting conditions among all age groups.3
The ACA's next two objectives, elevating healthcare quality and reducing expenditures, are being accomplished simultaneously through multiple avenues. The ACA provided the foundation for the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing (HVBP), Accountable Care Organizations (ACO), Bundled Payments for Care Improvement (BPCI), and Hospital-Acquired Condition Reduction Program (HACRP).4 At present, these programs primarily impact Medicare recipients, but commercial insurance companies are likely to follow suit or adopt similar practices. While individually unique as discussed below, each program seeks to increase the value of healthcare by rewarding quality care with optimal reimbursement, encouraging multidisciplinary collaboration to meet patient and organization goals.
Hospital Readmissions Reduction Program (HRRP)
Established by the ACA in 2012, the HRRP continues to grow and now extends beyond acute myocardial infarction, heart failure, and pneumonia. Beginning fiscal year (FY) 2015, the HRRP also included patients admitted for acute exacerbation of chronic obstructive pulmonary disease, elective total hip arthroplasty, and total knee arthroplasty. In FY 2015, HRRP increased the penalty from 1% to 3% for organizations with excessive readmissions of the operating diagnosis-related group (DRG).4
The program continues to evolve and react to readmission trends. The most recent updates beginning FY 2017 are the inclusion of readmission status–post coronary artery bypass graft surgery, expansion of the pneumonia cohort to encompass aspiration pneumonia, and a primary diagnosis of sepsis with secondary diagnosis of pneumonia. It also incorporates international classification of disease 10th revision codes into measurement methodology.5 The targeted readmission groups are a challenging population to care for, requiring the input of nursing professionals enabled to develop and implement appropriate patient or caregiver education and assess for the availability of necessary postdischarge services, including primary care follow-up.
Hospital Value-Based Purchasing (HVBP)
The Centers for Medicare and Medicaid Services (CMS) controls payments delivered via the HVBP in an effort to increase quality and curb spending. Since 2017, the program has reduced hospital base operating DRG payments by 2%, with the opportunity for hospitals to earn back a value-based incentive payment percentage based on the hospital system's total performance score, a summation of CMS quality domains that vary by FY.4,6 The HVBP program affects payments for acute care inpatient stays in over 3,500 U.S. hospitals and monitors influenza immunization, surgical site infection, and catheter-associated urinary tract infection.6
The measurement domains set forth for 2018 are equally divided by clinical care, safety, patient- and caregiver-centered experience of care, efficiency, and cost reduction.7 Despite this initiative's risk for imposing penalty without promise of reward, its outcome is generally positive. In FY 2018, more hospitals will have an increase in their base operating DRG payments than will have a decrease. The highest performing hospital will appreciate a net increase in payments of slightly more than 3% while the lowest performing hospital will incur a net reduction in payments of 1.7%.7
Accountable Care Organizations (ACO)
The CMS offers voluntary application to become an ACO with the goal of decreasing overlaps in care via partnerships between physicians and other providers and hospitals. These stakeholders become jointly accountable for the costs and quality of care provided to a patient population.8 The coordination of care between providers and the patient is meant to enhance communication and collaboration, leading to improved outcomes and reduced expenditures. Several ACO models seek to increase quality of care given to patient populations, especially the chronically ill.
- Pioneer ACO Model for providers and healthcare organizations experienced in coordinating care for patients across healthcare settings.
- ACO Investment Model, Advanced Payment ACO Model, which examines the effect of prepaid savings in rural and underserved areas.
- Medicare Shared Savings Program, which coordinates care of fee-for-service beneficiaries.
- Next Generation ACO Model, which provides new opportunity for ACOs already experienced in managing patient populations.
- Comprehensive ESRD Care Initiative, which serves individuals with end-stage renal disease receiving dialysis.9
The Innovation Center of CMS continually examines individual model performance, utilizing information learned to propose new models that either offer current participants more incentives or target new patient populations. These programs incentivize coordination of care by financially rewarding ACOs that minimize inflation of healthcare costs and meet predetermined quality of care performance standards.10 This partnership and incentive seeks to eliminate unnecessary services and overlaps that decrease healthcare value.
In addition, within each ACO are risk-sharing options. The one-sided model (Track 1) provides only an incentive in that an ACO meeting or exceeding a minimum savings rate (MSR) as determined by CMS benchmarking and satisfying the quality performance standard is eligible to receive a payment of up to 50% of the savings it generated. To earn greater reward, the ACO must assume financial risk. The two-sided models (Track 2 and Track 3) offer a maximum savings rate of 60% and 70%, respectively, but also require the ACO to share a percentage of its loss, up to 15%, if it doesn't meet the MSR and quality performance measures.10
As of January 2018, 561 participating ACOs were serving 10.5 million beneficiaries, but only 18% fall under a risk-based category.11 The challenge presented to healthcare providers and care organizations demands elimination of unnecessary costs and services while enhancing the quality of patient-centered care provided.
Bundled Payments for Care Improvement (BPCI)
CMS established the BPCI initiative and created four healthcare models to assess whether or not broader bundles can improve patient care at a lower cost among preselected DRGs of the inpatient population.12 Initially, four pilot models were developed with the goal of broadening payments around one DRG episode, each varying in risk and reimbursement method. A bundled payment is a single payment for an episode of care over a specified period of time for a procedure or condition and may consist of payment to multiple providers and settings across the care continuum.13 All models require a prenegotiated discounted rate for specific DRG episodes.
In January 2018, CMS added a BPCI Advanced model that incorporates outpatient episodes such as percutaneous coronary intervention, cardiac defibrillator, and spine and neck procedures with the exception of spinal fusion.14 Bundled payments are meant to add value to healthcare delivery, increase quality, and decrease expense via care coordination and multidisciplinary collaboration.
Hospital-Acquired Condition Reduction Program (HACRP)
The final program overseen by CMS seeks to financially penalize hospitals for poor inpatient outcomes, encouraging quality care initiatives that decrease the occurrence of adverse events. The HACRP began in FY 2015 with a 1% reduction in payments for hospitals ranked in the lowest quartile with regards to recognized hospital-acquired conditions (HACs).4 The HACs currently recognized are patient safety events, central line-associated bloodstream infection, catheter-associated urinary tract infection, surgical site infection, methicillin-resistant Staphylococcus aureus infection, and Clostridium difficile infection. This program saves Medicare $350 million annually.15 Prevention of HACs is an area nurses can excel in via shared governance and the utilization of evidence-based practice to manage at-risk populations.
As legislation evolves and the need for quality intensifies, nurses of all professional levels are needed to close in the gaps of the patient-care continuum. Nurses have tremendous opportunities to learn the unique needs of their patients and caregivers as they spend a great deal of time at the bedside providing even the most basic care. It's during these intimate times that nurses gain not only knowledge of their patients' health status, but also their economic, social, and spiritual status, which greatly impacts healthcare decisions and outcomes. Current healthcare system challenges summon nurses to embrace this opportunity for collaboratively molding nursing practices that are mutually beneficial and that optimize patient care.
Effect on Medicare reimbursement to institutions
From its inception, the ACA's primary political focus was to reduce healthcare spending through elimination of overpayment to providers and insurers, not sparing Medicare. President Obama and Vice President Joe Biden described their plan to conserve $716 billion in ACA-driven savings through a collective $517 billion decrease of Medicare Part A, $247 billion decrease of Medicare Part B, and an increase of $48 billion to Medicare Part D.16
Much of the ACA savings impact Medicare, an enormous subsidy to sustain, and the healthcare systems providing care to Medicare recipients. Consequently, hospital systems must adjust their performance and spending strategies to financially tolerate the 9% reduction in Medicare payments resulting from ACA-mandated spending cuts.16 Medicare and Medicaid reimbursement don't factor in the added time and resources required to care for older adults, many with complex healthcare requirements.17
In order to remain profitable, hospitals must implement practices aligned with the ACA's vision, even if savings are marginal. Participation in an ACO has demonstrated efficacy in improving quality measures, but only 25% of organizations have reduced costs enough to share savings with the government.18 In addition, programs such as HVBP and Patient-Centered Medical Homes have appreciated only small savings, if any, according to independent consultants.18 However, any value accumulated by organizations, whether via investment in lean principles or improved patient outcomes, is an asset at this time, as many previously successful healthcare institutions struggle to maintain financial stability. For instance, both the Mayo Clinic and Everett Clinic have experienced millions of dollars lost in treating Medicare patients since the introduction of the ACA and have subsequently limited acceptance of Medicare clientele.16 It's unclear to what extent the financial struggles of high-performance care organizations will impact access to healthcare or the quality of patient care.
Effects on older adults
Benefits: Medicare insurance remains distinct from insurance provided through the Health Insurance Exchange, which is a source for taxpayers to receive information regarding state or federal health insurance options and enroll in a health insurance plan. Fortunately, ACA-mandated changes are closing the gap in coverage between these two types of insurance. Medicare recipients now receive 100% coverage for recognized preventive services, such as vaccinations and routine screenings, and are provided with a 50% discount on name-brand pharmaceuticals while in the “donut hole” or Medicare Part D coverage gap encountered when the participant and drug plan have met a certain expenditure.1 Annual wellness exams, which include depression and cognitive impairment screenings, are fully covered under preventive services.19
Recent legislation has also facilitated the reform of Medicare coverage for outpatient psychological health services. Beginning in the first quarter of 2014, Medicare increased psychological health services coverage from 50% to 80%; this is a significant benefit considering one in five older adults has at least one identified mental health disorder.19 While these updates improve coverage and access to care, more must be done to ensure older adults receive optimal healthcare.
Challenges: The massive spending cuts to Medicare previously identified are likely to impact medical and hospital healthcare access and care provided to older adults. The ACA specification that private insurance plans must provide consistent treatment for physical and mental illnesses when considering medical necessity doesn't apply to Medicaid or Medicare coverage.19 In addition, the benefit to healthcare providers who serve Medicare recipients is decreasing. Compared with younger patients, older adults typically require more provider time to review medications and comorbidities, and to address complex healthcare needs. Due to inadequate reimbursement, only 55% of psychiatrists accept Medicare compared with 86% in the private sector. Unfortunately, this trend is spreading to medical providers and medical systems.16,19
The long-term impacts the ACA will inevitably impose on geriatric healthcare are yet to be seen, but if healthcare systems fail to implement lean practices and utilize enhanced partnerships, access to quality healthcare may be diminished for older adults.
There is a tremendous need for nurses to work to the maximum capacity of their license; however, they also have an individual responsibility to increase professional knowledge and skill according to changes in the practice environment. It's increasingly important for nurses caring for older adults to know how to perform functional assessments and holistic health assessments, identify appropriate health promotion practices, and utilize interdisciplinary collaboration to provide patient care.17 Herein lies a significant barrier to successfully navigating the ACA and provision of exceptional service. Nurses caring for older adults at every professional level must take the initiative to stay abreast of ongoing healthcare changes and pursue educational opportunities that enable them to provide high-quality geriatric care. General practitioners are inadequately trained to meet the needs of older adults with unique psychosocial and physical challenges, and there aren't enough geriatric specialized practitioners to meet the current and growing need.19
Caring for the geriatric population is perhaps one of the most challenging tasks in the nursing profession because of patients' multiple comorbidities, complex healthcare needs, and age-related barriers to care services. The ACA includes reforms that, through funding, increase the support of nursing student education and provide education on geriatric care for healthcare professionals, including advanced practice nurses, psychologists, and pharmacists.17
Clinical nurses can increase healthcare quality by assessing their patients' healthcare goals and resources. In addition, nurses promote a continuum of care by identifying the need for referral or consultation with other specialties and communicating their findings with the attending provider. Nurses should anticipate the incorporation of telehealthcare and mobile health technologies tailored to older adults, which have been shown to reduce ED visits and hospitalizations among high-risk patients with complex needs.20 Nurses of all practice levels are key participants in patient care and are important links in the care continuum.
The ACA's ambitious goals aim to revitalize the traditional healthcare system. Whether or not these goals can be reached without compromising one of the components is unknown at this point, as are the long-term repercussions. To compound the matter, there is dire need for nurses and providers to specialize in gerontology care, yet these practitioners have very little incentive to choose gerontology practice as their primary specialty because geriatric specialists earn significantly less than practitioners of other specialties and generalists.17 The complexity of care often commanded by this population combined with their unique barriers to appropriate care presents a challenge for all.
The commencement of the ACA marks a pivotal period in the United States healthcare delivery system. As the goals of the ACA present many benefits and challenges for all age groups, from birth to death, nursing professionals are poised to become leaders in healthcare. Nurses must remain educated, advocate for patients, break down system barriers, and use the strengths of this act to improve the lives of their patients.