Editor’s note: Beginning this week, we will have a monthly health and healthcare column. Dr. Alberto Manetta is Professor Emeritus at the University of California, Irvine School of Medicine and a part-time Hill resident.
The Affordable Care Act, which was signed March 23, 2010, enacted comprehensive reforms in health care and health insurance. On June 28, 2012, after much speculation the Supreme Court ruled that the central provision, the individual mandate, is constitutional.
The ACA is a reality unless something dramatic takes place as result of the presidential election. Even if that would be the case it would be very difficult to roll back some of the provisions already implemented.
The ACA ramifications depend upon the population. This first Health Care Column focuses on the ACA’s consequences on the health care of seniors. This is not an all-inclusive list, just the highlights of what has already been implemented as it applies to seniors.
Donut hole
The coverage gap, called the “donut hole,” refers to the gap in the Medicare prescription drug coverage (Part D), which in general takes place when seniors reach $2,530 in costs ($632.50 paid by the senior and $1,897.50 paid by the Medicare Part D plan). Beyond that level, seniors are responsible for the total cost of their prescriptions until their costs reach $4,550. This annual spending includes the yearly $310 deductible and copayments.
Since January 2011, seniors affected by the coverage gap received a 50 percent discount on brand-name prescriptions covered by the Medicare Part D plan. This percentage is expected to increase until the coverage gap is totally closed in 2020.Annual Wellness Visits
These preventive health care visits are now fully covered by Medicare without cost sharing. Seniors can now develop a personalized prevention plan.
Some of the most important prevention services now available include: screenings for bone mass measurement (very important in the prevention and management of osteoporosis), Pap smears and pelvic exams, cholesterol testing, colorectal cancer screening, diabetes screening tests, vaccinations including flu shots, the very important pneumonia vaccine and hepatitis B, HIV screening (for people at risk or seniors who request the test), mammograms, nutrition counseling to better manage diabetes or kidney disease, and prostate cancer screening.
These visits in combination with the services provided can be used to develop a prevention plan custom specifically tailored for the individual according to his or her risk factors.
Medicare Advantage
A type of health plan, also known as Medicare plus choice or Medicare C. These Medicare health plans are offered by private companies that enter into a contractual agreement with Medicare. Most of these companies are health maintenance organizations but it can also be preferred provider organizations, private plans and Medicare savings account plans.
Seniors in Medicare Advantage plans pay a fixed amount or copayment when they don’t have to meet a deductible or pay coinsurance like in the traditional Medicare program. About 23 percent of seniors are presently enrolled in Medicare advantage plans, which cost about $1,000 more per senior than traditional, fee-for-service Medicare.
Over the next few years, this difference will gradually disappear with substantial savings for Medicare. Although it was anticipated that these changes would reduce the number of seniors enrolled on Medicare C so far this has not proven to be the case.
This area is at the center of a policy debate. While Medicare Advantage supporters claim that their plans provide less fragmented care, the opponents claim spending more than the traditional Medicare level is unfair. The decrease in payments to plans participating in the Medicare Advantage program has been blunted through a quality bonus payment as part of a demonstration project.
Community Care Transitions Program
Approximately 20 percent of seniors discharged from hospital are readmitted within 30 days. In many cases this is unavoidable, but sometimes it is the result of poor coordination between hospitals and transfer of patients to other settings. Up to $500 million in funding is available from 2011 through 2015 for community-based organizations to improve transition services to manage Medicare patients’ hospital discharges.
Accountable Care Organizations
These are health care providing groups, such as hospitals, physicians and other services, who work together to coordinate the care for traditional Medicare patients. The goal is to deliver seamless, well-coordinated care within a patient-centered structure that meets standards of care while reducing cost. Thirty-two organizations are presently participating in a Pioneer ACO program model nationwide.
The ACA will continue to change over time. It is unlikely that we will arrive at a perfect formula, no country has. However, as time passes and with continued improvement, it is possible that the ACA will produce the originally intended outcomes — health care for all at an affordable price.
exactly, there are those who refuse to take care of themselves by eating the right foods. They rely on medicine to fix a problem that they could have prevented.