Critical Policy Issues Related to Access, Cost, and Quality of Care

Critical Policy Issues Related to Access, Cost, and Quality of Care Christina McClenaghan National University

Critical Policy Issues Related to Access, Cost, and Quality of Care Abstract There are issues relating to access to health care, cost of health care, and the quality of health care services that are available to the people in the United States. The Affordable Care Act (ACA) was passed by congress and signed into law by President Barack Obama on March 23, 2010. The U.S. Department of Health and Human Services explains that the ACA addresses policy issues surrounding access to care by implementing changes that will make insurance available to more individuals who do not currently hold health insurance either through an

employer or individually. Access to health care is driven by the cost of health care and insurance. The ACA sets rules regarding how insurance companies can set premium amounts. The ACA seeks to improve the quality of health care, in part, by linking payment for Medicare beneficiaries to health outcomes (HHS, 2012). Other quality measures instituted by the ACA will set regulations for achieving quality in health care delivery, and ways to measure outcomes of treatment and relate those outcomes to payment (HHS, 2012).

Critical Policy Issues Related to Access, Cost, and Quality of Care Critical Policy Issues Related to Access, Cost, and Quality of Care

Access, cost, and quality of health care services are inextricably linked in our health care system, and the formation of policy regarding health care. Health care policy refers to the set of rules used by a nation or facility to regulate behaviors, and distribute funds, goods and services. The availability of health care services that a person can access when needed is access, and a crucial determinant of overall health (Shi, Singh, 2012). Access is tied to cost. When health care services are too expensive, or an individual is not offered health insurance by their employer due to the high cost, access is impacted. Quality has been defined by the Institute of Medicine (IOM) as, the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 2012). Access, cost, and quality are addressed in the in the Affordable Care Act. The cost of health care can have different meanings to different people and organizations depending on the perspective. Shi and Singh (2012) state that there are three different perspectives to consider when addressing the costs of health care: the perspective of consumers and financiers, the national perspective, and the providers perspective. When a consumer considers cost, it is most likely that the individual considers the premium that he or she pays for health care insurance or the bill that he or she gets from their doctor for services rendered. The Unites States, from the national perspective, would consider how much the nation spends as a percentage of GDP. The providers would consider the cost of their office space, materials, advertising and other costs related to providing services (Shi, Singh, 2012). Regulation based cost-containment strategies are one way of containing cost in the health care market. Regulation based methods include supply-side controls. Price controls and utilization controls. Supply side controls include placing restrictions on capital expenditures and

Critical Policy Issues Related to Access, Cost, and Quality of Care restricting the supply of physicians. Price controls artificially determine prices. Examples of price controls include reimbursement formulas, prospective payment systems, diagnosis related groups, resource utilization groups, and global budgets (Shi and Singh, 2012). One method that

the ACA implements for reducing cost to the individual, and in some cases to the employer who would otherwise bear the burden of shared premiums for the employees health care insurance, is through the creation of health insurance exchanges. Kaiser Permanente Medical Group, one of the most successful managed care groups in the insurance industry, supports the formation of health insurance exchanges as a marketplace where millions of low-to-middle income people and small business owners (defined as those having less than 50-100 eligible employees, depending on the state in which the business operates) will be able to purchase affordable health care coverage (Kaiser, 2012). An insurance exchange is designed to bring individuals, small-group insurance purchasers, and small business owners who want to provide insurance coverage to their employees together to create larger pools which stand to become large enough to have market power and become economies of scale (Stoltfus-Jost, 2010). The ACA states that insurers must create one risk pool for people, regardless of whether or not the individuals purchase their health insurance in the exchange or outside of the exchange; small groups have to abide by the same requirements (Kaiser, 2012). If the health insurance exchanges work as anticipated, purchasers within the exchange will be able to purchase quality health insurance plans at affordable rates created by the larger size the group. The ability of individuals and small businesses to come together as these larger groups to negotiate price and health care insurance benefits should drive cost down while also expanding access to quality coverage options (Kaiser, 2012).

Critical Policy Issues Related to Access, Cost, and Quality of Care One way that the ACA seeks to relate quality to payment is through the development of Accountable Care Organizations. Accountable Care Organizations (ACOs) are groups of providers working together to coordinate care and manage the care of patients (Barry, et al., 2012). Specifically related to Medicare reimbursement to physicians, the ACA provides for increased reimbursement if they achieve specific cost saving measures, and meet certain standards relating to quality of care and reporting. An ACO must agree to participate in the program for a minimum of three years to be eligible for the increased reimbursement by CMS (Barry, 2012). Health care policy in the United States focuses on three key areas: cost, quality, and access. The Affordable Care Act seeks to lower costs of health insurance, maintain and ensure the quality of health care services, and expand access to health care services. Only time will tell in the ACA will be able to accomplish what it has been created to do. The ACA is the most influential piece of health care legislation that the United States health care system

Critical Policy Issues Related to Access, Cost, and Quality of Care References Barry, D.M., Luband, C.A., and Thames Lutz, H. (2012) The Impact of Health Care Reform Legislation on Medicare, Medicaid and CHIP. Retrieved from

http://www.healthlawyers.org/Events/Programs/Materials/Documents/HCR10/barry_luba nd_lutz.pdf Institute of Medicine of the National Academies. (2012) Crossing the Quality Chasm: The IOM Health Care Quality Initiative. Retrieved from http://www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-TheIOM-Health-Care-Quality-Initiative.aspx Kaiser Permanente BusinessNet. Health Care Reform for Employers. Insurance Exchanges (2014). (2012) Retrieved from http://info.kaiserpermanente.org/html/hcr_kp/insurance_exchanges.html Shi, L. & Singh, A.D. (2012) Delivering Health Care in America: A Systems Approach. 5. 472510. Stoltzfust-Jost, T. Health Insurance Exchanges Under the Affordable Care Act: Key Policy Issues. The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/Blog/Jul/Health-Insurance-Exchanges.aspx U.S. Department of Health and Human Services. (2012) HealthCare.gov. The Health Care Law and You. Retrieved from http://www.healthcare.gov/law/full/index.html