A Primer on the PPACA and Its Impact on Radiology Wes Angel, MD University of Tennessee Health Science Center, Methodist Program Outline • • • • Background of the PPACA PPACA Provisions PPACA’s Potential Impact to Radiology Summary Background: Reasons for PPACA • Rising healthcare expenditure1 • Large percentage of uninsured • Lack of access to healthcare for insured and uninsured alike • Rising drug costs Source: Kaiser Family Foundation http://facts.kff.org/chart.aspx?ch=202 Background: PPACA • Patient Protection and Affordable Care Act – AKA “Affordable Care Act” • Signed into law on March 23, 2010 • Number of pages2: 907 • Number of major provisions3: 92 Source: http://www.libertyhealthconsultants.com/surveyint ro.html PPACA: Major Tasks4 • Create consumer rights and protections – Guaranteed issue – Patient’s Bills of Rights • Expand insurance – Creation of insurance exchanges – Co-op insurance • Expand Medicaid • Start health insurance exchanges • Establish coverage requirements for small business PPACA: Financial Structure to Increase Revenue3 • Start excise taxes on: – Health coverage – Medical devices – Indoor tanning • Increases Medicare tax base • Imposes annual fees on: – Branded drugs – Health insurance providers • Changes tax structure on flexible savings accounts PPACA: Small Sample of Currently Active Provisions3, 14 • Insurance – Provides adult dependent coverage to Age 26 – Creates state option for Medicaid coverage to childless adults with income levels up to 133% of the federal poverty level (Section 1902) – Creation of consumer website to compare coverage options – Prohibits lifetime limits of insurance coverage • Cost reduction – Prohibits federal funding to states for certain hospital acquired infections and other provider preventable conditions – Aims to create a Medicare Independent Payment Advisory Board (IPAB) • Primary care – Provides 10% bonus payment for primary care services • Preventative medicine and public health – Allocates $5 Billion for 2010-2014 – Allocates $2 Billion Dollars each fiscal year after 2014 PPACA: Small Sample of Currently Active Provisions3, 14 • Revenue generation – Creates 10% excise tax on indoor tanning services • Graduate medical education – Increases GME positions – Funds ambulatory teaching health centers • Expansion of Drug Discount Program • Changes to Medicare provider rates PPACA: Future Provisions 20122,3 • Creation of ACO’s (Accountable Care Organizations) for Medicare – Group of healthcare providers – Various reimbursement models: capitation and fee-forservice – Ties reimbursement to quality of care • Annual pharmaceutical fees • Medicare value based purchasing • Reduced Medicare payments for hospital readmissions • New fraud screening efforts PPACA: Future Provisions 20132,3 • Closure of Medicare drug coverage gap • Increased Medicaid payments for primary care to match Medicare rates for 2013 and 2014 • Medicare tax increase – Increased wages tax rate by 0.9% – 3.8% tax on unearned high income • Medicare bundled payment pilot program • 2.3% excise tax on medical devices PPACA: Sample of Future Provisions 201420162,3 • 2014 – Expand Medicaid base – Individual requirement to have insurance – Guaranteed issue – Health insurance company fees – No annual limits on insurance coverage – Reduced reimbursement for certain Medicare hospital acquired infections • 2018 – Tax on high cost insurance PPACA’s Potential Impact to Radiology • Potential expansion of referral base • Establishment of ACO’s in Medicare – Creates potential for various roles of radiologists within ACO’s8,10 • Reimbursements – Increase in utilization rate of equipment from 50 to 90%5 – Increase in multiple procedure reduction rule from 25 to 50%5 – Decrease in professional component of 2-3%6 • Establishment of Center for Medicare and Medicaid Innovation – Potential impact on ordering and reimbursement of diagnostic imaging PPACA’s Potential Impact to Radiology (continued) • New Self Disclosure Requirements9 – Requires physician to provide written notice to patients that they may obtain services such as CT, MRI, and PET elsewhere if physician has a financial interest (Section 6003) – Requires establishment of self referral disclosure protocol (Section 6409) • False claims9 – Allows federal government to prosecute anti-kickback violations under the False Claims Act (Section 6402) – Mandatory requirement to return Medicare and Medicaid overpayments within 60 days (Section 6402) – Maximum period for submission of Medicare claims to less than 12 months (Section 6404) Summary • PPACA will continue to evolve with continuous changes to the law, its provisions, and its implementation • Implements multiple changes to Medicare and Medicaid • Provides near universal coverage by various means • Creates uncertain impact to radiology and the medical field as a whole • Interested in learning more? References/Resources 1. 2. 3. 4. 5. 6. 7. Kaiser Family Foundation www.kff.org, Last accessed December 15, 2011. Patient Protection and Affordable Care Act, http://docs.house.gov/energycommerce/ppacacon.pdf, Last accessed October 10, 2011. Implementation Timeline, http://healthreform.kff.org/Timeline.aspx, Last accessed October 10, 2011. U.S. Department of Health and Human Resources, http://www.healthcare.gov/, Last Accessed December 12, 2011. American College of Radiology, Impact to Radiology as an Result of PPACA, http://www.acr.org/Hidden/Economics/FeaturedCategories/mps/mpfs/2011-Medicare-Physician-FeeSchedule-FR/Impact-To-Radiology-As-A-Result-of-PPACA.aspx, Last accessed on October 10, 2011. American College of Radiology, Aggregate Estimated Impact of Equipment Usage Assumption Changes for Advanced Diagnostic Imaging Services (Diagnostic CT and MR) on PE RVUs Using 2008 Constant Volume, http://www.acr.org/Hidden/Economics/FeaturedCategories/mps/mpfs/2011-MedicarePhysician-Fee-Schedule-FR/Impact-To-Radiology-As-A-Result-of-PPACA/Usage-Assumption-ResultsDxCTMR.aspx, Last accessed on October 10, 2011 Allen, B., Donovan, W. D., McGinty, G., Barr, R. M., Silva, E., Duszak, R., Kim, A. J., et al. (2011). Professional component payment reductions for diagnostic imaging examinations when more than one service is rendered by the same provider in the same session: an analysis of relevant payment policy. Journal of the American College of Radiology : JACR, 8(9), 610-6. doi:10.1016/j.jacr.2011.06.012 References/Resources (continued) 8. 9. 10. 11. 12. 13. 14. Allen, B., Levin, D. C., Brant-Zawadzki, M., Lexa, F. J., & Duszak, R. (2011). 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Elsevier Inc. doi:10.1016/j.jacr.2009.09.010 Pentecost, M. J. (2011). Health care reform: the first anniversary. Journal of the American College of Radiology : JACR, 8(4), 221. Elsevier Inc. doi:10.1016/j.jacr.2011.01.002 Consumers Union, The Affordable Care Act: The First Year, http://www.consumerreports.org/health/resources/pdf/ncqa/health-reform.pdf, last accessed on December 12, 2011.