Affordable Care Act (ACA)

Subscribe to Affordable Care Act (ACA) via RSS

The Affordable Care Act enables the establishment of Health Benefit Exchanges of several types, including (i) State-based, (ii) State-Federal partnerships and (iii) Federally Facilitated Exchanges.[1] The purpose of the Exchanges is to, among other things, “provide competitive marketplaces for individuals and small employers to directly compare available private health insurance on the basis of price, quality and other factors.[2]

In theory, the information provided by the exchanges will “give small businesses the same purchasing clout as larger businesses.”[3] Those goals are laudable and hard to quarrel with–anyone who has tried to buy individual health insurance knows that the available information on comparability of insurance plans is at best insufficient and at worst opaque.Continue Reading Health Benefit Exchanges: False Claims Gold Mines?

Will bundled payments lead to restructuring of our primary care healthcare delivery system? Healthleaders has a great article discussing the vision for healthcare delivery system reengineering proposed by Thomas H. Lee, MD, the network president of Partners Healthcare and Michael E. Porter, PhD, Bishop William University Professor at the Harvard Business School. The two advocate for a revamping of our understanding of “primary care” doing away with the distinction between primary and specialty care in favor of an integrated care delivery model focused on patients. Lee and Porter propose grouping patients into categories and matching comprehensive physician services with patients. They promote embracing the bundled payment method of payment by insurers to provide incentive for these comprehensive services. The article specifically identifies several groups, including CareMore, as having already begun to transition into this coordinated care model.
Continue Reading Time to Revamp Primary Care?

By Eric Klein

The Supreme Court ruled today 5-4 that the Affordable Care Act is constitutional and upheld the individual mandate, requiring most Americans to maintain "minimum essential" health insurance coverage. The decision was written by Judge Roberts for the majority. The Court held that the argument relying on the Constitutional commerce clause would not support the Affordable Care Act, but then looked to the constitutional right of Congress to impose taxes. Noting that the enforcement and operational structure for the individual mandate compliance and penalties was administered through the Internal Revenue Service, the Court upheld the individual mandate as a valid exercise of the Taxing Clause of the U.S. Constitution.Continue Reading Supreme Court Upholds Individual Mandate in the Affordable Care Act, but Medicaid Expansion is in Question

The Department of Justice and Federal Trade Commission recently issued their final “Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program” pursuant to the 2010 Patient Protection and Affordable Care Act. The final statement was issued in conjunction with the Department of Health and Human Services’ Centers for Medicare and Medicaid Services’ final regulations implementing the shared savings program as part of a coordinated interagency effort to facilitate health care provider participation in the shared savings program, so as to achieve the cost savings and improvement in quality of care Congress intended. Both the final statement and CMS’ final regulations aim to further encourage and incentivize formation of Accountable Care Organizations and participation in the shared savings program. As such, the final statement includes significant, material changes from the proposed statement of antitrust enforcement policy with respect to ACOs issued earlier this year. (See the April 15 article on the proposed statement.)
Continue Reading No Mandatory Antitrust Review for ACOs

By Eric Klein, Kenneth Yood, Aytan Dahukey and Lynsey Mitchel

The Affordable Care Act (the “ACA”) establishes the general requirements for payments to participating Accountable Care Organizations (“ACOs”) pursuant to the Shared Savings Program, described in Section 3022 of the ACA.  The ACA provides that ACO participants will continue to receive payment under the original Medicare fee-for-service (“FFS”) program under Parts A and B. In addition, ACOs can receive payment for shared Medicare savings provided that they meet both quality performance standards and demonstrate achievement of savings against a benchmark of expected average per capita Medicare FFS expenditures. On March 31, 2011, the Centers for Medicare and Medicaid Services (“CMS”) released its proposed rule regarding ACOs (the “Proposed Rule”). This blog entry is an overview of the payment options for ACOs set forth in the Proposed Rule. (For a discussion of the legal structure and governance of ACOs, please see our April 11, 2011 entry.)
 Continue Reading Accountable Care OrganizationsPayment Options for ACOs Pursuant to the Proposed Rule

By David R. Garcia

The Department of Justice and Federal Trade Commission have recently proposed new guidelines delineating a three-tiered structure of antitrust scrutiny for accountable care organizations — the new healthcare delivery model mandated by the 2010 Patient Protection and Affordable Care Act — based on certain calculations of market shares of independent provider ACO participants. The proposed statement, intended to operate in conjunction with the Department of Health and Human Services’ Centers for Medicare and Medicaid Services’ proposed regulations on the same subject — is intended to ensure that providers have the antitrust clarity and guidance necessary to form pro-competitive ACOs, while also ensuring against the unintended effect of reducing competition. The statement will have significant ramifications for all providers interested in ACO formation. For a more detailed explanation of the proposed statement, please see the attached article.Continue Reading Levels of Antitrust Scrutiny for ACOs

By Eric Klein, Kenneth Yood, Aytan Dahukey and Lynsey Mitchel

This blog entry will be the first of a series of entries discussing the long anticipated 400 plus-page Accountable Care Organization proposed regulations (the “Proposed Rule”) released on March 31, 2011, by the Centers for Medicare & Medicaid Services (“CMS”). The Proposed Rule is designed to implement Section 3022 of the Affordable Care Act which contains provisions relating to Medicare payments to providers of services and suppliers participating in ACOs. Under these provisions, ACO participants can continue to receive traditional Medicare fee-for-service payments under Parts A and B, and be eligible for additional payments based on meeting specified quality and savings requirements. 

This entry discusses the Proposed Rule’s provisions regarding the legal structure and governance of ACOs.

The Affordable Care Act requires an ACO to “have a formal legal structure that would allow the organization to receive and distribute payments for shared savings” to “participating providers of services and suppliers.” Operationally, an ACO’s legal structure must provide both the basis for its shared governance as well as the mechanism for it to receive and distribute shared savings payments to ACO participants and providers/suppliers.
 Continue Reading Proposed Rule: Legal Structure and Governance of ACOS