An Evolving Landscape
Federal healthcare reform is made up of three separate but interrelated Acts, including the Patient Protection and Affordable Care Act (ACA), Mental Health Parity and Addiction Equity Act (Parity), and the Health Information Technology for Economic and Clinical Health Act (HITECH). This legislation provides the roadmap for transforming healthcare throughout the nation and influences all aspects of the healthcare delivery system.
At RDA, we approach healthcare reform through the Triple Aim Framework®. In this framework, developed by the Institute for Healthcare Improvement, optimizing healthcare systems performance requires the simultaneous focus on improving the experience of care, improving health outcomes, and reducing the cost of care. Initial results of early implementation are becoming available, and we have recognized the following trends:
- Many California counties are moving to a managed care model and selecting private insurance vendors to absorb existing and new Medi-Cal recipients into their plans. This means that individuals and families who have typically had Medi-Cal are now receiving care from the private sector. Healthcare providers who typically contract with Medi-Cal will now need to develop managed care contracts in order to continue serving their existing populations. Managed care plans will need to expand their provider networks to include more safety net providers and ensure that needed services are available.
- Healthcare providers will be asked to demonstrate the outcomes of their services. The previous healthcare system provided financial incentive for the quantity of services provided. The emerging healthcare system incentivizes the quality of services. For many healthcare providers, specifically providers whose systems are built on Medi-Cal and other public funding, it is imperative to develop the capacity to evaluate services and demonstrate effectiveness and efficiency.
- Emerging payment models provide financial incentives for people being well. As the business of healthcare transforms from paying for volume to paying for value, there is growing momentum to invest in wellness and prevention activities. Providers with expertise in wellness and prevention services for groups traditionally served by the public sector will likely have a greater role in new and emerging healthcare markets.