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benefits quarterly first quarter 20158
H e a l t hC a r eR e f o r m” L o o k b a c k ”
A Framework for the Discussion
Broadly speaking, health reform is unfolding in discrete
stages, with the period 2010-2013 focusing on insurance
reforms (eliminating lifetime maximums and many annual
limits, preventive benefits, etc.) and expanded access to cov-
erage (adult children to the age of 26 and full-time workers
defined as 30 hours or more, as examples). The year 2014
marked the introduction of the individual coverage mandate
as well as the launch of federal and state health insurance
exchanges (marketplaces) and state-by-state expansion of
Medicaid. These vehicles further expand access to coverage
and enhance affordability either through the expansion of
Medicaid or through low-income subsidies available to qual-
ified low-wage persons seeking coverage through the public
exchanges. The employer mandate and the introduction of
the full-time/part-time measurement requirements follow in
2015.
Next, 2018 marks the introduction of the so-called “Ca-
dillac” or excise tax which (based on Towers Watson 2014
projections) will hit roughly 58% of large employers in that
year, given current cost trajectories and definitions. Also un-
folding in future years will be activities addressing improved
care delivery, value-based contracting and the introduction
The Impact of the Affordable
Care Act on Large Employers:
A Retrospective
The Patient Protection and Affordable Care Act (ACA) has created a new environment for employer health ben­
efit plan management that is influencing costs, benefit design, delivery, administration, financing and compli­
ance as well as the positioning of health care within the benefits portfolio and the broader total rewards strat­
egy. This article will examine the key pragmatic effects of health reform for larger employers to date, quantifying
its direct costs and discussing the new dimensions of management that reform has introduced. The discussion
will focus on nongrandfathered self­funded plans and will address only major influences. It is not intended to
be all­encompassing and is, of necessity, general in nature. Each employer will have somewhat differing experi­
ences and results but should find the discussion to be helpful both in understanding what has evolved as well
as what is to come.
by Randall K. Abbott | Towers Watson
first quarter 2015 benefits quarterly 9
health care reform “lookback”
of new technologies as well as digitalization of more health
information. While “future years” are not of immediate con-
cern to most employers, these longer term ACA efforts will
inevitably influence employers as they unfold.
While the above will serve as our backdrop, we will focus
on the issues that human resources and benefits profession-
als have experienced and must prospectively manage in the
years immediately ahead. Those issues include the broader
strategic context, costs, eligibility and subsidization of plan
participants, benefit design, financing and risk transfer, ad-
ministration, network optimization and the delivery of care
in a new value-based marketplace. Each of these topics could
be a tome in and of itself; as a result, we will focus on key
pragmatic points, recognizing that deeper analysis is neces-
sary for each employer based on its own unique business,
workforce and strategic circumstances.
The Broader Context
Although employers have never been required to offer health
care benefits to their workforces, virtually all larger employers
have done so since World War II. ACA’s passage began a new
conversation about the employer’s role in providing health care
benefits. Shortly after the law passed, numerous employers ex-
plored the possibility of exiting direct sponsorship of health
benefits with an eye toward eliminating coverage and sending
all employees and their families to the public exchanges when
they became operational. That assessment quickly highlighted
several key points that have now caused 98% of large employ-
ers to say they intend to continue providing employer health
coverage (Towers Watson/NBGH 2013/2014 Employer Survey
on Purchasing Value in Health Care).
The decision to continue offering health benefits is
grounded in the recognition that eliminating coverage re-
sults in a pay cut for every participating employee since
health benefits are a tax-free benefit. While all employees
could go to the public exchanges as individuals to obtain
guaranteed issue coverage, only a portion of them would be
eligible to receive federal low-income subsidies equal to, or
greater than, the employer’s typical subsidy. In addition, em-
ployers would lose the availability of the deduction for health
benefits. They would face the need to replace some or all of
the lost compensation with pay, which would be taxable to
the employee and would incur all applicable employer pay-
roll taxes. Failing to provide minimum essential coverage to
at least 95% of employees (70% in 2015) triggers a penalty
of $2,000 a year per full-time employee (minus the first 80
in 2015 and minus the first 30 thereafter). These elements
compound to make “exit” a relatively unattractive option for
most employers.
While the vast majority of employers continue to provide
health coverage, the 2014 Towers Watson/NBGH survey
found that only 25% of large employer respondents are con-
fident they will provide coverage ten years from now.
The decision by employers to stay in the health benefits
game has fueled a robust conversation about the position-
ing of health benefits within the total rewards package, who
should be covered and how employers should subsidize cov-
erage. Only 4% of Towers Watson/NBGH survey respondents
indicate they have no plans to recalibrate their health care
strategy, with 18% already having done so and the remain-
ing 78% having plans underway. (And nearly half are doing
so within a broader total rewards context.) Employer actions
include marked increases in dependent premium rates, rapid
growth in spousal surcharges and innumerable discussions
reprising the idea of employers establishing a “defined con-
tribution” for their share of health coverage costs.
ACA is not the only dynamic fueling these conversations,
but it certainly has been a catalyst and will continue to be a
springboard for discussion as 2018 approaches and employ-
ers face the business risk of the excise tax. The continuing
rise in annual health plan costs (projected at 5.2% for 2015
before plan changes and 4.0% after plan changes), plus the
onerous implications of the excise tax, are causing employ-
ers to focus on optimizing health plan performance. As one
consultant put it, “The new gold standard for health plan cost
trend is managing to the CPI.” A 5% or greater trend rate will
be virtually unsustainable for many employers as the excise
tax emerges, since the tax is indexed at a variation of the con-
sumer price index (CPI) rather than medical cost trend.
The Cost of ACA for Large Employers
ACA’s cost impact varies by employer, depending upon
its historical benefit design, eligibility requirements and
other plan provisions. Broadly speaking, ACA has been a
benefits quarterly first quarter 201510
significant added cost to employers.
Some argue the law will offer longer
term relief as value-based contracting
and reimbursements are introduced in
the marketplace, providers focus more
on efficiency, quality of care and out-
comes, and technology is enhanced.
But, to date, the law has unquestionably
increased employer costs.
As noted, each employer will see
different cost effects depending upon
its circumstances. For example, if a
plan had a robust range of preventive
benefits and covered children to the age
of 25, the expansion of preventive ser-
vices for the adult child to the age of 26
would have only a minimal cost effect.
The cost would be greater for those with
more restrictive benefits and eligibility
provisions. It is possible to quantify a
range of impacts for large employers.
The table depicts an annual percentage
increase due to various health reform
mandates expressed as a range based
on Towers Watson experience and pro-
jections for large employers.
The expansion of Medicaid in some
states can help offset some of these add-
ed costs for employers with low-wage
workforces. The yet-to-be implemented
automatic enrollment provision will
likely be an incremental cost to many
employers. With the exception of those
with a very high percentage of workers
eligible for Medicaid, this writer has
seen no large employer that experienced
either a cost reduction or a moderation
in costs because of ACA to date.
Eligibility and Subsidization
ACA has created a new focus on
who is covered and how employers
subsidize employee and dependent
participation. Employers face poten-
tial increases in participation because
of the individual mandate and the au-
tomatic enrollment provision resulting
in some prior opt-outs joining the plan.
Other increases in participation could
come from newly eligible employees to
the 30-hour rule, the expansion of cov-
erage to the age of 26 for adult children
and the possible influx of spouses due
to either the individual mandate or ac-
tions taken by the spouse’s health plan
in response to health reform. An op-
portunity to reduce plan participation
has also emerged with Medicaid ex-
pansion and the availability of guaran-
teed issue coverage through the public
exchanges for Consolidated Omnibus
Budget Reconciliation Act (COBRA)
continuees and pre-Medicare retirees.
These individuals may also be eligible
for federal subsidies. (Given the rocky
rollout of the public exchanges in 2014,
employers have been cautious in their
migration efforts.)
As a result of these new circum-
stances, employers now have the op-
portunity to assess their populations to
determine the most appropriate ways
to deliver benefits to each segment. The
newly available benefit delivery chan-
nels (public and private exchanges for
actives and retirees), as well as the tra-
ditional self-managed employer plan,
are all opportunities to revisit how
health benefits can be most effectively
delivered for unique segments of the
employer group. This concept, referred
health care reform “lookback”
T A B L E
Annual Percentage Increase due to Various
Health Reform Mandates, Expressed as a Range
Preventive services covered and expanded at 100% 0.0­1.5%
Removal of annual and lifetime limits 0.0­1%
Coverage of adult children to age of 26 0.0­1.5%
Patient­Centered Outcomes Research Institute (PCORI) fee: ,0.1%
Total incremental cost 2010­2014 , 0.1­4.1%
Transitional reinsurance fee, 2014 1/21.3%
Transitional reinsurance fee, 2015 1/20.9%
Transitional reinsurance fee, 2016 1/20.5%
Health insurer fee (applies only to insured plans beginning in 2014) 1.5­3.0%
Reduction in opt­outs due to individual mandate 0.0­5.0%
Integrated out­of­pocket maximum for medical and drug 0.0­1.0%
2018 excise tax varies based on plan costs, rate of cost trend and year but triggers at
$10,200 for individuals and $27,500 for a family with a 40% nondeductible tax on
amounts over those thresholds. Computed by employee.
Source: Based on Towers Watson experience and projections for large employers.
first quarter 2015 benefits quarterly 11
to as cohort value optimization (CVO), seeks to connect peo-
ple with the greatest value in terms of benefits, choice and
cost.
Increasingly, employers are no longer relying on just the
self-managed group plan for all benefit participants. The co-
hort-based segmentation process began with the availability
of private Medicare exchanges nearly a decade ago and has
expanded with the introduction of the public exchanges as
well as the availability of private exchanges for actives and
early retirees. The private Medicare exchanges have bur-
geoned in recent years. With the emergence of the public
exchanges, we are seeing nascent activity channeling pre-
Medicare retirees, COBRA continuees and part-time work-
ers to them. As employers become more comfortable with
these new channels, we will increasingly see use of hybrid de-
livery channels for leveraging each arrangement to optimal
advantage. As examples, COBRA continuees can often enjoy
more choice, lower costs and possible federal subsidies in the
public exchanges, as can early retirees—especially those pre-
Medicare retirees with “access only” employer plan arrange-
ments or low employer subsidies toward coverage. CVO of-
fers advantages to the employer and the employee, former
employee or retiree and is possible, in part, because of ACA.
Employers are broadly affected by ACA as they consider
how they will subsidize coverage and how employees will
share in plan costs. Under the law, the affordability of an
employer-sponsored plan to the employee is defined as the
share that is paid by the employee via premium contribu-
tions. The employee share of premiums cannot exceed 9.5%
of household income for the cost of the lowest option em-
ployee-only plan. This has required employers to a) do the
requisite calculations and b) emphasize point-of-care cost
sharing in lieu of premium-based cost sharing. In addition,
the value of incentives must now be incorporated into the
determination of whether the plan is, in fact, affordable, with
a suite of guidelines prescribing how to assess the premium
value—including incentives—and its affordability.
The 30-hour threshold for full-time determination, the af-
fordability test and the actuarial value of the plan are all key
factors in determining whether an employer meets the re-
quirements to “play” and avoid the $2,000 penalty mentioned
earlier. If the cost of the lowest value employee plan exceeds
9.5% of household income and the employee is awarded a
subsidy through the public exchanges, the employer is now
levied a penalty of $3,000 per year per affected employee.
The discussion on who to cover and how to cover them
includes all of the elements described above but also includes
a focus on spousal coverage. As noted earlier, the availability
of coverage through the public exchanges, the need to im-
prove health plan performance through optimal cost man-
agement and the actions of other employers have all com-
bined to cause many employers to revisit the commitment
to spousal coverage. Of late, employers have often increased
dependent rate tiers, and 37% have introduced spousal sur-
charges, with an additional 10% planning to do so in 2015.
The spousal surcharge trend has increased across all indus-
tries and is now averaging $100 per month, with a low of $50
to a high of $125 (Towers Watson/NBGH 2014). The ACA
influence is clear: The public exchanges offer an alternative
for guaranteed issue coverage and, where the need to man-
age cost is acute, eliminating or surcharging spousal cover-
age is an option, but it must be considered within the broader
“deal” or employee value proposition.
These ACA requirements have combined to require new
administrative functions and parameters surrounding how
costs are shared with employees; they also introduce the risk
of new penalties for noncompliance.
Benefit Design
Beyond defining eligibility for full-time employees and
adult children, ACA has materially affected benefit plan
design for employer-sponsored plans. While the federal in-
fluence on retirement plans has long been a fact of life for
employers, health benefit plans faced considerably fewer
pure design requirements, except for those needed to com-
ply with the various Section 105 nondiscrimination rules or,
in the case of insured plans, to comply with applicable state
mandates. Employers could design plans with very minimal
benefits (such as the so-called mini med plans), apply limita-
tions on lifetime benefits and not be required to cover certain
benefits now deemed “essential” under insured plans.
Employers now face both a floor and a ceiling under
ACA. First, the plan must meet a minimum actuarial value
of 60%, which means that, of total eligible charges, the plan
health care reform “lookback”
benefits quarterly first quarter 201512
health care reform “lookback”
must reimburse at least 60% of those charges. Second, be-
ginning in 2018, the value of the plan (when combined with
other health benefits included in the definition) cannot ex-
ceed a dollar value of $10,200 for an individual or $27,500 for
a family under the excise tax provision.
These two requirements have had a profound effect on
benefit design already. Minimum benefit plans have been
phased out. Employers have had to validate that their benefit
plan is above the minimum and are focusing on examining
the level of benefits provided prospectively as they anticipate
the effects of the excise tax thresholds on projected 2018 costs.
Pragmatically, the minimum benefit requirement has
produced at least three results:
1. Employers have upgraded benefits on plans that
failed to meet the minimum.
2. Benefits have been eliminated as prospectively unaf-
fordable.
3. The employer has directed affected employees to the
public health exchanges to purchase coverage (with
or without the support of an employer-sponsored
transitional concierge or navigator to assist in evalu-
ating exchange-based options and determining the
potential for subsidies).
The 60% minimum is largely a nonissue for large em-
ployer plans since most employer-provided health plans cur-
rently have an actuarial value in the range of 80-85%. How-
ever, as the excise tax looms, plan sponsors are assessing plan
values within the context of their larger excise tax risk, with
the expectation that benefit values will erode in the future as
employers adversely affected by the excise tax work to reduce
their exposure through redesign, cost-mitigation strategies
and improving care and condition management as well as
workforce health status.
The inclusion of ACA-required benefits ranging from in-
full preventive services to elimination of lifetime maximums
(as noted previously) has contributed to the need for design
changes and a close eye toward monitoring compliance with
the law and new regulatory guidelines, which often require
updating or refining plan provisions or rules.
Financing and Risk Transfer
The law has delineated from inception the difference be-
tween insured and self-funded employer health plans in its
application and has imposed added levies on insured plans.
The health insurer fee noted earlier has caused some smaller
employers to reconsider insured status and explore the vi-
ability of self-funding both to avoid the incremental ACA in-
surer tax as well as to avoid the added cost of insurance ver-
sus a self-funded arrangement (which can add from 5-11%).
But the trade-off is cash flow volatility and the added risk
corridor that a self-funded plan with reinsurance typically
requires.
Self-funded plan sponsors have revisited excess reinsur-
ance (stop-loss) levels to determine whether the elimination
of annual and lifetime benefit limits requires an adjustment
to the stop-loss attachment point in place. Interestingly,
health reinsurers informally surveyed for this article have
not yet cited a trend toward higher stop-loss rates due to
ACA, although they have noted that aggregate premiums
have increased in some cases as employers elected to adjust
stop-loss levels to reflect the loss of lifetime limits and the
added risk potential.
A further risk transfer consideration may emerge as the
excise tax is triggered in 2018. Under the law as currently
written, insured dental and vision plans are excluded from
the excise tax calculation; self-funded dental or vision plans
are included. If this oddity is sustained through final regu-
lations, it is inevitable that employers facing the excise tax
will actively explore adopting insured arrangements for
these benefits. Many observers, however, question whether
this anomaly will survive as final regulations are drafted, as-
suming the excise tax itself is made effective as currently de-
signed.
Administration
Unquestionably, ACA has increased the administrative
burden on employers because of the continual need to moni-
tor compliance, meet new communication requirements, im-
plement new measurement standards and increase reporting.
The fundamental task of monitoring, reviewing and inter-
preting a steady stream of guidance has added to legal and
benefit staff burdens, as has the need to modify contracts
and plan administration provisions to achieve and maintain
compliance. It is easy to forget the myriad of administrative
first quarter 2015 benefits quarterly 13
health care reform “lookback”
changes necessitated—and the com-
munication efforts required—due to
ACA. Examples include the notice on
maintenance of grandfathered status
(where applicable), expansion of pre-
ventive services, extension of coverage
to adult children to the age of 26, elimi-
nation of maximums, introduction of
women’s health benefits, the health flex-
ible spending account cap at $2,500, the
change in health savings account with-
drawal penalties, new rules on wellness
programs and any associated incentives,
new claim appeal and external review
provisions, communications on the
availability of public health exchanges
and, of course, the summary of ben-
efits and coverage, to name a partial list.
And, in the years ahead, more will be
required.
Perhaps one of the greatest chal-
lenges faced by many employers has
been the requirement (expected to be
implemented in 2015) related to the ini-
tial and ongoing measurement of full-
time and part-time status. This complex
provision requires employers to estab-
lish measurement periods for tracking
hours worked to prove that full-time
workers are, in fact, appropriately cov-
ered. The focus on defining full-time
status for health coverage at 30 hours
a week (130 hours a month) has given
rise to a careful scrutiny of workforce
planning needs within many organiza-
tions—especially those with workforces
that are heavily part-time, temporary or
seasonal.
The reporting requirements under
Section 6055 (individual mandate re-
porting) and Section 6056 (employer
mandate reporting) to support Inter-
nal Revenue Service enforcement are
significant and will require a continu-
ing employer effort to track, report and
submit this data. Overall, the admin-
istrative effort under ACA has added
dramatically to the employer’s health
benefit management activities while
also necessitating the use of actuaries,
consultants and attorneys to aid in in-
terpretation and implementation of the
requisite provisions both within the
employer organization and with exter-
nal vendors or service providers.
Network Optimization
and Care Delivery
ACA has both fueled and acceler-
ated an employer focus on optimiz-
ing the network delivery of care and
the manner in which care and condi-
tion management are applied to their
populations. Prior to reform, numer-
ous employers were seeking to adopt
or expand value-based arrangements,
which focus on not just the discounted
unit cost of care but rather the total
cost, encompassing price, efficiency,
quality of care and the outcome of the
care delivered. ACA includes numer-
ous requirements that will migrate the
reimbursement of health care to value-
based arrangements in the years ahead.
This accelerant is affecting employ-
ers—and ultimately plan members—
as hospitals, health systems and physi-
cians respond to the law by changing
practices, consolidating and entering
into risk-bearing or risk-sharing ar-
rangements. Employers are seeing the
effects of this as entities like account-
able care organizations arise and as
health plans begin to move from pure
discounted fee-for-service contracting
to a variety of value-based arrange-
ments. Even today, employers with na-
tional networks are experiencing the
effects of value-based approaches as
health plans adopt various efficiency
and quality measures in their network
contracting with primary care physi-
cians and hospitals.
Other employers are moving the
market themselves through direct con-
tracting arrangements or are pressing
to develop high-performance networks
and the expansion of procedures di-
rected to centers of excellence. In the
years ahead, employers will increasing-
ly utilize hybrid network arrangements
drawing on national vendors, directly
contracted configurations and, often,
narrower networks defined by the pro-
vider’s demonstrated willingness to
deliver based on both cost and quality
of care. This aspect of ACA is only now
being better understood by employer
plans but is both real and an opportu-
nity for positive change.
Another aspect of care accelerated
by ACA is the focus on primary care
and the need to place more wellness
and condition management within
the provider community rather than
with health plan administrators or
specialty third-party vendors. There is
a renewed emphasis on primary care
and increased emphasis on the patient-
centered medical home. While neither
are new topics (the medical home con-
cept is more than two decades old), it
has renewed recognition of the need for
patients to have both primary care and
a medical home.
The emphasis on population health
benefits quarterly first quarter 201514
health care reform “lookback”
management and the move to providers assuming risk for
the outcome of care is also creating a foundation for tran-
sitioning more of the wellness efforts and condition man-
agement activities from third parties into the provider en-
vironment. Based on conversations with both health plans
and providers, this shift will be gradual and will likely
stretch out five to seven years, and a greater provider role
in these areas is emerging.
Finally, the expansion of health care coverage under
ACA to those previously uninsured has added to concerns
about a physician shortage and increased difficulty access-
ing care. The shortage of physicians is real and is spurred
not just by health reform but, in larger part, by an expand-
ing, aging population with mounting health risks. There
also is a generational shift as baby boomer physicians rap-
idly retire. Employers in many areas will be faced with ac-
cess concerns and, depending upon locale, may need to
consider bringing services on site through an employer-
sponsored clinic or health center. In addition, telemedi-
cine will be a key component of care delivery utilizing the
technology now available via smartphones and tablets.
Some observers believe technologies like telemedicine and
remote monitoring will be the key to managing the short-
age. These phenomena will challenge employers to rethink
many aspects of traditional network structure and care de-
livery in the months and years ahead.
Putting It All Together
This brief retrospective highlights the significant impact
of ACA already affecting employers and foreshadows the
challenges and opportunities to come. Without a doubt,
ACA has affected more than health benefit plans—It has be-
come a total business issue with employers facing not only
its health benefit management implications but also the
broader administrative, systems and reporting challenges. It
also raises the strategic implications of how ACA, the emer-
gence of public exchanges and federal subsidies (as well as
private exchanges) will change the employer role in health
care benefit delivery, the positioning of health care within the
organization’s total rewards strategy, workforce planning and
ultimately the employee value proposition.
The financial effects have been real, and the 2018 excise tax
will create further costs for roughly 60% of employers based
on their current trajectories. This risk requires thoughtful
scenario planning now to anticipate the change needed, the
delivery options available and the glide path required to get
there in the months remaining.
While the challenges for employers are great, the Tow-
ers Watson Health Care Changes Ahead Survey conducted in
the summer of 2014 shows that 83% of the large employer
respondents fully expect employer-sponsored health care to
be a core part of their total rewards package and employee
value proposition in 2016 and beyond. As the later phases of
health reform unfold, giving rise to more value-based care,
more technology and innovation, one can hope that reform
will bring with it new opportunities and an improved health
care system.
In the meantime, employers must focus on optimizing
health plan performance, improving workforce health and
determining the most appropriate benefit delivery channels
to achieve the greatest value for the company and employees
alike.
Reference
Towers Watson/National Business Group on Health (May 2014) Full Re-
port: Towers Watson/NBGH 2013/2014 Employer Survey on Purchasing Value
in Health Care, The New Health Care Imperative: Driving Performance, Con-
necting to Value. Available at www.towerswatson.com/en-US/Insights/IC-
Types/Survey-Research-Results/2014/05/full-report-towers-watson-nbgh-
2013-2014-employer-survey-on-purchasing-value-in-health-care.
A U T H O R
Randall K. Abbott is a senior consultant
and North American practice leader at
Towers Watson, based in Boston, Massachu­
setts. His work encompasses health benefit
strategy, workforce health improvement,
total benefits strategy and positioning benefits within the
broader total rewards context. He has been deeply involved
in the evaluation of exchange­based delivery of health
care, including both public and private exchanges.
Copyright of Benefits Quarterly is the property of International Society of Certified Employee
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3
· Which important healthcare policy affecting healthcare access would you as a healthcare executive or policymaker want to focus on immediately? Who are your stakeholders on the step of needs assessment, policy-making, regulatory implementation, and oversight? Discus 1-2 of primary and secondary stakeholders and provide an explanation of why you believe these are the key players in the process. Substantiate your ideas.
To answer this question, consider the ideal healthcare policy and that resources are limited.
3
Meghan
As a healthcare executive, I would focus my attention on the policy related to the utilization of telemedicine. Telemedicine is the remote delivery of services through a phone call or virtual platform (video visit) between a provider and a patient. Telemedicine has proven to improve access to care for those that experience social and physical determinants (ex: patients that reside in rural areas, elderly, lack of finances to pay for transportation, childcare). Since the decline of the COVID-19 pandemic, payors at state and federal levels have placed rapid restrictions on telemedicine. A variety of regulatory barriers have kept telehealth from reaching its full potential to increase competition and access (Reforming America’s Healthcare, n.d.). The majority of payors determined that patients can no longer receive care via telemedicine if they are not in the same state as the provider. If a patient works in a different state or travels out of state for leisure, healthcare facilities have to restrict that access to care. Reimbursement has emerged as a crucial issue as projects attempt to evolve from the demonstration stage to a mainstream component of health delivery (Whitten et al., 2003).
The primary stakeholders to assist with this policy change would be: patients, providers, and the payors. It will be important to propose and implement policy changes related to telemedicine and the quality of care as well as access to care.The opportunities for major advances in public health policy and practice are simply unparalleled (Rosenbaum, 2011).Under the current model: if a patient, with a chronic condition such as high blood pressure, traveled out of state to visit their child at college and forgot their medicine or was experiencing concerning symptoms, they would not have access to care through telemedicine. This patient would then need to spend hours in an ER with providers that are not privy to the longevity of care or have access to the patient medical records. The secondary stakeholders to assist with this policy change would be patient family members and those from the local government groups. Most times the secondary stakeholders are more vocal and will even invite the media to specific events.
Continued telehealth use will require that emergency relaxations of telehealth policies be permanently passed into law. Actual use will depend on health system infrastructure and processes, the way health systems are reimbursed, and the type of care being delivered (Pina et al., 2022).
References
Piña, I. L., Allen, L. A., & Desai, N. R. (2022). Policy and payment challenges in the postpandemic treatment of heart failure: Value-based care and telehealth.Journal of Cardiac Failure,28(5), 835–844. https://doi.org/10.1016/j.cardfail.2021.08.019
Reforming America’s healthcare system through choice and competition(n.d.). Retrieved June 3, 2022, from https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf
Rosenbaum S. (2011). The Patient Protection and Affordable Care Act: implications for public health policy and practice.Public health reports (Washington, D.C. : 1974),126(1), 130–135. https://doi.org/10.1177/003335491112600118
Whitten, P., & Kuwahara, E. (2003). Telemedicine from the Payor Perspective: Considerations for Reimbursement Decisions.Disease Management & Health Outcomes,11(5), 291–298. https://doi-
Heather
As a healthcare executive, I would focus my attention on the policy related to the utilization of telemedicine. Telemedicine is the remote delivery of services through a phone call or virtual platform (video visit) between a provider and a patient. Telemedicine has proven to improve access to care for those that experience social and physical determinants (ex: patients that reside in rural areas, elderly, lack of finances to pay for transportation, childcare). Since the decline of the COVID-19 pandemic, payors at state and federal levels have placed rapid restrictions on telemedicine. A variety of regulatory barriers have kept telehealth from reaching its full potential to increase competition and access (Reforming America’s Healthcare, n.d.). The majority of payors determined that patients can no longer receive care via telemedicine if they are not in the same state as the provider. If a patient works in a different state or travels out of state for leisure, healthcare facilities have to restrict that access to care. Reimbursement has emerged as a crucial issue as projects attempt to evolve from the demonstration stage to a mainstream component of health delivery (Whitten et al., 2003).
The primary stakeholders to assist with this policy change would be: patients, providers, and the payors. It will be important to propose and implement policy changes related to telemedicine and the quality of care as well as access to care.The opportunities for major advances in public health policy and practice are simply unparalleled (Rosenbaum, 2011).Under the current model: if a patient, with a chronic condition such as high blood pressure, traveled out of state to visit their child at college and forgot their medicine or was experiencing concerning symptoms, they would not have access to care through telemedicine. This patient would then need to spend hours in an ER with providers that are not privy to the longevity of care or have access to the patient medical records. The secondary stakeholders to assist with this policy change would be patient family members and those from the local government groups. Most times the secondary stakeholders are more vocal and will even invite the media to specific events.
Continued telehealth use will require that emergency relaxations of telehealth policies be permanently passed into law. Actual use will depend on health system infrastructure and processes, the way health systems are reimbursed, and the type of care being delivered (Pina et al., 2022).
References
Piña, I. L., Allen, L. A., & Desai, N. R. (2022). Policy and payment challenges in the postpandemic treatment of heart failure: Value-based care and telehealth.Journal of Cardiac Failure,28(5), 835–844. https://doi.org/10.1016/j.cardfail.2021.08.019
Reforming America’s healthcare system through choice and competition(n.d.). Retrieved June 3, 2022, from https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf
Rosenbaum S. (2011). The Patient Protection and Affordable Care Act: implications for public health policy and practice.Public health reports (Washington, D.C. : 1974),126(1), 130–135. https://doi.org/10.1177/003335491112600118
Whitten, P., & Kuwahara, E. (2003). Telemedicine from the Payor Perspective: Considerations for Reimbursement Decisions.Disease Management & Health Outcomes,11(5), 291–298. https://doi-