Health Care Delivery Reform: Will the ACA’s Changes Stick?

While the Affordable Care Act has been a “major innovation driver for health care system transformation,” there are still barriers to obtaining and paying for health care — especially long-term care.

“Over the last several decades, the nation’s health care delivery and long-term care systems have become even more fragmented — leading to confusion, poor health outcomes and higher costs of care,” Bruce Chernof, president and CEO of the SCAN Foundation, asserted in a March opinion piece. At the same time, the need for long-term care services has increased “dramatically” over the past 20 years, Chernof pointed out, but just one-third of Americans ages 40 and older have saved money to pay for such care.

“Contained in the ACA are important provisions focused on the needs of vulnerable adults that start to address these challenges,” Chernof wrote. Those elements “are quietly having a profound impact on today’s health care landscape,” Chernof added in a separate opinion piece this month. However, “a great deal of work remains to institutionalize system change that offers value to individuals, providers, payers and regulators,” he said.

Of all the states that have embraced the ACA, California “is a leading state in exploring and adopting new models of care” under the law, according to Chernof.

Efforts in California

The California Department of Health Care Services told California Healthline that the ACA “created many new opportunities for states to redesign their delivery systems in ways that promote high-quality care and lower costs,” adding, “California has participated in several of these programs.”

A SCAN Foundation policy brief highlights California’s efforts “to improve care for older adults and people with disabilities.” Many counties are testing at least one new care delivery model under the ACA. For instance:

  • Cal MediConnect, the state’s dual eligibles demonstration initiative, has been implemented in six counties, with another scheduled to be added in August;
  • One integrated dual eligible special needs plan is operating in the state, covering about 8,000 individuals in Los Angeles, Riverside and San Bernardino counties;
  • 8 community-based care transition programs are operating in the state, covering residents in Los Angeles, Orange, San Diego and San Francisco counties;
  • 35 accountable care organizations are operating in the state, covering nearly 450,000 residents across 35 counties; and
  • Medi-Cal health homes are expected to be launched in the same counties as Cal MediConnect in January 2016, with the program expanded to the remaining counties by July 2016.

All of the models are focused on improving coordinated care.

However, even in California “implementation varies by county,” creating “challenges in understanding the multitude of changes as well as how to engage in these new systems of care,” according to Chernof.

Barriers to Progress

“California, along with the rest of the nation, is facing workforce shortages to care for our aging population, particularly in our most rural areas,” DHCS said. The agency added that Medi-Cal beneficiaries, caregivers, senior residents and individuals with disabilities must use a “fragmented” and “disconnected” system to receive care.

“This fragmentation often leads to beneficiary confusion, delayed care, inappropriate utilization and unnecessary costs,” DHCS told California Healthline.

Meanwhile, health information technology limitations also could affect the success of care delivery reforms under the ACA. Rhonda Richards, senior legislative representative for AARP’s Government Affairs Health and Family Team, in an interview with California Healthline cited the importance of “making sure long-term services providers are connected and able to communicate with other providers electronically or otherwise to share information and better coordinate care … along an array of care settings.”

In addition, Richards said the inclusion of family caregivers in delivery system reforms will be a key to their success. While the infrastructure in place often lacks measures that ensure the inclusion of family caregivers, Richards said that “efforts are underway to develop better quality measures.” She added, “Sometimes [the measures] may be good and strong, but sometimes there are areas for improvement there.”

However, DHCS said programs to reform health care delivery “are an important way to surmount some of these challenges and reflect a new approach to delivering services,” adding, “These challenges in the current system make programs that improve integration and coordination of care essential to improving population health.”

Calif., Other States Must Continue Momentum

“Continued efforts are critical, building on successes and lessons learned, including understanding which components of the programs work best to meet the range of needs among the state’s diverse older adult population,” according to the SCAN Foundation policy brief.

Chernof wrote that stakeholders’ next steps should be to:

  • Create quality benchmarks that focus on the patient’s idea of success;
  • Expand the health assessment process to include functional needs as a rationale for comprehensive care; and
  • Promote quality improvement evaluations at both the local and state levels to determine which programs are and are not working.

In California, the brief suggests officials also should focus on:

  • Developing a strategy for oversight and implementation of long-term services and supports;
  • Increasing the affordability of long-term services and supports, as just 5% of Californians over age 40 are covered by long-term care insurance; and
  • Recognizing and supporting the role of family caregivers, considering the state’s low ranking — 49th — in AARP’s 2014 State LTSS Scorecard.

In addition, the SCAN Foundation has released a request for proposals to boost aging and disability coalitions in California. Such regional coalitions currently cover 95% of the state.

What Does Success Look Like?

Moving forward, Richards said, “Regardless of the particular [care delivery] model, I think things that will be important are looking at how to make sure consumers who are using the models understand what will happen and how it works,” as well as “what changes will impact them and what it means for their care.”

According to Chernof, the “last five years have produced real progress … at both the federal and state levels” in better coordinating long-term care services. “For older adults, the ACA has fostered delivery system innovation at the state and regional levels.”

However, he noted, “Most of these new models … are in the early stages of implementation” and “judging the full success of these programs … will require more time and thoughtful evaluation.”

Around the Nation

Cutting off funding. GOP Sens. David Vitter (La.) and Ted Cruz (Texas) are aiming to cut off federal contributions that members of Congress and their staff use to purchase coverage through Washington, D.C.’s small-business exchange.

The end draws near. Stakeholders and lawmakers are preparing for the end of the Children’s Health Insurance Program.

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