Summary:  Breaking down the Affordable Care Act (ACA) into its basic building blocks will help each of us to better understand the initial intent of the ACA.

The ACA was enacted in 2010 with provisions becoming effective through 2015 and beyond. Many of the provisions have been delayed beyond the dates originally set. For the official information regarding each of the provisions and the current effective dates, please visit The department given ultimate responsibility for administering the ACA is the Department of Health and Human Services. Additionally, the Center for Medicare and Medicaid Services (CMS) has been given responsibility for carrying out many aspects of the ACA.

The ACA has 4 main goals or purposes:

  • Reduce healthcare spending
  • Make healthcare more affordable
  • Increase accessibility and transparency
  • Increase accountability and quality outcomes

Let’s see if we can get back to basics regarding the ACA and spell out the building blocks upon which the ACA is built.

ACA Basics – Healthcare Spending

As we are all aware, healthcare spending has reached the point of being scary. Proportionally, costs are rising each year, due in part to inefficiencies and waste. The ACA is designed to reduce healthcare spending by addressing just about every aspect of healthcare. Without some sort of healthcare reform, there is no end in sight for reigning in the costs.

ACA Basics – Accessibility and Transparency

Increasing care accessibility can reduce healthcare spending. One of the major contributors to healthcare spending is the amount of visits to the emergency room that are not considered true emergencies. The price tag for emergency room services is much greater than the cost of those services administered for example through primary care. Traditionally, primary care has been known for keeping “doctor’s hours”, 9-5 Monday through Friday. Unfortunately, not all illnesses and injuries can be treated during this limited timeframe. Emergency rooms become a place of convenience, open 24 hours a day and 7 days a week. The ACA addresses this issue through a variety of ways including an emphasis on the medical home and patient centricity. How can we make healthcare more accessible? Many projects are underway to revamp primary care to extend office hours, provide electronic appointment scheduling, follow up reminders, and electronic medical records to share information among appropriate healthcare providers.

Additionally, Healthcare Exchanges became effective as of October 1, 2013. These exchanges are designed to increase transparency among plans and insurers as well as provide a relatively easy way to choose plan options most suitable to each individual’s situation. The website provides all of the information including links to individual state sites to make informed decisions. In fact, the government is so heavily invested in the success of the exchanges and the accessibility to more individual, penalties are now going to be assessed for those who choose not to carry healthcare coverage.

ACA Basics – Accountable Care and Quality Outcomes

Holding providers accountable for the care they provide is the 2nd aspect of the ACA. This involves treating patients in the right setting at the right time with the right treatment. Accountability additionally encompasses revamping the healthcare delivery system as we know it. Previously, physicians were paid on a fee-for-service basis, but now the emphasis is moving toward fee-for-value. The premise is to pay for value versus volume and quality versus quantity.  New delivery systems are in the works including Accountable Care Organization, Bundled Payments, and ultimately fee-for-value.  With the new delivery systems comes a shift in risk and a complete change in traditional thinking.  A renewed emphasis on customer satisfaction has also factored into the equation. Reimbursement is now tied to the results of customer satisfaction surveys. Providing excellent customer service is no longer a goal but a necessity or requirement to maximize reimbursement.

ACA Basics – Affordable Care

The ACA has as one of its main goals (even included in the name of the act) to provide affordable care. It is important to note that this is one of the goals but may not actually be one of the end results. With the creation of the Healthcare Marketplace is the creation of healthcare insurance subsidies. In a nutshell, the subsidies are designed to assist individuals in certain income levels with their health insurance premiums.  On the other side of this coin, the subsidies become taxable and are therefore reported as part of individual tax returns. Additionally, there is the potential that if you earn more than the estimated amount, you may have to pay some or all of the subsidy back.

BHM Healthcare Solutions –

If all of this seems very complex, you are not alone in your thinking. The ACA is well over 900 pages and was passed prior to Congress actually reading and understanding the ACA and all of its complexities. The saying was “Let’s pass it and then see what is in it”. That being said, not too many individuals have a full grasp of all of the nuances associated. BHM Healthcare Solutions are experts on the ACA and have helped many organizations with their healthcare reform consulting needs. Some of the services include transitioning to a Managed Care Organization, transitioning to an Accountable Care Organization, transitioning to the new delivery systems (bundled payments, fee-for-value, capitation models), increasing emergency room efficiency/throughput, reducing readmissions, reducing claim denials, managing the revenue cycle, accreditation consulting, and providing peer reviews through our Independent Review Organization services.

Contact us today to see how we can best assist you with your healthcare consulting needs. Let’s tackle the ACA together and watch your bottom line swing upward.

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