Brent Braveman, Christina A. Metzler; Health Care Reform Implementation and Occupational Therapy. Am J Occup Ther 2012;66(1):11-14. doi: 10.5014/ajot.2012.661001.
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© 2017 American Occupational Therapy Association
Individual mandate for health insurance. Most individuals in the United States will be required to have health insurance beginning in 2014. Those who do not have coverage will be required to pay a yearly financial penalty of the greater of $695 per person (up to a maximum of $2,085 per family) or 2.5% of household income, which will be phased in from 2014 to 2016. Exceptions will be given for financial hardship and religious objections, for certain Native Americans, for people who have been uninsured for fewer than 3 mo, for those for whom the lowest cost health plan exceeds 8% of income, and for individuals with an income below the tax-filing threshold (Henry J. Kaiser Family Foundation, 2010).
Health insurance exchanges. Individuals who do not have access to affordable employer-based coverage will be able to purchase coverage through a health insurance exchange at the state level. Premium and cost-sharing credits will be available to families with incomes up to 400% of the Federal Poverty Level to make coverage more affordable (Henry J. Kaiser Family Foundation, 2010). Small businesses could purchase coverage through a separate exchange. This new type of health insurance marketplace will provide consumers with information to enable them to choose among plans that are designed along the lines of federal and state requirements.
New mandates for employers. Employers will be required to pay penalties for employees who receive tax credits for health insurance through the exchange, with exceptions for small employers (those with at least 2 but no more than 50 employees on average).
Changes to insurance regulation. New regulations will be imposed on all health plans that will prevent health insurers from denying coverage to people for any reason, including health status, and from charging higher premiums on the basis of health status and gender. Lifetime limits on coverage will be eliminated, and young adults will be able to remain on their parent’s health insurance until age 26.
Medicaid expansion. Medicaid will be expanded to 133% of the Federal Poverty Level (in 2009, $14,404 for an individual, $29,327 for a family of four) for all individuals age 65 or younger.
Postacute care bundling uses a single payment for all services related to a specific treatment or condition (e.g., a stroke), possibly spanning multiple providers in multiple settings (RAND Corporation, 2011). A single episode of care might include initial hospitalization; rehospitalization; postacute care; and physician and other services, such as occupational therapy.
Accountable care organizations (ACOs) are groups of providers associated with a defined population of patients that are accountable for the quality and cost of care delivered to that population. Providers could include a hospital, a group of primary care providers, specialists and, possibly, other health professionals who share responsibility for the quality and cost of care provided to patients as care is provided across multiple settings (e.g., acute care hospital, skilled nursing facility, patient home).
Medical home models focus on coordination of care and are led by a personal physician with the patient serving as the focal point of all medical activity. The medical home model promotes a team-based approach to care of a patient through a spectrum of disease states and across the various stages of life.
Recognition as an integral member of the primary care team within reform strategies such as medical homes and ACOs. To do this, occupational therapy practitioners must define our possible roles in primary care and articulate our contribution to meeting the health care needs of individuals as well as to achieving the positive outcomes these new structures will be working toward—cost effectiveness, quality care, and improved coordination.
Increased involvement in prevention and wellness activities and interventions. The PPACA includes a mandate for an annual wellness visit for Medicare patients with their physician. The visit will include a personal risk assessment (including any mental health conditions) and a review of functional ability and level of safety, including an assessment of any cognitive impairment and screening for depression (Healthcare.gov, 2011). These visits could set the stage for increased recognition of occupational therapy as an intervention to address problems and issues identified as compromising health.
Inclusion of “rehabilitation and habilitation services” as a required category in the mandatory benefits package. Occupational therapy has always been involved in providing habilitative services, but mostly through special programs like the Individuals With Disabilities Education Improvement Act of 2004 (IDEA) Part C Early Intervention Program. With expanded coverage in basic insurance, the potential for increased provision of habilitation may create opportunities for practitioners in community settings; with children and adolescents; and in the areas of self-management, participation, and full function.
Inclusion of mental health and substance abuse disorder services, including “behavioral health treatment,” as a required category in the mandatory essential benefits package. This inclusion may create opportunities for occupational therapy practitioners to provide these services, because more Americans will have access to health insurance. Occupational therapy must become part of both mental health and physical health systems to ensure integration.
Decreased direct reimbursement for services if new payment structures focus on paying for episodes of care or if the new structures focus on revenues and are not held accountable for quality and positive patient outcomes;
Exclusion from the development of key implementation strategies such as medical homes if the profession is not proactive in defining potential and actual roles and the contributions that occupational therapy can make to objectives such as cost-effectiveness, full recovery, full return to productivity, and other societal aspects of health care; and
Other disciplines establishing themselves as key players in rehabilitation, habilitation, mental health, prevention and wellness, chronic illness management, and long-term care. Our advocacy—in policy and in our daily work—must defend occupational therapy’s capabilities as we collaborate with others.
Health benefits/medical necessity
Prevention and wellness
Providing consultation and guidance to AOTA advocacy staff,
Reviewing drafts of official AOTA comments to governmental and regulatory agencies or on AOTA Official Documents, and
Developing educational materials and resources for AOTA members.
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