The Access to Care Report (#14) / Access to care under the ACA depends on insurance plan design

October 10, 2013

health-care-lawThis is #14 in a series of Access to Care Reports. (See also postings by Mitchell Law Office)

Access to health care under the Affordable Care Act (ACA) will depend on the structure of the Qualified Health Plans (QHPs) now being sold through the new Health Exchanges. The care received will often depend on which services are covered or not covered, and on the deductibles and copayments that must be paid.

As attorneys seek to help clients deal with ACA-related issues, it will be important to understand how the design of insurance policies is taking place, and how this design affects access.

Access to care depends on a combination of factors, ranging from the type of care needed by an individual to the need for acceptance by an appropriate provider. An important element of access is the ability to pay for care, both in terms of the willingness (and ability) of an individual to seek out care, and the willingness (and ability) of the selected providers to deliver the needed services. Improving the financial aspect of this access dynamic is the primary purpose of the ACA.

In turn, access also depends on the design requirements placed on QHPs. The various performance measures that are chosen, and the ways in which the QHPs are evaluated (and accredited) help shape design policy and the resultant access.

Under the ACA, each QHP must offer a set of essential health benefits (EHBs). But the limitations placed on these services will have a critical impact on access to care. Thus, access must be designed into policies.

The strategy chosen by the Department of Health and Human Services (HHS) seeks to assure a reasonable balance among  covered services through an accreditation procedure for plans.

Various evaluation measures are being applied by accrediting groups in the review process. Sample measures include the adequacy of: the provider network; prescription drug coverage; handling of diabetes complications; handling of asthma complications; call center performance; and hospitalization and rehospitalization rates. As noted here, these and many other types of data provide indicators of access and quality of care.

For example, the adequacy of the provider network determines whether an individual is able to make a timely appointment with an appropriate provider to receive the care that is needed. The coverage of prescription drugs determines whether it is feasible for a patient to follow up with treatment as directed.

Handling of diabetes complications is critical to improve the health status of those diagnosed with diabetes, while the handling of asthma events is critical to prevent medical crises for those diagnosed with asthma.

Call center performance determines whether individuals can obtain timely advice regarding medical needs.

Hospitalization and rehospitalization rates determine how effectively overall care is able to prevent acute medical needs.

These and other measures can help evaluate and accredit QHPs. Insight into the QHP measures used by accreditation groups can assist attorneys in dealing with the legal issues that involve access to care under the ACA.

More on  related ACA and access to care topics may be found in a recent book by the authors that describes implementation of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.

Previous installments of “Access to Care Reports” address the various ways in which access to care issues are affecting legal practices:

Report #1   Report #2   Report #3   Report #4   Report #5   Report #6   Report #7   Report #8   Report #9   Report #10   Report #11   Report #12  Report #13