The Obamacare Report (#15) / Does accreditation limit innovation in the ACA?

October 15, 2013

health-care-lawThis is #15 in a series of Obamacare Reports. (See also postings by Mitchell Law Office)

The accreditation process has developed over the years as a way to assure the quality and appropriateness of health care services. It may be argued that this activity has been largely successful. However, it may also be argued that the resulting system of controls sometimes places Health System organizations in “boxes” that require conformance, and may often prevent the exploration of new ideas.

Accreditation is basically a “top-down” method of control. It has sometimes been stated that this approach to managing services is necessary—because health care is so technical, and individuals are not capable of evaluating which services are appropriate and best for them.

However, individuals have often responded to this situation by seeking out alternative types of care over which they have more control.

The resultant Health Care System is very expensive, and often does not allow the flexibility that would be preferred by patients in some situations. Insurance funding for significant variations from the “approved approaches” to care is largely unavailable.

The accreditation process is designed to maintain the existing System; patient preferences for funded alternatives usually are not a consideration.

Attorneys are involved in this System both personally (as patients) and professionally (as legal representatives of individuals and organizations). They thus often are in a position to see both the strengths and weaknesses of accreditation as a controlling authority.

The new health insurance plans being sold by insurance companies under the Affordable Care Act (ACA) must all be accredited as Qualified Health Plans (QHPs) in order to be offered through the new Health Exchanges (as previously discussed). The accreditation process also is a significant factor in access to care (as also considered recently). recently).

A sort of “hardening of the arteries” of the Health Care System can result without a pathway to trying other types of insurance coverage. The result can be to slow down major changes in the System that may be needed to cope with financial pressures and public preferences in many cases.

The QHPs largely allow patient flexibility only within the accredited categories of care. Another approach to Plan design could be to allow patients to partially customize their  coverage to include alternative types of care. Insurance companies have shown substantial ingenuity in designing Medicare Advantage plans that include numerous extensions of the usual medical services covered (such as gym memberships and wellness programs).

The definitions of allowed services could become more extended, leaving room for individuals to explore these options.

In a limiting case, a QHP might be viewed as a combination of defined services and a “funding account” for other approaches to services. The insurance policy could become something like a hybrid Health Savings Account (HSA).

The objective could be to open up the process of providing health care services to include other alternatives and allow an element of decision making to rest with those facing health care issues.

Attorneys may have a critical role to play in helping create discussions about accreditation-related issues, as they represent both individuals and health care organizations, and tend to observe both the strengths and weaknesses of present accreditation strategies.

More on these and related ACA 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 “Obamacare Reports” address the various ways in which implementation of the ACA is 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   Report #14