America’s healthcare system is often described as a patchwork: a mix of public programs, private insurance, and stopgap laws meant to catch people before they fall through the cracks. But what happens when several of those safety nets are weakened or removed all at once?

It was nice while it lasted – due to a provision of the Patient Protection and Affordable Care Act (“ACA”), services furnished by certain primary care providers (“PCPs”) were subject to an enhanced payment rate for Calendar Years 2013 and 2014. These PCPs had to have (a) been Board certified in the specialty designation of family medicine, general internal medicine or pediatric medicine or have a subspecialty designation recognized by specific boards or associations, or (b) furnished more than 60% of claims in specific evaluation and management or vaccine administration services under certain codes to have been eligible for these enhanced payments.[1] The payments were raised to the level of the Medicare Part B fee schedule rate (unless the actual billed charge for the service was lower), and providers had until April 1, 2013 to self-attest to being eligible.[2] The increase applied to both fee-for-service and managed care Medicaid plans.

The first part of this article discussed pharmacist provider status and argument both for and against it. Today’s post now turns to regulatory hurdles, developments towards provider status and the acknowledgment of changing roles in the pharmacist workforce.

While the passage of the Patient Protection and Affordable Care Act (“ACA”) ushered in a new era of access to health care, it only served to exacerbate a growing crisis in the provision of health care – lack of providers. As of April 2015, the Health Resources and Services Administration lists the population of the United States that lives within a health professional shortage area (“HPSA”) for primary care as 103,847,716, with 1,023,989 of those living in Kentucky.[1] This shortage calls for a reimagining of ways that non-physician providers can fill the care gap, and the debate surrounding the provider status of pharmacists with regard to federal health care programs is evidence of a changing mindset.

In the last days of 2014, the IRS released regulations that finalized the compliance requirements for charitable hospitals. These new 2014 IRS regulations relate to the Community Health Needs Assessment (CHNA or needs assessment) requirements for nonprofit hospitals or nonprofit organizations operating a hospital contained in Section 501(r) of the tax code, which was created by the Patient Portability and Affordable Care Act (“ACA”). Section 501(r) requires that thorough CHNAs be conducted every three years in order to maintain their 501(c)(3) nonprofit status. These needs assessments must define the community served by the hospital, the needs of the community, and a strategy addressing the identified community needs. Since each facility that fails to meet CHNA requirements loses its nonprofit status and has to pay a $50,000 excise tax, nonprofit hospitals and networks need to pay special attention to the changes and incorporate these new requirements into their needs assessments.

In 2012, thirty-two organizations were selected to participate as “Pioneers” in a pilot Accountable Care Organization (“ACO”) program created through the Affordable Care Act (“ACA”).  The program’s goals were to revolutionize the health system and reduce medical costs by basing physician and hospital pay on quality rather than quantity.

Compliance and preparedness are two very real, everyday concerns for long-term care facilities. Not only are these important aspects of daily operations for the safety of the employees and patients, they are paramount because any day a visitor from the Office of the Inspector General (OIG”) or Occupational Safety and Health Administration (“OSHA”) could show up for an inspection.  Is your facility prepared?

The Office of the Inspector General (“OIG”) has always encouraged Medicare and Medicaid providers to implement a compliance program. For 14 years, as a matter of fact, OIG has provided compliance guidance in 11 healthcare sectors (including: hospitals, nursing facilities, home healthcare, hospice and third-party billers). With the passing of the Patient Protection and Affordable Care Act (“PPACA”), compliance plans and programs are now mandatory for any provider enrolled in a Federal health care program, including Medicare.

The mandatory expansion of Medicaid was an important element of the Affordable Care Act as providing health care benefits to uninsured was intended to achieve equity.  The expansion of Medicaid rolls was also intended to reduce the cost of providing care for the uninsured and the need for disproportionate share hospital funding, which is an adjustment to account for the needs of hospitals serving a large number of low-income patients.  With the ability to opt out of the Affordable Care Act’s expansion of Medicaid eligibility (read more: The Federal Medicaid Apple:  Poison or the Cure?), the opt-out states may create financial problems for hospitals that depend on disproportionate share payments to cover part of their costs for providing non-reimbursed services to the indigent and uninsured.  The Affordable Care Act’s decrease in disproportionate share payments to hospitals is not changed by the Supreme Court’s ruling.

As the uncertainty about healthcare reform was extinguished by the Supreme Court in its 5-4 decision upholding the Affordable Care Act, with the provision that the Department of Health and Human Services may not withhold Medicaid funding from states that refuse to adopt the Medicaid expansion, all states, including Kentucky, now have important decisions to make about expansion of Medicaid to a projected 22.3 million uninsured eligible individuals.  Under the Affordable Care Act, the federal government will pay the full cost of covering the newly eligible Medicaid participants for three years from 2014 to 2016.  Thereafter the federal share will gradually decline until it reaches 90% in 2020.  For traditional Medicaid, the federal government now pays, on average, about 57% of a state’s total Medicaid costs.  With 826,941 Kentucky Medicaid beneficiaries in January 2012, and an additional 290,000 individuals that would be covered under the expansion, Governor Steve Beshear has announced that he is studying the issues and the costs.