US Healthcare System: HIPAA, HITECH and PMCs

• The chapter discusses the prospects for the U.S. health care system post-Affordable Care Act (ACA).

Current State of U.S. Health Care System

• The ACA of 2010 brought comprehensive reform to the U.S. health care system.
• The ACA maintained a mixed public and private system.
• The ACA required most U.S. citizens and legal residents to have health insurance.
• State-based American Health Benefit Exchanges were created for individuals to purchase coverage with premium and cost-sharing credits for those with incomes between 133–400% of the federal poverty level ($18,310 for a family of three in 2009).
• Separate exchanges were created for small businesses to purchase coverage.
• Penalties were imposed on employers if employees receive subsidies for health insurance through an exchange, with exceptions.
• New regulations were imposed on health plans and individual/small group markets.
• Medicaid was expanded to 133% of the federal poverty level.

Zigzag Theory of U.S. Health Care Reform

• ACA's passage was not the end of health care reform, but rather part of a zigzag pattern, with increased public-sector involvement followed by reactions to turn back or moderate this.
• The Trump administration sought to limit government and emphasized private-sector engagement.
• The Tea Party movement advocated for personal freedom, economic freedom, and a debt-free future, influencing American policy.
• Wealthy families, including the Koch brothers, the Coors brewing family, and the DeVos family, worked to change American policy.
• These groups challenged the post-WWII consensus that an activist government was a public good, advocating for limited government, lower taxes, minimal social services, and reduced industry oversight.
• Republican politicians and the Republican Party succeeded through large donations from affluent donors.
• Republicans in Congress attempted to repeal the ACA, claiming it killed jobs, raised taxes, and increased health care costs.
• The Center to Protect Patient Rights, funded by the Koch brothers, launched a campaign against the ACA, falsely claiming it was a "government takeover" of health care.
• Opponents weakened the ACA by delaying provisions such as taxes on generous health plans and health insurance providers.
• An excise tax on medical device manufacturers was suspended through 2017.
• Many states rejected Medicaid expansion, impacting the goal of full health care coverage.
• The Consumer Operated and Oriented Plan Program (CO-OP) faced challenges, with 12 of 23 ACA-funded CO-OPs collapsing due to underfunding, risk corridor program issues, deadlines, marketing restrictions, and difficulties in setting up brand new insurance companies.
• The Trump administration accelerated private-sector involvement in the health care system.
• No alternative to the ACA was passed.
• Executive actions, federal legislation, and legal actions were employed to weaken the ACA.
• Medicare exemplifies the zigzag pattern, with subsequent modifications expanding private-sector involvement after its original enactment in 1965.
• 1965: Medicare was passed, providing health care for people 65 and older, administered by CMS, and paid providers on a fee-for-service basis (traditional or original Medicare), consisting of Part A (hospital insurance) and Part B (other medical insurance).
• 1997: Medicare+Choice (Part C), now Medicare Advantage (MA), was developed as a managed care option to lower costs, with CMS providing funds to private companies to administer the plans as an alternative to traditional Medicare.
• 2003: The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Part D) was passed to assist seniors with drug costs, following the Medicare+Choice design and provided funds to private administrators.
• 2019: An executive order was issued to expand the MA Plan, making it more attractive than traditional Medicare by contracting to private companies.

U.S. Health Care System Trends

• The ACA provided a framework for health care delivery without halting change, as the U.S. system remains a mix of public and private stakeholders.
• Trends in consolidation, consumerism, technological advancement, and payment reform impact health care delivery.
• Efforts are being made to improve health care quality, efficiency, and value to patients inside and outside the ACA framework.
• Many ACA policies would likely remain even if overturned because they represent trends existing before the bill's passage.

Consolidation in the Health Care System

• Consolidation has been ongoing for the past 20 years
• In 2015, there were mega-mergers between drug companies, hospital systems, and health insurers.
• Market size increases have attracted regulatory scrutiny and calls for antitrust enforcement.
• High regional private health spending is linked to market concentration, and insurance market competition lowers premiums.
• Consolidation occurs vertically between payers and providers. horizontally with creation of provider systems, and in continuum of care.
• National payer chains, such as United, Aetna, and Blue Cross Blue Shield, dominate, along with national health care delivery chains like CHS, HCA Healthcare, and Tenet Healthcare.
• Federal regulations over state regulations, result in a trend towards nationalization of payers and providers.

Big Data and Health Information

• Electronic health records, allowing data mining to understand how genomics, environment, and behavior affect health/medical care.
• Access to data will increase emphasis on quality reporting and pay for performance, ultimately improving outcomes.
• Medical procedure evaluations and protocols will improve via new data systems with machine learning and analytics.

Prevention and Mental Health

• Mental, behavioral, and physical health are increasingly linked.
• There is focus is on prevention to control costs, connecting primary care and public health for early diagnosis.
• Health care systems are targeting population health by promoting health in populations.

Cost of Prescription Drugs Under Scrutiny

• Pharmaceutical pricing is a major issue in cost control, including inpatient care (coronary events, liver failure).

Hospital Versus Ambulatory Care

• Ambulatory, home, and community care are used more in place of inpatient services, with expanded communication and monitoring.

Consumerism

• Self-care is the most common form of health maintenance
• Control over one's health and body has strong appeal, influencing patient empowerment and consumerism.

Choosing Complementary Medicine

• Americans spend a lot of money on complementary or alternative medical care.
• Hospitals add complementary medical therapies, like acupuncture, massage, guided imagery, pet therapy, music/art therapy.
• In 2012, Americans spent $14.7B out-of-pocket on alternative health providers and $12.8 billion on natural supplements.

Impact of New Technology

• Technological innovations and policy changes are implemented to seek improvements to quality, efficiency, and cost.
• Automation is being rolled out, eliminating lower-level jobs while accelerating/supplementing jobs with new tech.
• Personalization of treatment is increasing availability through revolutionizing approaches to medicine and health.
• Emphasis on manufacturing what we used to manufacture, like body parts, implants and replacements
• Medical devices and drugs will be personalized and need to be evaluated, but the effectiveness will be based on the approach rather than the chemical.
• Shorter term technology is allowing for “site of service" optimization
• Telemedicine
• Highly-developed individualized and predictive medicine
• Common gene therapy
• Intellectual property reforms around lifesaving therapies is a goal.
• No need for hospitalization is the end-goal.

Patient Access to Medical Records

• The Health Insurance Portability and Accountability Act (HIPAA) of 1996, and the Health Information Technology for Economic and Clinical Health (HITECH) Act, a patient's right to view, download, transmit, and otherwise gain access to their medical records was passed into law and promulgated in regulations that followed
• These created the potential for third parties to assist patients or provide insights into health; to the extent that devices are empowered with patient data that meets legal requirements, they would be subject to regulation by the FDA.

Zigzag or a Private System?

• Historically, the US health care system has been a mix, with public and private players
• Since the 1980s, conservative stakeholders have pushed for increased private involvement, reducing public services.
• there is a spread "privatization creep" in health care and other sectors. Commodification of water is occurring globally
• The US may be heading toward an integrated delivery system owned primarily by large for-profit companies.

More Privatization in Health Care

• Traditionally, health care was primarily nonprofit sector
• Traditionally, health care was primarily nonprofit sector, but that is changing
• There is an increasing presence of profit-making organizations in the U.S. health care system.
• Two forms of private investment:
  • Public
  • Private equity
• Private equity investors are increasing substantially.
• Some private equity firms agressivley pursue quick profits
• Strategies
  • Take out loans using newly acquired healthcare facilities as collateral
  • Sell the health care organization's land, faciltiies and capital assets to other investors
  • To attract such a buyer, the private equity firm must boost the organization's profits, which usually requires rapidly cutting costs, raising prices, or increasing the number of services provided.
• All These strategies are aggressive, but legal

Health Care Values

• A stated obligation to ethical standards of practice is common to all health care occupations
• American Medical Association (AMA) Principles of Medical Ethics are foremost, with a goal to maintain these ethics
• Oaths and declarations of ethical conduct for all health professionals have their roots in the Hippocratic Oath.
• AMA principles:
  • Doing no harm
  • Providing competent care
  • maintaining confidentiality
  • Respect patient autonomy and primacy
  • Engage honestly
• Ethical principles of practice form one side of the social contract between society and health care.
• The ethical principles of practice form one side of the social contract between society and health care.

Health Care Values and Privatization

• Corporate ownership in the health care system-both public investor and private equity—inhibits providers caring based on ethical principles.
• A study of 1,000 physicians indicated dissatisfaction among physicians with corporate-owned practices:
  • Almost 60% reported erosion in clinical autonomy and negative changes to patient care quality as a result.
  • 47% said that practice policies or incentives frequently led them to change treatment options to reduce costs.
  • 61% said they had moderate or low autonomy to refer patients outside of their own-ownership structure/system.
  • 45% reported that ownership changes worsened their relationships with patients, with decreased visit time and communication reported as top negative impacts of ownership changes.
• Doctor dissastifaction includes:
  • Interference with provider autonomy
  • Inability to find a job
  • Imposed strict job restrictions if still dissatisfied
  • Putting profit over patient care
  • Reduced pay etc
• Senate hearings have taken place regarding the potential harm of the impact of private equity's impact on the health care system.

US healthcare is not optimum

• The US does not hit desired standards for quality, equity and efficiency
• US Healthcare performs near the bottom compared to peer nations
• Other nations have healthcare that primary care emphasize
• It has potential to improve US healthcare by simply applying the imaginations and tenacity

This lesson covers US healthcare system topics including HIPAA, HITECH, and the role of private military companies. It explores patient data access, healthcare models, and the impact of legislation on healthcare delivery. Additionally, it touches on the regulation of health-related smartphone apps.