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By Charu Raheja, PhD
There has been a lot of debate about the new Affordable Care Act. This article explains the new law, its goal, and its impact on various groups. In a nutshell, the new law creates a nationwide health insurance system to help all Americans get coverage. The government will subsidize the new insurance coverage by expanding its Medicaid program to individuals who can’t afford insurance. It also provides subsidies to some businesses for insuring their workers. The goal is to extend insurance to more than 30 million people who are currently uninsured, thus sharply reducing the number of Americans without coverage.
What exactly is the new law intended to do and how will it work?
There are two basic parts to the Affordable Care Act:
1. It will create insurance exchanges for those buying individual policies and it will prohibit insurers from denying coverage on the basis of pre-existing conditions. These insurance exchanges are going to make it much easier to compare different insurance companies, allowing individuals to easily shop for and buy an insurance plan.
2. At the same time, the federal government is going to provide subsidies to help lower and middle-income Americans buy private coverage.
One concern has been that the new plan is going to be very expensive for the government and for insurance companies. To help manage the costs, the plan creates a panel of experts to limit government reimbursement to only those treatments shown to be effective, and it creates incentives for providers to “bundle” services rather than charge by individual procedure.
A second concern is that many healthy individuals will not buy insurance even with the subsidy. If this happens, it will be very expensive for the insurance companies because only the very sick are going to get new insurance, which will cause the cost per person to go up. To fix this problem, the federal government is proposing a tax penalty on individuals who do not buy insurance. This new law is to take effect in 2015, and it essentially creates a tax on individuals who don’t buy insurance.
How does the law affect health care providers and nurse triage?
Providers and medical groups serving Medicaid insured patients are going to see an expansion in their Medicaid population since more people are now going to have insurance.
This can be a good thing, but at the same time there are some significant provisions and limitations on reimbursements.
First, the Affordable Care Act provides incentives to bundle services, meaning less reimbursement for individual procedures.
Second, providers will earn a bonus or take a pay cut depending on whether they come under or exceed a cost target. Therefore, they will need to look for ways to decrease unnecessary health care expenses to prevent potential financial constraints. Nurse triage will be an important first step to ensure that the right patients get the right level of care at the right time.
Providers and accountable care organizations will either make or lose money depending on whether or not they can prevent unnecessary use of medical resources. Nurse triage systems help ensure that patients get their questions answered without having to go to emergency rooms or even see their doctors unnecessarily. Based on our studies, about 70% of patients who believe that they need emergency care do not in fact need to go to an ER. That means, that out of 100 people in an emergency room, over half of them do not need to be there.