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Appendix B: The Patient Protection and Affordable Care Act: Opportunities for Public Health Agencies and Population Health--Sara Rosenbaum
Pages 129-152

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From page 129...
... No single section of the ACA holds all of the population health elements of the law; instead, the goal of improved health for all Americans pervades the legislation through an exceptionally wide range of strategies. Some of these strategies are aimed at infusing a greater prevention orientation into health care itself.
From page 130...
... The first is Community Transformation Grants. The second is the community benefit reforms to the Internal Revenue Code that apply to nonprofit hospitals that seek federal tax exempt status and that have implications for state tax exempt policy as well.
From page 131...
... Under the ACA, certain clinical preventive services without cost-sharing must be made available on a population-wide basis.4 Furthermore, embedded in the definition of "essential health benefits" -- which will define the scope of coverage in the individual and small group market, as well as for newly eligible Medicaid beneficiaries -- is a strengthened orientation toward coverage for the management of serious conditions associated with health disparities (see Box B-1)
From page 132...
... How states design their exchanges, how exchanges are governed, the ground rules set by states for qualified health plans, and the steps states take to prevent adverse selection against the exchange market will determine the quality and affordability of coverage for low- and moderate-income families as well as small employers. In short, establishing and operating an exchange raises a broad array of policy considerations for public health agencies.
From page 133...
... Public health agencies also will be important sources of technical support for exchange regulatory and oversight operations, particularly in the design of qualified health plan certification standards, standards governing exchange navigator programs, the identification of key population health issues of special importance to an exchange when evaluating the capabilities of qualified plans, and the analysis of performance data across multiple plans. Certification Standards for Qualified Health Plans Exchanges may make health plans available only if certified as "qualified health plans" (PPACA §1311[d]
From page 134...
... .) State Benefit Mandates Under the ACA, states may require qualified health plans to offer benefits required under state benefit mandates that fall outside of the federal 7Federal law defines essential community providers as providers that serve "predominantly" low-income medically underserved individuals and requires the secretary, in implementing rules, to establish basic network inclusion standards.
From page 135...
... and yet are of sufficient importance to merit coverage and additional supplementation as a population health matter. Given their preventive and chronic care expertise, as well as their knowledge of health disparities, public health agencies bring important expertise to bear on the question of whether certain additional state benefits should be incorporated into qualified health plan benefit design.
From page 136...
... Similarly, health agencies possess expertise in assuring that health information is presented in a culturally appropriate manner and with due consideration regarding consumers' level of health literacy. Health Plan Network Adequacy and Use of Essential Community Providers Qualified health plans must be able to demonstrate the accessibility of their provider networks as well as their use of essential community providers (in accordance with federal standards that will govern the inclusion of such providers in plan networks)
From page 137...
... However, anecdotal evidence suggests that important preventive procedures and immunization services may be lacking in some states. Upgrading Medicaid preventive services for adults is an area in which public health agencies might play an important technical support role, evaluating existing coverage and payment practices within their states, proposing modifications and prioritization recommended, and recommending the use of modified clinical practice guidelines in the case of patients at risk for medical underservice (for example, allowing payment for preventive services furnished in certain community settings such as group homes for persons with mental disabilities)
From page 138...
... Health departments might also carry out data collection activities for Medicaid agencies aimed at documenting participation by women, adherence of providers to prescribed treatment regimens and guidelines, and measuring and linking participation to health outcomes through vital statistics data. Incentives for Preventing Chronic Disease The ACA authorizes the secretary of HHS to award grants to states to develop chronic disease initiatives for Medicaid beneficiaries (ACA §4108)
From page 139...
... Benefits under this option consist of family planning services and supplies (for which the special family planning 90 percent federal payment rate is available) as well as "family planning related services," which consist of diagnosis and treatment services that are provided pursuant to a family planning service and in a family planning setting.
From page 140...
... A public health agency might collaborate with a Medicaid agency in numerous ways: the development and submission of the state plan option, the design of the special benefit package, the identification of family planning providers that might participate in an expanded program, outreach to eligible populations and enrollment,14 the dissemination of practice guidelines, the performance measurement and monitoring, the design of payment incentives to promote evidence-driven practices, and the collection and publication of performance information and information on health outcomes. Patient Safety, Health Care Quality, and Population Access The ACA contains extensive provisions aimed at nudging the health care system toward prevention and efficiency.
From page 141...
... Agencies could seek to establish themselves as a multipayer source of information on best practices in patient safety and system transformation, playing a type of clearinghouse and technical support function for both public and private payers and community health practices. Health agencies might receive financial support from state Medicaid agencies to provide assistance to clinicians transitioning to the adoption of health information technology (HIT)
From page 142...
... Of particular importance in resolving issues of access, quality, safety, efficiency, and system transparency for medically underserved populations will be public health agency leadership and collaboration with entities that share their broad mission: community health centers; public hospitals; family planning agencies; teaching health centers created by the ACA and eligible for grants and subsidies to train primary health care professionals in community settings (PPACA §5508) 17; and nonprofit hospitals with community benefit obligations (discussed at greater length below)
From page 143...
... In sum, public health agencies are positioned to play a central role in the translation of health system reform and patient safety into integrated delivery systems serving medically underserved populations. COMMUNITY TRANSFORMATION GRANTS AND TAX-EXEMPT HOSPITAL POLICY Two population health-related reforms are of special interest because of their potential to yield important investments in broader population health activities.
From page 144...
... . Together, the CTG program and its National Network companion share a set of simple yet profound purposes • T o launch multiple interventions whose goal is to make fundamen tal improvements in population health, • T o lessen the burden on the health care system while achieving its central involvement in the effort, • T o develop a new approach to the collection and use of public health information in order to bring an immediacy and action ori entation to longstanding surveillance practices, and 18Under the statute, worksite wellness promotion activities also are identified, but this is not listed as a CDC priority (42 USC §300g-13[c]
From page 145...
... As with the CMMI, the CTG program has been conceptualized as an incubator whose sum is larger than its parts. The CMMI is structured to stimulate transformational activities on a multipayer basis; similarly, the CTG program is intended to stimulate multisector population health investments that take direct aim at the risk factors most responsible for death and disability in the United States: weight, poor nutrition, inadequate physical activity, use of tobacco, and emotional well-being and mental health.
From page 146...
... ) establishes the legal standard for determining whether nonprofit hospitals will be treated as tax-exempt for federal income tax purposes.
From page 147...
... Prodded by Congress, the IRS conducted an assessment and noted in a 2009 report that there existed "considerable diversity" in hospitals' community benefit activities. In 2008, the IRS required nonprofit hospitals to file supplemental information describing their community benefit-related spending (IRS, 2007)
From page 148...
... . Of greatest interest in the context of this analysis, however, is the obligation to undertake a community health needs assessment and adopt an implementation strategy that grows out of the needs assessment process.
From page 149...
... is tasked with reviewing the community benefit standard "at least once every 3 years" to ensure compliance (PL 111-146 §9007)
From page 150...
... This cycle obviously takes money: money to convene stakeholders, assess community need, and reach consensus; money to plan and design the intervention; pilot funding to launch innovations such as worksite wellness programs, accessible clinical preventive services in targeted communities and neighborhoods, safer and attractive destination points for active living, new approaches to healthier nutrition such as community and school food gardens, and services that promote emotional and mental health; and money to support evaluation, diffusion, and public health policy translation. The challenge for public health agencies is to rapidly put these tools to work, both the funds that are clearly and directly earmarked for public health activities through the CTG program, as well as the resources that are held in trust by hospitals on their communities' behalf.
From page 151...
... 2008. Nonprofit Hospitals: Variation in Standards and Guidance Limits Comparison of How Hospitals Meet Community Benefit Require ments.
From page 152...
... 2011b. A Profile of Health Insurance Exchange Enrollees.


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