TMA's Health System Reform Executive Summary

Health System Reform - Important Points and Items

Congress has passed and President Obama has signed the Patient Protection and Affordable Care Act to reform the nation's health care system.

"The health system reform bill is now law," then TMA President William H. Fleming III, MD, said after the president signed the bill. "While the legal and political wrangling will go on for years, the physicians of Texas remain committed to our patients. We want to keep what's good and fix what's broken in our health care system.

"Frankly, we cannot allow our political views or the new law to get in the way of what medical care is all about: physicians caring for our patients. Patients and their doctors must work together to take advantage of this change. We cannot waste this opportunity to improve the access and care we provide to our patients."

TMA's experts analyzed the bill and prepared this analysis of what the bill does and does not do. The main thing it does not do is eliminate the Sustainable Growth Rate (SGR) formula that determines Medicare payments to physicians. Congress must stop temporarily delaying fee cuts and permanently fix the foundation of the Medicare system before adding a new health care system for 30 million people on top of it.

"We need more than Band-Aids," Dr. Fleming said in TMA's open letter to Congress. "We need more than sutures. We need a complete transplant. This is all about Medicare patients' access to physicians' care. Congress created this problem, and only Congress can fix it."

You can help persuade Congress to establish a fair Medicare payment system by signing TMA's petition urging Congress to abolish the SGR formula and preserve senior citizens' access to care.

Sign the petition online at  www.ipetitions.com/petition/meltdown/ .

Top of page  

 Here is a quick summary of the health system reform bill. 

Insurance Reforms  

  • Additional consumer information on benefits;
  • Uniform standards for electronic transactions between plans and physicians; and
  • Penalties for employers failing to enroll employees for insurance coverage.

High-Risk Pool  

  • 90 days after enactment, establishes a national high-risk pool to provide coverage for previously uninsured individuals with preexisting conditions.  The pool will be phased out in 2014 as the health insurance exchanges become operational.

Expansion of Medicaid and CHIP  

  • Effective immediately, prevents states from reducing eligibility levels for patients on Medicaid and the Children's Health Insurance Program (CHIP);
  • In 2013 and 2014, increases Medicaid payments to Medicare parity for defined primary care services;
  • Beginning in 2014, extends Medicaid coverage to children and adults up to 133 percent of poverty (about 1.2 million newly eligible);
  • In 2014, requires states to offer simplified and single eligibility process; and
  • Extends funding of CHIP through 2015.

Quality Development and Reporting  

  • The U.S. Department of Health and Human Services will develop a national quality strategy;
  • Data on physicians will be made public on the Internet with limited review on quality criteria used or accuracy;
  • Individual physician reports comparing them to colleagues supposed to be available by 2012;
  • Payment cuts to physicians in 2017 that are utilizing higher than average Medicare resources on patients;
  • Movement away from fee-for-service to salary-based payment model; and
  • Allows nurse practitioners, pharmacists, and others to practice independently from physicians (if state law allows).

Payment  

  • No SGR fix;
  • Establishes Independent Medicare Advisory Board for the purpose of reducing the per-capita rate of growth and a net reduction in total Medicare spending;
  • Voluntary Medicare Physician Quality Reporting Initiative (PQRI) reporting system, which has significant bugs, is going to morph into a pay-for-performance system by 2015;
  • Provides 10-percent bonus payment to certain primary care practitioners and surgeons; and
  • Fraud provisions of the Office of HHS  General expanded greatly, including expansion of Medicare Recovery Audit Contractors; limited process for physicians to respond or deal with allegations of fraud without facing payment holds; proactive duty and responsibility for physicians to report overpayments (even without actual knowledge) or face severe penalties.

Other  

  • Severe restrictions on physician ownership of hospitals, and
  • Limited provisions on medical liability (only pilots for states to pursue noncap alternatives) and no clarification that quality standards are not used as legal standards.

Top of page  

Here is a more detailed breakdown of the bill. 

Insurance  

Group and individual health plans may not establish lifetime maximum benefits in terms of dollar limitation on any enrolled person.

Essential health benefits include:

  • Ambulatory patient services,
  • Emergency services,
  • Hospitalization,
  • Maternity and newborn care,
  • Mental health and substance abuse disorders,
  • Prescription drugs,
  • Rehabilitative and habilitative services and devices,
  • Laboratory services,
  • Preventive and wellness services and chronic disease management, and
  • Pediatric services including oral and vision care.

 A group or individual health benefit insurer may not rescind a health benefit plan, except when a covered person has committed fraud or intentionally misrepresented a material fact as described in the plan.

A group and individual health plan must provide coverage for, and without cost-share requirements for:

  • Those preventive services that have an "A" or "B" rating in current recommendations of the U.S. Preventive Services Task Force,
  • Recommended immunizations, and
  • Preventive care for women and children.

Within 12 months from enactment of the bill, the U.S. Department of Health and Human Service (HHS) must develop standards for insurers to follow in giving enrollees summaries of benefits and coverage explanations that accurately describe the coverage provided.

Starting in 2013, there will be a 40-percent tax on employer-provided tax-excluded health benefits that exceed $8,500 for employee coverage or $23,000 for family plans. Plan cost includes employer and employee share including contributions to health savings or reimbursement accounts including flexible spending accounts, health savings accounts, and health reimbursement arrangements. Employers are required to disclose the value of all tax-excluded health benefits on employees' W-2 forms.

All health plans are required to disclose the information required in section 1311(e) (regarding transparency in coverage for plans participating in the exchange), such as claims payment policies, financial information, and rating practices.

The HHS secretary is required within two years from enactment of the bill, and with the help of stakeholders, to develop reporting guidelines for health plans on benefits and provider payment structures that:

  • Improve health outcomes through implementing quality reporting, case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model;
  • Implement activities to prevent readmission into hospitals through discharge planning and post-discharge reinforcement;
  • Implement activities to improve patient safety and reduce medical errors; and
  • Implement wellness and health promotion.

Health insurers must report to HHS, which will post on a website:

  • Amount of premium revenue spent on clinical services;
  • Activities to improve quality; and
  • The nature of other nonclaims costs.

The health plan must provide an annual rebate check to each enrollee, on a pro-rata basis, if the insurer loss-ratio is less than:

  • 85 percent for a large-group market, and
  • 80 percent for a small-group or individual market.

Health plans must implement an appeals process for adverse determinations of enrollees' issues. 

HHS, in conjunction with the states, shall establish a process for the annual review of unreasonable increases in premiums, beginning with the 2010 plan year.

Medical Reimbursement Data Centers are established to:

  • Develop fee schedules that reflect market rates for medical services and geographic differences in those rates, and update to reflect changes; and
  • Make data available on an Internet website and regularly publish information concerning the methodology.

HHS shall establish a temporary high-risk pool program to provide health coverage for eligible individuals. 

HHS shall establish a temporary reinsurance program for eligible retirees and their dependents ages 55-64.

State and federal governments must reach out to consumers through the Internet to inform them of affordable insurance options. 

HHS must adopt uniform standards and operating rules for electronic transactions that occur between providers and health plans that are governed under HIPAA. Among the items to be standardized are:

  • Benefit eligibility verification,
  • Prior authorization, and
  • Electronic funds transfer payments.

Premium rates can vary only by individual or family coverage, rating area, age, or tobacco use. The preexisting condition prohibition for children is in effect immediately. There is controversy over the effective date, and the administration has announced it will issue rules to clarify. The law also requires guaranteed offer of coverage and guaranteed renewal. Any waiting period imposed by the coverage may not exceed 90 days. Also, certain essential benefits must be provided. 

An insurer cannot exclude a nonphysician practitioner (or a physician) from participation solely based on the type of health care license held by the practitioner.

Annual cost-sharing requirements shall be limited to a certain amount. 

Insurers may not refuse to cover costs for routine patient care, which include all items and services consistent with the coverage provided in the plan (or coverage) that is typically covered for a qualified individual who is not enrolled in a clinical trial. 

Any state standard or requirement must apply uniformly to all health plans in each insurance market to which the standard applies.

Only qualified health plans may offer coverage on a state health exchange. ERISA self-funded plans and multiple employer welfare arrangements do not fall under the term "health plan."

States are required to develop American Health Benefit Insurance Exchanges no later than Jan. 1, 2014, to help small employers (up to 100 employees) purchase health coverage and be self-sustaining beginning on Jan. 1, 2015. This includes allowing the exchange to charge assessments or user fees to participating health insurance issuers or to otherwise generate funding to support its operations.

Individuals, on request, shall receive from their health plans the "amount of cost share" they will be responsible for paying with respect to specific items or services by a participating provider. At a minimum, this shall be available through a website.

Federal employee health benefit plans are not required to participate in exchanges.

The HHS secretary shall develop a national quality strategy that includes priorities to improve the delivery of health care services, patient health outcomes, and population health. It creates processes for the development of quality measures involving input from multiple stakeholders and for selecting quality measures to be used in reporting to and payment under federal health programs.

A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the individual market, including those enrollees who do not enroll in such plans through the exchange, to be members of a single risk pool.

If a state is not an electing state, or if the secretary determines, on or before Jan.1, 2013, that an electing state will not have an exchange operational by Jan. 1, 2014, or has not taken the actions the HHS secretary determines necessary to implement it, the HHS secretary shall (directly or through agreement with a not-for-profit entity) establish and operate such exchange within the state, and the HHS secretary shall take such actions as are necessary to implement such other requirements.

The HHS secretary shall establish a program to carry out the Consumer Operated and Oriented Plan (CO-OP) program. The purpose of the CO-OP is to foster creation of qualified nonprofit health insurance issuers to offer qualified health plans in the individual and small-group markets in the states in which the issuers are licensed to offer such plans.

The comptroller general of the General Accountability Office shall conduct an ongoing study on competition and market concentration in the health insurance market in the United States after the implementation of the reforms in such market under the provisions of, and the amendments made by, this act.

The HHS secretary shall establish a community health insurance option to offer, through the exchanges (other than exchanges in states that elect to opt out), health care coverage that provides value, choice, competition, and stability of affordable, high-quality coverage throughout the United States. Individuals enrolled in community health insurance options are NOT prohibited from paying out-of-pocket the full cost of any item or service not included as an essential health benefit or otherwise covered as a benefit by a health plan.

No later than July 1, 2013, the HHS secretary shall, in consultation with the National Association of Insurance Commissioners, issue regulations for creating health care choice compacts under which two or more states may enter into an agreement. The HHS secretary shall mandate the method by which individuals will be identified as high-risk individuals for purposes of the reinsurance program. The method must include a list of at least 50, but not more than 100, medical conditions that are identified as high-risk conditions.

The law provides a tax credit for small employers with fewer than 25 full-time equivalent employees and average annual compensation levels not exceeding $50,000 who provide health care benefits and pay at least half of the premium cost. The credit phases out with increased employer size and higher employee compensation.

Employers with more than 200 employees must automatically enroll employees in their group plans. There will be fines on employers with more than 50 full-time employees if the employer does not provide minimum essential coverage, or imposes waiting periods of more than 60 days, and its employees enroll in exchange-provided plans using federal tax credits or cost-sharing assistance. The fines can be up to $3,000 per employee who obtains exchange coverage, but is capped at $750 per total number of employees. 

Flexible spending account contributions are limited to $2,500 starting in 2011, with annual inflation adjustments in subsequent years.

The law limits the amounts charged for emergency or other medically necessary care provided to individuals eligible under their written financial assistance policy to not more than the average amount charged to individuals who have insurance covering such care. Hospitals are prohibited from taking extraordinary collection actions against a patient until the hospital has made reasonable efforts to determine whether the patient is eligible for financial assistance.

Blue Cross or Blue Shield organizations or other nonprofit organizations that provide health insurance must maintain a medical loss ratio of at least 85 percent to be eligible for special tax benefits currently provided to such organizations.

Top of page  

 Medicare 

Medicare Advantage (MA) plan payments will be reduced, starting in 2011. MA plan bonus programs based on measures of clinical quality and enrollee satisfaction will be implemented, and there are financial penalties if medical loss ratio falls below 85 percent starting in 2014.

Prescription drug plan (PDP) sponsors must include all covered Part D drugs, but they may limit access to such drugs through prior authorization or utilization management rules. PDPs must utilize specific, uniform dispensing techniques, such as weekly, daily, or automated dose dispensing, when dispensing covered Part D drugs to enrollees who reside in long-term care facilities to reduce waste associated with 30-day fills. A single, uniform exception and appeals process for the determination of prescription drug coverage for enrollees under PDPs and MA-PD plans is required. The initial coverage limit was increased by $500 for the plan year beginning Jan 1, 2010. Procedures must be established that may include a reconciliation process to fully reimburse PDPs and MA-PDs for reductions in beneficiary cost sharing. 

The 2010 income thresholds for Part B premiums for the period January 2011 through December 2019 is continued.

The law establishes an Independent Payment Advisory Board to reduce the per-capita rate of growth in Medicare spending. Recommendations must result in a net reduction in total Medicare spending.  

No later than Jan. 1, 2012, the HHS secretary must establish a shared savings program that promotes accountability for a patient population and coordinates items and services under Medicare parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery.

For a limited subset of states with sparse populations - North Dakota, South Dakota, Utah, Montana, and Wyoming (Texas does not qualify) - the law creates a floor on Medicare payment adjustments in relation to the practice expense index. Budget neutrality is waived. 

The law requires Medicare additional incentive payments of 10 percent of payment amount for service to certain:

  • Primary care practitioners (as defined in this section) providing primary care services on or after Jan. 1, 2011, and before Jan. 1, 2016; and
  • General surgeons performing major surgical procedures on or after Jan. 1, 2011, and before Jan. 1, 2016, in a health professional shortage area.

The HHS secretary may revoke enrollment (of not more than 1 year for each act) for a physician or supplier that fails to maintain and provide access to documentation relating to written orders or requests for payment for durable medical equipment, certifications for home health services, or referrals for other items or services written.  

The law requires a face-to-face encounter with a patient prior to certification of home health services, and allows for a face-to-face encounter with a physician, physician assistant, nurse practitioner, or clinical nurse specialist before certification of durable medical equipment.

Top of page  

Medicaid 

Starting in 2014, Medicaid for children and adults under age 65 is expanded to 133 percent of the federal poverty level, including childless adults. Currently, Texas covers working parents up to 20 percent of the federal poverty level and up to 13 percent of poverty for nonworking parents (those on the Temporary Assistance for Needy Families program). Childless, healthy adults are not currently eligible. States will have the option to expand coverage to adults. As in current law, undocumented immigrants are not covered except in an emergency. (Note, children with incomes at or below 133 percent of poverty who are now enrolled in CHIP will be transitioned to Medicaid in 2014). The vast majority of the costs of expansion will be paid by the federal government. In the first three years, Texas will receive a 90-percent federal matching rate (compared with 60 percent currently). Subsequently, federal funding will gradually decline to a 90-percent matching rate by 2020. 

The state of Louisiana, as a state where the president has declared a major disaster, may receive, according to estimates, at least $1 million in Medicaid subsidies as estimated by the Congressional Budget Office. 

In 2013 and 2014, the federal government will provide 100-percent funding to increase Medicaid payments to Medicare parity for primary care services provided by family physicians, pediatricians, and general internists. Primary care services are defined as evaluation and management codes and vaccine administration. Law does not increase payments for CHIP.

States must maintain current CHIP eligibility until October 2019. The law maintains current rules regarding CHIP benefits and cost sharing. It increases the federal CHIP matching rate by 23 percent for each state up to a cap of 100 percent. If federal allotments for CHIP are insufficient and result in states establishing waiting lists, the law specifies that the children will be eligible for subsidies under the health care exchange. The provision is effective immediately.

The law establishes funding for the Medicaid and CHIP Payment and Access Commission (MACPAC), which is modeled on the Medicare Payment Advisory Commission. The entity, which already has been appointed, will evaluate Medicaid and CHIP payment and regulatory policies that undermine Medicaid and CHIP patients' ability to obtain timely health care services. MACPAC and MEDPAC must consult with each other on issues of mutual concern.

States must simplify Medicaid enrollment, including the ability to apply and reapply electronically, and must establish a coordinated, single web-based pathway for people simultaneously to apply for coverage and be screened for eligibility for coverage available through the health care exchange, Medicaid, or CHIP. This is effective in 2014.

The law provides for a single eligibility determination process for an exchange that automatically notifies individuals of eligibility for Medicaid or CHIP.

Medicaid disproportionate share payments to hospitals are reduced by $18 billion between 2014 and 2020.

The law requires all state Medicaid programs to provide coverage of comprehensive tobacco cessation services for pregnant women (effective fiscal year 2011). Texas currently covers most tobacco cessation prescription drugs, but not counseling.

The law prohibits Medicaid payments for hospital-acquired conditions as determined by the HHS secretary. It requires the HHS secretary to identify state-based initiatives to deny payments for hospital-acquired conditions and to incorporate the best practices that are applicable to Medicaid into federal regulations.

Top of page  

 Reimbursement 

The Recovery Audit Contractor program is expanded to Medicaid, and Medicare Parts C and D. The state will contract with recovery audit contractors for recouping overpayments under the state plan or waiver.

A state agency is required to exclude any individual or entity from participating in the program under the state plan, if such individual or entity owns, controls or manages an entity that has unpaid overpayments, is suspended or excluded from participation under this title, or is affiliated with an individual or entity that has been suspended or excluded from participation under this title.

The HHS Office of Inspector General may obtain information from any provider, or others who directly or indirectly order, provide, manufacture, or prescribe items or services payable by any federal health care program, including documents necessary to validate claims such as a prescribing physician's medical records. The HHS secretary may suspend payments to a provider or supplier pending an investigation of a credible allegation of fraud against the provider or supplier. Physicians have a duty to report and return overpayments. The law is modified such that a person need not have actual knowledge of this section or specific intent to commit a violation of this section in order to be found in violation.

The HHS secretary shall maintain a national health care fraud and abuse data collection program for the reporting of final adverse actions against health care providers and suppliers, and such information will be furnished to the National Practitioner Data Bank. 

Effective for claims filed on or after Oct. 1, 2010, states will use compatible methodologies of the national Correct Coding Initiative and such other methodologies.

A new bundled payment pilot in up to eight states to integrate payment for services in a hospital and concurrent physician services is authorized. The HHS secretary is required to ensure that payments are adjusted for severity of illness and other characteristics, among other requirements.

The current 2010 incentive payment for satisfactorily reporting PQRI measures is 2 percent. In 2011, the incentive payment drops to 1 percent, and for 2012, 2013 and 2014, the incentive payment drops to 0.5 percent. In 2015 a penalty of -1.5 percent will be applied to eligible professionals who did not satisfactorily report, and in 2016, and forward; a -2.0 percent penalty will be assessed. Feedback to eligible professionals on their reporting performance must happen in a timely fashion. A Physician Compare Internet site will be created and will use PQRI measures, assessments of outcomes, episodes of care and risk-adjusted resource use, efficiency measures, patient satisfaction and family engagement measures, an assessment of the safety and effectiveness of care, and any other information the secretary shall determine appropriate. The plan must permit a physician to "review" his or her results before they are made public. The program must ensure an accurate portrayal of a physician's performance, reflect the care "provided to all patients" in Medicare and "other payers."

Episode groupers (combines separate but clinically related items and services into an episode of care for an individual) will be developed by Jan. 1, 2012. Details of the episode groupers will be made public. In addition, reports comparing patterns of resource use of individual physicians with patterns of other physicians will be made available in 2012. Adjustments to the reports will be made to account for differences in socioeconomic and demographic characteristics, ethnicity, and health status of individuals. The methodology will be made available to the public. The law does not allow for administrative or judicial review.

Payment modifiers will be developed for differential payment under the physician fee schedule based on quality of care compared with cost. The value-based payment adjustment is intended to cut payments to physicians whose patients are incurring higher-than-average Medicare cost unless the physician's patient population rates equally high in the available quality measures. Conversely, it will provide payment increases to physicians when measured quality is high and Medicare cost is low. The payment modifier will be used for all physicians beginning Jan. 1. 2017. Special circumstances for physicians in rural areas and underserved communities will be taken into consideration. No administrative or judicial review is provided.

The HHS secretary is directed to establish a pilot program for integrated care (involving payment bundling) for an episode of care provided to an applicable beneficiary around a hospitalization in order to improve the coordination, quality, and efficiency of health care services. An episode of care includes three days before the admission to a hospital for an applicable condition, the length of stay in a hospital, and 30 days after the patient is discharged.

The HHS secretary shall conduct a demonstration program to test a payment incentive and service delivery model that utilizes physician- and nurse-practitioner-directed, home-based primary care teams designed to reduce expenditures and improve health outcomes.

The Deficit Reduction Act of 2005 is amended to extend gainsharing demonstration projects. Such projects test and evaluate methodologies and arrangements between hospitals and physicians designed to govern the utilization of inpatient hospital resources and physician work to improve the quality and efficiency of care provided to Medicare beneficiaries through FY 2011.

The law extends the work Geographic Practice Cost Indices (GPCI) floor, which expired on Jan. 1, 1010, through 2010. This change to the GPCI and its effect on fees is retroactive to Jan 1, 2010: 

Austin 0.8 percent
Beaumont 3.8 percent
Brazoria 1.7 percent
Fort Worth 1.2 percent
Galveston 1.4 percent
Houston 0.3 percent
Rest of Texas 4.6 percent

This provides a small (2-3 percent) fee increase for physicians in the "Rest of Texas" payment area and negligible changes for other areas.

A process for the Centers for Medicare & Medicaid Services (CMS) to revise relative values independently from the AMA Relative Value Update Committees work is established. It allows CMS to commission their own studies, employ contractors, and gather data independently. 

Beginning Jan. 1, 2015, a qualified health plan may contract with a hospital with more than 50 beds only if such hospital utilizes a patient safety evaluation system  and implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge.

Top of page  

Quality of Care 

The law establishes a nonprofit corporation, not a governmental agency, to provide independent comparative effectiveness research that evaluates and compares health outcomes and clinical effectiveness, risks, and benefits of two or more medical treatments or services. The corporation shall not develop or employ a measure that discounts the value of a life because of an individual's disability as a threshold to establish what type of health care is cost effective or recommended.

The law creates a program to support and assist primary care physicians in preventive medicine, health promotion, chronic disease management, mental and behavioral health services (including substance abuse prevention and treatment services), and evidence-based and evidence-informed therapies and techniques.

Any regulation that creates an unreasonable barrier to the ability of individuals to obtain appropriate medical care is prohibited.

The HHS secretary is directed to establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.

The HHS secretary is directed to, at least triennially, identify gaps where no quality measures exist as well as existing quality measures that need improvement, updating, or expansion, consistent with the national strategy for use in federal health programs. The information will be made public on an Internet website.

The HHS secretary shall collect and aggregate data on quality and resource use measures from information systems used to support health care delivery to implement the public reporting of performance information.

The law creates within CMS a Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care furnished to individuals. It promotes care coordination between providers of services and suppliers that transition health care providers away from fee-for-service-based reimbursement and toward salary-based payment.

The Center for Quality Improvement and Patient Safety of the Agency for Healthcare Research and Quality, through research, must develop training and innovative methodologies that represent "best practices" in health care quality, safety, and value. Health care provider associations and professional societies are eligible for these contracts.

The law creates the Program to Facilitate Shared Decision Making to engage patients, caregivers, or authorized representatives and clinicians in decision making. The program also provides information regarding treatment options and incorporates patient preferences and values in the medical plan.

The law establishes that grants may be awarded to entities to carry out demonstration projects to develop and implement academic curricula that integrate quality improvement and patient safety in the education of health professionals.

Top of page  

Miscellaneous 

The "whole hospital" exception in the Stark Anti-Referral law and rules is significantly narrowed. A physician who owns a whole hospital that does NOT meet the new requirements for an exception is prohibited from making referrals to that facility and receiving payment for those services. In other words, the general prohibition will apply unless the new requirements are met.

The National Prevention, Health Promotion and Public Health Council is established to coordinate federal public health activities and develop a national strategy to improve the nation's health. The council must develop a report by July 2010 and annually through 2015, describing national health promotion and disease prevention priorities; describing science-based initiatives to achieve Healthy People 2010 nutrition, exercise, and smoking cessation goals; identifying the five leading disease killers; and including a plan for consolidating federal health programs and centers to promote healthy behavior and reduce disease risk.  The HHS secretary is to support the planning and implementation of a national public and private partnership for an outreach and education campaign to raise public awareness of how to improve health across the life span. 

Community health teams to support medical homes are established. The health team must include an interdisciplinary, interprofessional team and can include doctors of chiropractic and licensed complementary and alternative medicine (CAM) practitioners. The entity must provide services to individuals with chronic conditions.  Health team activities are defined. The health team's support must include access to pharmacist-delivered medication management services, coordination of CAM, and 24-hour care management during transitions in care settings, and must demonstrate capability to implement and maintain requirements of certified electronic medical record technology. 

The law requires medication therapy management services provided to targeted individuals to include performing health and functional status of patients; formulation of medication treatment plan agreed upon by the prescriber; recommending or administering medication therapy; and monitoring, which may include ordering or performing laboratory assessments. Pharmacists' recommendations must be communicated to other health care providers in a timely fashion; however, the timeframe is not defined. 

School-based health centers must provide comprehensive primary health care services including physical assessment for minor, acute, and chronic medical conditions, mental health and substance-use disorder assessments, crisis intervention, counseling and treatment, and referrals as appropriate. 

In consultation with relevant groups and entities, the HHS secretary must establish publicly available guidelines for health risk assessment to aid in identifying chronic diseases, injury risks, modifiable risk factors, and other health needs of the individual. This may be provided at the community level by a health care professional or other means. 

The Architectural and Transportation Barriers Compliance Board, now known as the Access Board, is required to create technical standards for medical diagnostic equipment in medical settings, including physician offices, to improve accessibility. This will be regulated under the ADA. This includes equipment such as exam tables and chairs, mammography equipment, x-ray machines, and the like.

The HHS secretary is allowed to negotiate contracts for purchasing adult vaccines from vaccine manufacturers, and allows states to purchase adult vaccine at the secretary's negotiated price. The law directs the Centers for Disease Control and Prevention to establish a demonstration program to award grants to states to improve immunization rates through interventions aimed at high-risk populations of children, adolescents, and adults.

Chain restaurants with 20 or more locations are required to post the number of calories in each standard menu item and a statement regarding suggested daily caloric intake.

HHS is required to ensure that any federally conducted or supported public health program or activity uniformly collects certain data. This includes data on race, ethnicity, disability status, language, and any other information deemed appropriate regarding health disparities.

The National Health Care Workforce Commission is established to:

  • Review current and projected health professions supply and demand; and
  • Make recommendations to Congress and the administration on national health care workforce priorities, goals, and policies.

Title III of Public Health Service Act is amended to fund development and operation of nurse-managed health clinics. Advanced practice nurses are to manage and provide primary care or wellness services to underserved or vulnerable populations at clinics associated with a school, college, university or department of nursing; federally qualified health center (FQHC); or independent nonprofit health or social services agency.

Appropriations for FQHCs to serve medically underserved populations are reauthorized and increased.

A pharmacy benefits manager contracted with a qualified health plan (offered through the new insurance exchanges) or a prescription drug plan sponsor is required to report to the HHS secretary the percentage of prescriptions provided through retail pharmacies vs. mail order pharmacies, the amount and type of rebates received, inventory management fees, product stocking allowances, and other fees associated with administrative services. 

The law provides for the posting of public information comparing nursing homes on an official Internet website. Information to be included will be staffing data such as turnover, information regarding the outcome of complaints, adjudicated instances of criminal violations within the facility or by a facility employee, links to state surveys, and a complaint form.

The HHS secretary will establish a program to identify "efficient, effective, and economical" procedures for long-term care facilities or providers to conduct background checks on prospective direct-patient-access employees on a nationwide basis.  Fingerprinting will be required, as well as coordination of State and federal background checks. 

This section establishes a nonprofit corporation, not a governmental agency, to provide independent comparative effectiveness research, to evaluate and compare health outcomes and clinical effectiveness, risks, and benefits of two or more medical treatments or services. The corporation shall not develop or employ a measure that discounts the value of a life because of an individual's disability as a threshold to establish what type of health care is cost effective or recommended.

The bill levies these taxes:

  • $2.3 billion on large pharmaceutical companies, beginning in 2010;
  • $2 billion on large medical device companies, beginning in 2010, and increasing to $3 billion in 2017;
  • An annual tax on large health insurance companies, beginning in 2011 at $2 billion, and gradually increasing to $10 billion in 2017; and
  • An additional Medicare payroll tax of 0.9 percent on taxpayers earning $200,000 ($250,000 for joint returns).

The law also expresses the sense of the Senate that:

  • Health reform presents an opportunity to address issues related to medical malpractice and medical liability insurance;
  • States should be encouraged to develop and test alternative models to the existing civil litigation system; and
  • Congress should consider state demonstration projects to evaluate such alternatives.

Top of page 

Health System Reform Action Center 


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?