In
the next several postings I want to present a series on how the Theory of
Constraints, Lean and Six Sigma (a.k.a. TLS) can help hospitals overcome the looming
ramifications of the Affordable Care Act (ACA).
In this first posting I will attempt to summarize some of the new
regulations associated with this new law and how they might impact the
profitability of hospitals and other medical facilities as well as small
businesses.
We
all know that healthcare costs have been growing to unsustainable levels for
the past decade or more. And while
healthcare costs continue to increase dramatically, healthcare quality
continues to be a significant problem for many institutions. The reform measures initiated by the ACA will
most certainly drive an increase in medical costs which will further stress an
already stressed industry as well as tax payers and employers. The ACA will most definitely force hospitals
to make fundamental changes in the way they operate and deliver healthcare at
more affordable rates. So what are the
ramifications of the ACA to business owners?
If
you are a small business owner, for example, in 2014 the implications of this
new law can be devastating when the impending penalties for not providing
healthcare coverage. The implications of
the ACA are determined by the size of the business and the number of full-time employees with an emphasis on
“full-time.” The potential penalties are
as follows:
·
0-25 Employees: The business will receive a tax credit to
offset the cost of purchasing healthcare coverage for employees, but there will
be no penalty if they don’t provide coverage.
·
26-49 Employees: The business will not be penalized if they do
not provide coverage, but they won’t receive a tax credit if they do provide
coverage.
·
50+ Employees: The business will have to pay a fine ($2,000
to $3,000 per employee) if they do not provide coverage.
Several
things jump out at me immediately. The
expression full-time employees, tells
me that one of the ways to avoid the above scenario is to cut back hours on
employees to less than 40 hours per week to make them part-time. There have
already been unsubstantiated reports that some restaurants (e.g. Red Lobster)
are doing just that. If you have a
business full of part-time employees (i.e. less than 40 hours), then you can
avoid all penalties. Another thing that
becomes obvious is that if you currently have say 55 employees, then you might
be tempted to reduce that number to say, 49 employees or make everyone a
part-time employee. In these days of
high unemployment what choices would employees have? They probably couldn’t go to a competitor
since they may be taking the same or similar actions to hold down penalties and
the expense of adding insurance coverage.
The
tax credits I mentioned earlier fit the following three conditions:
·
They cover at least 50% of the cost
of single healthcare coverage to each employee.
·
They have fewer than 25 full-time
employees.
·
They pay average annual wages below
$50,000.
So,
at least to me, the ACA doesn’t offer much of an incentive for small business
owners to provide medical coverage to employees, especially when you consider
just how much insurance premiums cost small businesses. In fact, based upon everything I’ve read, it
provides no incentives to stimulate any kind of job growth.
In
addition to the costs associated with the ACA, there are penalties that are
supposedly tied to quality of care by hospitals. For example, if a patient is admitted to a
hospital, treated and released and is then re-admitted in less than 30 days,
there is a huge financial penalty assessed to the hospital. And although this portion of the law is aimed
at improving healthcare, I don’t understand how it will. Suppose a patient is admitted for chest
pains, but the hospital sees no signs of a heart attack on the EKG or other
tests. The patient is released and ten
days later is re-admitted for chest pains again. This time the hospital sees an abnormal EKG
or other tests and begins treatment for a minor heart attack. Even though the hospital followed normal
protocol during the first admittance, they get penalized because the patient
was re-admitted within the 30 day window.
I can see hospitals avoiding admitting the patient and over-crowding the
out-patient area just to avoid the potential financial penalty.
Patient
satisfaction is another area of concern under the ACA. It seems that reimbursements for Medicare
will now be based on a sort of “report card.”
These report cards are based upon how the hospital met the patient’s
expectations and the lower the satisfaction rating, the lower the reimbursement
dollars to the hospitals. This includes
hospital emergency rooms where I can see low satisfaction ratings as more and more
patients take this route and waiting times become extended. The Hospitalist
reported that some of the most prestigious hospitals in the US receive bad
patient reviews and yet they get high scores on clinical quality metrics. On the other hand, some hospitals that have gotten
great patient satisfaction ratings have scored significantly lower than the
national average on mortality rates from heart attacks, heart failure or
pneumonia. I’ve read that 30% of the ACA
financial incentive is based upon how well a hospital scores on patient
satisfaction.
The launch of the ACA started in October of this
year when hospitals were the first to implement it with medical reimbursements
being distributed starting in 2013. The
reimbursements will be dependent upon a hospital’s score from 17 different
“process-of-care” measures as well as 8 different patient-care measures. This law will no doubt result in increased
transparency as hospital performance is required to be publicly reported for
care dealing with heart attacks, heart failure, pneumonia, surgical care,
healthcare associated infections , and patient’s perception of the care they
received. One thing for certain…..if
there are waiting rooms full of patients, they will be dissatisfied and if they
are, hospitals will pay the price in reduced reimbursements.
So there you have what I have read about the
Affordable Care Act. There are probably
other important things to consider, but these are some of the more important
items. In my next few postings we’ll
take a look at how hospitals might improve the flow of patients while at the
same time looking at ways that they might positively impact the patient’s
perception of their treatment.
Bob Sproull
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