A Primer on the PPACA and Its
Impact on Radiology
Wes Angel, MD
University of Tennessee Health Science Center,
Methodist Program
Outline
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Background of the PPACA
PPACA Provisions
PPACA’s Potential Impact to Radiology
Summary
Background: Reasons for PPACA
• Rising healthcare
expenditure1
• Large percentage of
uninsured
• Lack of access to
healthcare for
insured and
uninsured alike
• Rising drug costs
Source: Kaiser Family Foundation
http://facts.kff.org/chart.aspx?ch=202
Background: PPACA
• Patient Protection and
Affordable Care Act
– AKA “Affordable Care
Act”
• Signed into law on
March 23, 2010
• Number of pages2: 907
• Number of major
provisions3: 92
Source:
http://www.libertyhealthconsultants.com/surveyint
ro.html
PPACA: Major Tasks4
• Create consumer rights and protections
– Guaranteed issue
– Patient’s Bills of Rights
• Expand insurance
– Creation of insurance exchanges
– Co-op insurance
• Expand Medicaid
• Start health insurance exchanges
• Establish coverage requirements for small business
PPACA: Financial Structure to Increase
Revenue3
• Start excise taxes on:
– Health coverage
– Medical devices
– Indoor tanning
• Increases Medicare tax base
• Imposes annual fees on:
– Branded drugs
– Health insurance providers
• Changes tax structure on flexible savings accounts
PPACA: Small Sample of Currently Active
Provisions3, 14
• Insurance
– Provides adult dependent coverage to Age 26
– Creates state option for Medicaid coverage to childless adults with income
levels up to 133% of the federal poverty level (Section 1902)
– Creation of consumer website to compare coverage options
– Prohibits lifetime limits of insurance coverage
• Cost reduction
– Prohibits federal funding to states for certain hospital acquired infections and
other provider preventable conditions
– Aims to create a Medicare Independent Payment Advisory Board (IPAB)
• Primary care
– Provides 10% bonus payment for primary care services
• Preventative medicine and public health
– Allocates $5 Billion for 2010-2014
– Allocates $2 Billion Dollars each fiscal year after 2014
PPACA: Small Sample of Currently Active
Provisions3, 14
• Revenue generation
– Creates 10% excise tax on indoor tanning services
• Graduate medical education
– Increases GME positions
– Funds ambulatory teaching health centers
• Expansion of Drug Discount Program
• Changes to Medicare provider rates
PPACA: Future Provisions 20122,3
• Creation of ACO’s (Accountable Care Organizations)
for Medicare
– Group of healthcare providers
– Various reimbursement models: capitation and fee-forservice
– Ties reimbursement to quality of care
• Annual pharmaceutical fees
• Medicare value based purchasing
• Reduced Medicare payments for hospital
readmissions
• New fraud screening efforts
PPACA: Future Provisions 20132,3
• Closure of Medicare drug coverage gap
• Increased Medicaid payments for primary care to
match Medicare rates for 2013 and 2014
• Medicare tax increase
– Increased wages tax rate by 0.9%
– 3.8% tax on unearned high income
• Medicare bundled payment pilot program
• 2.3% excise tax on medical devices
PPACA: Sample of Future Provisions 201420162,3
• 2014
– Expand Medicaid base
– Individual requirement to have insurance
– Guaranteed issue
– Health insurance company fees
– No annual limits on insurance coverage
– Reduced reimbursement for certain Medicare hospital
acquired infections
• 2018
– Tax on high cost insurance
PPACA’s Potential Impact to Radiology
• Potential expansion of referral base
• Establishment of ACO’s in Medicare
– Creates potential for various roles of radiologists within
ACO’s8,10
• Reimbursements
– Increase in utilization rate of equipment from 50 to 90%5
– Increase in multiple procedure reduction rule from 25 to
50%5
– Decrease in professional component of 2-3%6
• Establishment of Center for Medicare and Medicaid
Innovation
– Potential impact on ordering and reimbursement of
diagnostic imaging
PPACA’s Potential Impact to Radiology
(continued)
• New Self Disclosure Requirements9
– Requires physician to provide written notice to patients that
they may obtain services such as CT, MRI, and PET elsewhere if
physician has a financial interest (Section 6003)
– Requires establishment of self referral disclosure protocol
(Section 6409)
• False claims9
– Allows federal government to prosecute anti-kickback violations
under the False Claims Act (Section 6402)
– Mandatory requirement to return Medicare and Medicaid
overpayments within 60 days (Section 6402)
– Maximum period for submission of Medicare claims to less than
12 months (Section 6404)
Summary
• PPACA will continue to evolve with continuous
changes to the law, its provisions, and its
implementation
• Implements multiple changes to Medicare and
Medicaid
• Provides near universal coverage by various
means
• Creates uncertain impact to radiology and the
medical field as a whole
• Interested in learning more?
References/Resources
1.
2.
3.
4.
5.
6.
7.
Kaiser Family Foundation www.kff.org, Last accessed December 15, 2011.
Patient Protection and Affordable Care Act, http://docs.house.gov/energycommerce/ppacacon.pdf,
Last accessed October 10, 2011.
Implementation Timeline, http://healthreform.kff.org/Timeline.aspx, Last accessed October 10, 2011.
U.S. Department of Health and Human Resources, http://www.healthcare.gov/, Last Accessed
December 12, 2011.
American College of Radiology, Impact to Radiology as an Result of PPACA,
http://www.acr.org/Hidden/Economics/FeaturedCategories/mps/mpfs/2011-Medicare-Physician-FeeSchedule-FR/Impact-To-Radiology-As-A-Result-of-PPACA.aspx, Last accessed on October 10, 2011.
American College of Radiology, Aggregate Estimated Impact of Equipment Usage Assumption Changes
for Advanced Diagnostic Imaging Services (Diagnostic CT and MR) on PE RVUs Using 2008 Constant
Volume, http://www.acr.org/Hidden/Economics/FeaturedCategories/mps/mpfs/2011-MedicarePhysician-Fee-Schedule-FR/Impact-To-Radiology-As-A-Result-of-PPACA/Usage-Assumption-ResultsDxCTMR.aspx, Last accessed on October 10, 2011
Allen, B., Donovan, W. D., McGinty, G., Barr, R. M., Silva, E., Duszak, R., Kim, A. J., et al. (2011).
Professional component payment reductions for diagnostic imaging examinations when more than one
service is rendered by the same provider in the same session: an analysis of relevant payment policy.
Journal of the American College of Radiology : JACR, 8(9), 610-6. doi:10.1016/j.jacr.2011.06.012
References/Resources (continued)
8.
9.
10.
11.
12.
13.
14.
Allen, B., Levin, D. C., Brant-Zawadzki, M., Lexa, F. J., & Duszak, R. (2011). ACR white paper: Strategies
for radiologists in the era of health care reform and accountable care organizations: a report from the
ACR Future Trends Committee. Journal of the American College of Radiology : JACR, 8(5), 309-17.
Elsevier Inc. doi:10.1016/j.jacr.2011.02.011
Bloom, G. E., & Smith, G. R. (2011). Key provisions of the Patient Protection and Affordable Care Act.
Journal of the American College of Radiology : JACR, 8(1), 69-70. doi:10.1016/j.jacr.2010.10.001
Breslau, J., & Lexa, F. J. (2011). A radiologist’s primer on accountable care organizations. Journal of the
American College of Radiology : JACR, 8(3), 164-8. Elsevier Inc. doi:10.1016/j.jacr.2010.08.005
Greaney, T. L. (2011). Accountable care organizations--the fork in the road. The New England journal of
medicine, 364(1), e1. doi:10.1056/NEJMp1013404
Pentecost, M. J. (2009). Health care reform: what Americans want. Journal of the American College of
Radiology : JACR, 6(12), 831. Elsevier Inc. doi:10.1016/j.jacr.2009.09.010
Pentecost, M. J. (2011). Health care reform: the first anniversary. Journal of the American College of
Radiology : JACR, 8(4), 221. Elsevier Inc. doi:10.1016/j.jacr.2011.01.002
Consumers Union, The Affordable Care Act: The First Year,
http://www.consumerreports.org/health/resources/pdf/ncqa/health-reform.pdf, last accessed on
December 12, 2011.