Despite the Supreme Court upholding nearly all aspects of the Affordable Care Act, the industry hasn’t seen the last challenge to the law’s provisions, said Margret Amatayakul, president at Margret A Consulting in Schaumburg, Ill.

Citizens, Congress and governors still could raise new challenges to the law, and the administration, as it tweaks provisions, could delay certain regulatory actions or waive penalties, she noted during a Health Data Management Web seminar on July 2. Some of the challenges could be made not to weaken but to strengthen reform provisions, predicted seminar co-presenter Pat Kennedy, president at PJ Consulting in Rockville, Md. For instance, insurers will lobby to strengthen the individual mandate to reduce their risk of offering coverage to individuals with pre-existing conditions.

For now, implementation of reform provisions will continue, including some with wide support that have to a degree been eclipsed by controversial aspects. For instance, the clock is ticking on developing and implementing “operating rules” to further standardize the HIPAA administrative and financial transactions, Amatayakul said.

She walked seminar attendees through the operating rules, including rules for the eligibility and claim status transactions that have a compliance date of Jan. 1, 2013. Other rules will cover electronic funds transfers and electronic remittance advice (2014); and claims/encounters, coordination of benefits, enrollment/disenrollment, premium payments, attachments, and referral certification and authorization (2016).

A major component of reform is establishment of accountable care organizations, which represent a major change management challenge to providers, Amatayakul noted. Information technology tools to will be essential to managing the change, such as ensuring the use of evidence-based care protocols, but a cultural mindset must accompany the technology, she warned. “You can put all the technology in place, but it won’t matter if you don’t accept the change.”

Health insurers and employers have their own challenges, Kennedy said. A shift seen in the past couple years to waive co-pays and deductibles to induce consumers to get preventive care will accelerate. Insurers must become smarter, stop policing providers and become a partner, he contended. Consequently, payers increasingly will focus on electronic communication with providers through bi-directional exchange of clinical and claims data, to better coordinate treatment and analyze gaps in care.

The payers have to move fast, as each wants their share of the 30+ million new insured lives that reform is expected to bring. But they, like providers, have many issues on their plates and large insurers may have to prioritize the states where they initially focus on implementing reforms, Kennedy said.

Above all, the biggest challenge for providers and payers will be engaging consumers to take more control over their health, he added. “If we don’t get members to take more responsibility for health care, I’m not sure how we’ll drive down costs while improving the quality of care.”

To empower and engage consumers, providers and payers will create messaging systems via text or email waiving co-pays if patients reorder their prescriptions in a timely manner, schedule foot exams or other preventive care, and engage in other treatment adherence activities, Kennedy predicted. “We have to figure out how to do it nationwide. Plain old wellness programs are not working. We have to focus on the 20 percent spending the most and the 20 percent who might join them.”

The HDM Web seminar, “First Glance: The Ramifications of the Health Reform Ruling,” is available on demand at

Register or login for access to this item and much more

All Health Data Management content is archived after seven days.

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access