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Management Issue 1:
Implementing the Affordable Care Act

Why This Is a Challenge

The work of the Department of Health and Human Services (HHS or the Department) in implementing the Affordable Care Act (ACA) continues. Although much has been accomplished, significant provisions remain to be implemented, most notably the Affordable Insurance Exchanges (the Exchanges), which add a new dimension to the Department's program landscape. While implementing the Exchanges, the Department must concurrently focus on sound administration of a wide range of new and modified program responsibilities covering reforms to private insurance, Medicare, Medicaid, the Children's Health Insurance Program, public health service programs, and others. Notable reforms include those that seek to transform Medicare and Medicaid by changing from volume-driven to value-driven payment mechanisms and by focusing on achieving better health and lower costs through promoting coordinated rather than fragmented care.

As with any new initiative, the Department faces substantial challenges in ensuring efficient and effective implementation and administration of the ACA so that the programs achieve their objectives and operate free from fraud waste, and abuse. Developing effective oversight strategies to prevent, detect, and correct any problems that occur is critical. The large number of new and complex program responsibilities under the ACA makes achieving these twin goals challenging.

Responsibility for implementing ACA provisions, administering new and changed programs, and overseeing ACA funding rests with Operating Divisions (OpDiv) and Staff Divisions (StaffDiv) across the Department. Many programs, including the Exchanges, also require close coordination and sharing of sensitive data between the Department and other Federal and State agencies, necessitating effective management of intergovernmental relationships and infrastructure. In addition, the Department will be forging new relationships with private insurers, providers, employers and consumers, all of whom will need clear information about benefits and responsibilities under ACA programs.

Progress in Addressing the Challenge

The Department and its Government partners have issued and will continue to issue regulations and other guidance for ACA programs. Numerous informational resources are available to inform the public about ACA programs. The Department has taken steps to foster the integrity of new programs, as illustrated by the regulations for the Medicare Shared Savings Program (MSSP), which incorporate a number of specific safeguards intended to mitigate potential vulnerabilities. Although it is too early to assess the outcome of these particular regulations, the Centers for Medicare & Medicaid Services' (CMS) efforts to integrate program integrity into the initial design of the MSSP is a promising approach that should be replicated in other programs.

The Office of Inspector General (OIG) has provided technical assistance on identifying risks and preventing fraud, waste, and abuse.

OIG has ongoing and planned work assessing a range of ACA programs, including the Exchanges, the Early Retiree Reinsurance Program, and the Prevention and Public Health Fund.

What Needs To Be Done

The Department and its partners should be vigilant in identifying and addressing existing and emerging fraud, waste, and abuse risk areas across all ACA-related programs. This will require a comprehensive approach to program integrity that integrates effective front-end program gatekeeping, sound payment design, the promotion of provider compliance, vigilant monitoring of program operations and outcomes, and rapid remediation of detected problems. The Department should continue to apply lessons learned about accountability, transparency, compliance, and risk management from its experience with the American Recovery and Reinvestment Act of 2009 (Recovery Act) and other programs. Staff overseeing ACA grants and contracts should be trained on effective internal controls and best practices for preventing and detecting fraud, waste, and abuse. Data systems supporting ACA programs must be scrutinized for accuracy and completeness, as well as compliance with security and privacy rules. The Department should continue its efforts to provide stakeholders with clear guidance about ACA programs.

A number of specific ACA-related challenges are addressed elsewhere in these Top Management Challenges.

Key OIG Resources

Management Issue 2: Identifying and Reducing Improper Payments

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201