Health Care Reform Eric H. Schultz, President and CEO

Transcription

1 Health Care Reform Eric H. Schultz, President and CEO Sentinel Benefits & Financial Group September 21, 2011

2 Affordable Care Act The Basics Insures the uninsured Individual and employer mandates Reforms insurance markets Controls health care costs According to Congressional Budget Office estimates, over the next 10 years, it will Extend coverage to 32 million Americans Cost $938 billion Result in a $143 billion reduction in the federal deficit 2

3 Market Reforms Starting in 2014 Guaranteed-issue No pre-existing condition exclusions Individual and employer mandates Exchanges (like the Massachusetts Connector) Federally defined essential benefits package 3

4 Federal US House passed repeal bill; rejected by Senate Focus now the debt Supercommittee. Medicare and Medicaid could be addressed as part of that debate, though the Ryan budget proposal is DOA. Congress must enact another doc fix bill by January 2012 campaign season has begun; health care will be a key issue Challenges to the Affordable Care Act working their way toward the Supreme Court 4

5 Massachusetts Update Payment Reform Governor s Bill Chapter 305 Hearings Provider Price Commission State Budget Municipal Health Reform Medicaid 5

6 Chapter 305 Hearings Division of Health Care Finance & Policy (DHCFP) Significant provider price variation persists Little variation in quality No correlation between hospital s share of Medicaid patients and private payer prices If private payer prices for hospital inpatient services and physician and professional services were narrowed to the 20th and 80th percentiles, the savings would be about $267 million. Other formulas yield even greater savings. Attorney General: Global payment does not necessarily correlate lower costs or better quality 6

7 Payment Reform Governor Patrick s proposed legislation Establishes framework for creation and oversight of Accountable Care Organizations (ACOs) Goal is to move most providers away from fee-for-service and into alternative payment methodologies, such as global payment, by 2015 DHCFP to establish Standard payment methodologies which plans must offer to ACOs Cost containment benchmarks DOI to establish Limits on provider rate increases which could vary for different classes of providers. Health plans would be prohibited from entering into contracts that did not comply with the limits. 7

8 Key Issues to Watch Who s in control and how much power they are given Provider participation in ACOs: voluntary vs mandatory Payment structures: standardization vs flexibility Provider rate regulation Governor s proposal Attorney General s rate convergence proposal Something else System-wide spending targets Antitrust controls ACOs as health plans Impact on patient choice 8

9 Government pressure is useful and effective, but private-sector efforts to cut costs are quicker than, and preferable to, a government rate-setting scheme. --Boston Globe editorial 9/18/11 9

10 We make health care work better. 10

11 Our Strategy Innovate Diversify Manage Costs 11

12 Product and Network Design Innovate More information and choice to make the right choice 12

13 Consumer Engagement Strategy Innovate Consumer Engagement Strategy Consumer Programs Employer Programs Product, Network Aligned Health Goals Provider Partnership Strategy Care Delivery Models Product, Network 13

14 Provider Partnership Strategy Innovate Payment Models Care Delivery 14

15 Four Care Delivery Models Innovate 1. Patient Centered Medical Home 2. Specialty Medical Home 3. Episode based procedures 4. Complex care model 15

16 Success Innovate Decrease Health Care Costs Improve Quality Deliver Value 16

17 Gain Greater Market Share Diversify Geographically Demographically 17

18 Our Premium Dollar Manage Costs 18

19 We make health care work better Not-for-profit health plan Strong technology infrastructure and operational capabilities Solid partnerships Nationally renowned by J.D. Power for customer satisfaction and quality of care And, according to NCQA 19

20 in America 8 years in a row! 20