Practicing Medicine in the Era of Health Reform

Transcription

1 Practicing Medicine in the Era of Health Reform Session 16 Panel Discussion The Affordable Care Act: Evaluating the Rollout and Discussing Next Steps James Roosevelt, Jr., Esq. Jon Kingsdale, PhD David Green, MD August 13, Tufts Health Care Institute

2 Introduction and Overview of the Affordable Care Act James Roosevelt Jr., J.D. CEO, Tufts Health Plan Co-chair, Tufts Health Care Institute Clinical Instructor, Tufts University School of Medicine

3 Life before ACA 47M lacked health insurance Many stayed in jobs because they didn t have other health insurance options Lack of preventive care Preexisting conditions meant denied access 3

4 The ACA changed four aspects of health care Access Quality Delivery Cost 4

5 Life after ACA More than 16.4M uninsured gained health insurance 35% reduction in uninsured as of March 2015 Millions have been determined eligible for Medicaid for children (CHIP) Nearly 6M young adults gained insurance through parents coverage 5

6 Panel Discussion The Affordable Care Act: Basic Structure of the Act and of Exchanges Jon Kingsdale, Ph.D. Managing Director, Wakely Consulting Group Adjunct Professor, BUSPH & Brown SPH

7 Coverage of the Nonelderly by Poverty Level, 2011 Employer/Other Private Medicaid/Other Public Uninsured 32% 29% 15% 12% 5% 4% 48% 32% 73% 90% 20% 39% <100% FPL % FPL % FPL 400%+ FPL NOTE: FPL The federal poverty level was $22,350 for a family of four in Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.

8 Majority of uninsured were childless adults The Nonelderly Uninsured Population by Age and Parent Status, 2011 Children, 16% Adults without dependent children, 59% Parents, 25% 47.9 M Uninsured Children includes all individuals ages Parents are defined as adults with dependent children ages 0-18 and adults without children do not have dependent children ages Both parents and adults without children include adults ages Data does not total 100% due to rounding. SOURCE: KCMU/ Urban Institute analysis of 2012 ASEC Supplement to the CPS.

9 Most uninsured are in working households, 2011 Family Work Status Part-Time Workers, 16% No Workers, 22% 1 or More Full- Time Workers, 62% Total = 47.9 Million Uninsured NOTE: The federal poverty level was $22,350 for a family of four in Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.

10 Uninsured Rates Among Nonelderly by State, NH WA MT ND VT ME AK CA OR NV ID AZ UT WY NM CO SD NE KS OK TX MN WI IA IL MO AR MS LA MI OH IN KY TN AL NY PA WV VA NC SC GA MA RI CT NJ DE MD DC FL HI National Average = 18.2% <14% Uninsured (13 states & DC) 14 to 18% Uninsured (20 states) >18% Uninsured (17 states) SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplement to the CPS (two-year pooled data).

11 Uninsured do get some care $1,686 per person in 2008 ($4,463 for insured) 1/3 out of pocket Federal gov t Neighborhood health centers VA Subsidies through Medicare Hospitals, community clinics, doctors Uncompensated care Emergency room care

12 3.0 Diagnosis of Late-Stage Cancer Uninsured vs. Privately Insured Ratio of probability of diagnosis of late vs. early stage cancer, Uninsured/private insurance Equal likelihood between Uninsured and Insured Colorectal Cancer Lung Cancer Melanoma Breast Cancer NOTE: Odds ratios were adjusted for age, sex, race/ethnicity, facility type, region, and income and education on basis of postal code. They represent the odds of being diagnosed with stage III or state IV cancer vs. stage I cancer. Analysis based on cases occurring between SOURCE: Kaiser Family Foundation, based on Halpern MT et al, Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis." The Lancet Oncology. March 2008.

13 Barriers to Health Care Among Nonelderly Adults, by Insurance Status, 2009 Percent of adults (age 18 64) reporting: No Usual Source of Care 11% 11% 55% No Preventive Care 6% 6% 42% Went Without Needed Care Due to Cost* 9% 4% 26% Uninsured Medicaid/Other Public Employer/Other Private Could Not Afford Prescription Drug* 6% 13% 27% In past 12 months. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. SOURCE: KCMU analysis of 2009 NHIS data.

14 ACA Simplified Expand ACCESS for minority of Americans Set minimum standards for most coverage Improve population health through prevention Support experiments on quality and cost Expand and redistribute health workforce Pay for it by shifting money from Medicare Pay for it with miscellaneous new taxes

15 Key Elements of Coverage Reform: Shared Responsibility Individuals: -Mandate -Premium contribution Government: -QHP Premium assistance -Medicaid eligibility expansion Employers: > 50 FTEs offer affordable coverage 15

16 ACA s 3 main coverage provisions Sources of coverage Medicaid expansion, ~16 mm Reformed & subsidized Individual Market, ~14mm Parents coverage, 2 3 mm 30 September

17 Major Medicaid changes in ACA Significant expansion in eligibility 16mm, if all states expand eligibility Eligibility shifts to income test 138% of federal poverty level Feds pay 100% for expansion thru 2016, 90% as of 2019 Minimum benefits expanded State expansion now voluntary but all other requirements in place

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20 Market Reforms in individual and ESI coverage Essential health benefits Adjusted community rating Guaranteed issue & renewal No upper limits on coverage Administrative simplification Health insurance exchanges

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22 22 Health Insurance Marketplace Penetration

23 How to Offer Consumers Comparable Choice? Both state and federal exchanges offer consumers four coverage levels or actuarial values Bronze Silver Gold Platinum Actuarial Value of Essential Benefits: Actuarial Value of Essential Benefits: Actuarial Value of Essential Benefits: Actuarial Value of Essential Benefits: 60% 70% 80% 90% But what s actuarial value? 23

24 How tax credits are calculated Benchmark premium Second lowest cost Silver plan in community Minus amount person expected to pay Varies as percent of income 2%-9.5% Equals subsidy

25 KISS: Put in County, Age, Household Size & Metallic Level Plan Overview Estimated Monthly Premium $ Price after estimated $0.00 tax credit $ Price after estimated $0.00 tax credit $ Price after estimated $0.00 tax credit Health Care Provider Search Providers Search Providers Search Providers Standard Gold Point of Service (POS) Remove from comparison Healthy Partner Preferred Remove from comparison Apply Apply Anthem Gold DirectAccess Standard cddk Remove from comparison Plan Type POS PPO PPO Plan Level *Gold *Gold *Gold Apply Quality Rating (NCQA) Not yet rated new carrier Not yet rated new carrier *Gold: deductible = $1,000 in network; $3,000 out of network; Out of Pocket Max = $3,000 Ind l/$6,000 Family; Physician Visits = $0 preventive/$20 primary care/$35 specialist; Hospital = $500/day up to $1,000 per stay; E.R. = $150 Rx = $150 deductible, then $10 for generics, $25 for tier 2, $40 for tier 3, 30% for tier 4

26 Some Interim Results of the ACA Plans are being used Prescriptions being filled Tests being taken Physicians are being accessed What about access for the already insured?

27 Three of Five Adults with New Coverage Said They Had Used Their Plan; of Those, Three of Five Said They Would Not Have Been Able to Access or Afford This Care Before Have you used your new health insurance plan to visit a doctor, hospital, or other health care provider, or to pay for prescription drugs? Prior to getting your new health insurance plan, would you have been able to access and/or afford this care? No 34% Yes 60% No 62% Yes 36% Plan has not yet gone into effect 6% Adults ages who selected a private plan or enrolled in Medicaid through the marketplace or have had Medicaid for less than 1 year Don t know or refused 2% Adults ages who have used new health insurance plan Note: Segments may not sum to 100 percent because of rounding. Source: The Commonwealth Fund Affordable Care Act Tracking Survey, April June 2014.

28 Adults Reporting Medical Bill Problems Declined in 2014 Percent of adults ages In the past 12 months: Had problems paying or unable to pay medical bills Contacted by a collection agency about medical bills* Contacted by collection agency for unpaid medical bills Contacted by a collection agency because of billing mistake Had to change way of life to pay bills Any of three bill problems (does not include billing mistake) Medical bills being paid off over time % 39 million 21% 36 million 13% 22 million 7% 11 million 14% 24 million 28% 48 million 21% 37 million 29% 53 million 23% 42 million 16% 30 million 5% 9 million 17% 31 million 34% 62 million 24% 44 million 30% 55 million 22% 41 million 18% 32 million 4% 7 million 16% 29 million 34% 63 million 26% 48 million 23% 43 million 20% 37 million 15% 27 million 4% 8 million 14% 26 million 29% 53 million 22% 40 million 34 % 40% 41% 35% Any of three bill problems or medical debt 58 million 73 million 75 million 64 million * Subtotals may not sum to total: respondents who answered don t know or refused are included in the distribution but not reported. Source: The Commonwealth Fund Biennial Health Insurance Surveys (2005, 2010, 2012, and 2014).

29 The Number of Adults Reporting Not Getting Needed Care Due to Cost Declined in 2014 Percent of adults ages In the past 12 months: Had a medical problem, did not visit doctor or clinic 22% 38 million 24% 41 million 26% 49 million 29% 53 million 23% 42 million Did not fill a prescription 23% 39 million 25% 43 million 26% 48 million 27% 50 million 19% 35 million Skipped recommended test, treatment, or follow up 19% 32 million 20% 34 million 25% 47 million 27% 49 million 19% 35 million Did not get needed specialist care 13% 22 million 17% 30 million 18% 34 million 20% 37 million 13% 23 million Any of the above access problems 37% 63 million 37% 64 million 41% 75 million 43% 80 million 36% 66 million Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, and 2014).

30 Panel Discussion The Affordable Care Act: Evaluating the Rollout and Discussing Next Steps David Green, MD, FACS Sr. Vice President Medical Affairs/ Chief Medical Officer Concord Hospital, Concord, NH

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33 Expand coverage Control costs Improve delivery system PPACA 3/23/2010

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35 PPACA at 5 Years (my assignment) What is different since 3/23/2010? What is the effect on delivery of care? What will evolve and change in the next 5 years?

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37 Disruptive Change As long as an organization continues to face the same sort of problems that its processes were designed to address, managing an organization can be straight forward. These factors also define what an organization cannot do, and constitute disabilities when problems facing a company change fundamentally. Christenson 2000

38 What is different since 3/23/2010? A new way of thinking! Population Health We have data! Embracing risk and accountability Value vs. Volume Transparency Collaboration and alignment Payors and providers Physicians and hospitals Providers and patients

39 What is the effect on delivery of care? + Medicaid Expansion? CDHP on HIE +/ Essential Health Benefits Package USPSTF Narrow Networks + Center of Innovation + Bundled Payment Pilot Programs + Value Based Purchasing + Community Needs Assessment +/ Data Acquisition and Analytics

40 What is the effect on delivery of care? MSSP Concord Hospital Elliot Health System Southern NH Health System Wentworth Douglass Hospital

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43 What will evolve and change? (It s not just the PPACA) Meaningful Use ICD 10 MACRA 2015

44 MACRA 4/16/2015 (Medicare Access & CHIP Reauthorization Act) Repealed the SGR for Physicians Moves all providers into value based payments by 2019 through MIPs (Merit Based Incentive Programs) or participation in APM MIPs Consolidates PQRS, MU, VBM

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46 MACRA (The death of FFS medicine?) Track 1 0.5% annual update , 0 next 10 years MIPs composite score Upper & lower quartile +/ 4% 2010 to +/ 9% 2020 Track 2 5% annual update No MIPs Limited MU Participate in APM with downside risk

47 What will evolve and change? as we know, there are known knows; there are things we know we know We also know there are known unknowns; that is to say we know there are some things we do not know.

48 What will evolve and change? (known unknowns) Alignment and consolidation scale! Data acquisition and analytics will evolve Consumerism (price, quality) impact? Standard work based on EBM less autonomy Transparency and Accountability Patient Engagement telehealth? Alternative Payment Mechanisms value Managing risk Population Health

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50 The four aspects of healthcare changed by the ACA Access Insurers prohibited from denying coverage or charging higher prices as a result of preexisting medical conditions Charging women higher premiums than men Retroactively terminating coverage for individuals who become sick Imposing annual or lifetime caps on benefits Medicaid expansion Health insurance exchanges 50

51 The four aspects of healthcare changed by the ACA Quality Greater emphasis on prevention No copays for preventive health care services Wellness and health outcomes 51

52 The four aspects of healthcare changed by the ACA Delivery Monumental challenge, given that health care consumes nearly 20 percent of GDP Creates framework for establishment of ACOs that rewards quality benchmarks and cost efficiencies Pilot projects created to support shift from fee for services methodologies to bundled payments (for episodes of care) and global payments (for defined populations over a given period of time) 52

53 The four aspects of healthcare changed by the ACA Cost Claims that national reform is a budget buster is a myth Between 2014 and 2015 the average growth rate in the second lowest silver premium was 2% Push for global payments and better outcomes saves money versus fee for service In 2014 premiums were 16% lower than what the Congressional Budget Office projected 53

54 Impact on employers Most people under 65 get insurance through employers Mandate pay or play Currently affects employers with 100 or more employees: must either provide insurance or pay a penalty $2,000 penalty per employee not covered Companies with 50+ employees have to comply by January

55 Impact on employers Some larger employers push people to exchanges Some providing subsidy and creating private exchanges Small employers Many are offering insurance for the first time Some see it as a burden Some do this versus offering wage increases 55

56 Impact on insurers Growth in QHP and Commercial insurance Fees and taxes associated with implementation Market factor requirements pushed insurers to lay out components of what plans are Sparked competition NH example: year one, one plan on exchange. Year two, six plans on exchange 56