Health Policy Update 2017 Kevin Grumbach, MD

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1 Department of Family & Community Medicine University of California, San Francisco Health Policy Update 2017 Kevin Grumbach, MD UCSF Annual Review in Family Medicine December 7, 2017

2 Disclosures No commercial conflicts of interest Policy advisor to Obama Administration and Congress on Affordable Care Act Member of Physicians for a National Health Program and California Physicians Alliance

3 Nobody knew health care could be so complicated.

4 Coverage

5 Affordable Care Act

6 ACA Key Coverage Measures Mandates on individuals and employers with 20+ employees to purchase private insurance if not publicly insured and citizen or legal resident Tax subsidies for small employers and individuals (citizens and legal residents) Insurance market reform (e.g., no exclusions for preexisting conditions) Health Insurance Exchanges (e.g., Covered California)

7 ACA Key Coverage Measures Expansion of Medicaid States required to make all citizens and legal residents <138% poverty level eligible for Medicaid No more categorical eligibility criteria (eg, dependent children, disability) Federal government funds 90% and states 10% cost of newly enrolled Supreme Court ruled that feds cannot force states to participate in expansion

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9 Failed Efforts at Repeal and Replace

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11 HHS Eliminated ACA Cost Sharing Reduction Payments Oct 2017 CSRs subsidized portion of patient cost sharing on exchange plans for enrollees with incomes <250% FPL

12 Family Planning

13 Children s Health Insurance Program Formerly Healthy Families Program in CA; post ACA integrated into Medi-Cal For children in families with income above ACA eligibility level (>138%FPL <266% FPL) Congress has not passed renewal of federal funding match, which expired Sept 30, 2017

14 And also needing renewed funding effective October 1 Community Health Center grants National Health Service Corps Teaching Health Centers And more

15 Senate Tax Cut Bill Passed Dec 1 Eliminates ACA Individual Mandate CBO Projection 13M lose insurance 10% increase in exchange premiums due to adverse risk selection

16 Implications of Tax Cuts Adding $1Trillion to Federal Deficit Senator Marco Rubio We have to generate economic growth which generates revenue, while reducing spending. That will mean instituting structural changes to Social Security and Medicare for the future...the driver of our debt is the structure of Social Security and Medicare for future beneficiaries. President Trump "We re looking very strongly at welfare reform, and that ll all take place right after taxes, very soon, very shortly after taxes."

17 Affordability Is a Real Issue For Exchange Plans Cost of Health Plan Premium to Patient $24,000 $18,000 $12,000 Bronze Gold Silver Platinum $22,548 $19,512 $19,260 $12,984 Silver ($3K Ded) 67% Bronze ($6K Ded) 23% Gold ($1K Ded) 7% Platinum ($250 Ded) 3% $6,000 $0 $48 $4,200 $888 $1,140 Lowest cost plans, Oakland CA, Covered California for 2018 plan year Fam 4 $40K Fam 4 $100K National Data, Kaiser Family Foundation, 2017 Marketplace Enrollment

18 High Deductibles not Unique to ACA Exchange Plans

19 The Revival of the Single Payer Movement

20 Payment and Delivery System Reform Many federal policies initiated in prior administration are continuing Movement from fee for service to population based payment models, with shared risk

21 MACRA Medicare Access and CHIP Reauthorization Act of 2015 Bipartisan Bill on Medicare Part B payment (replaced SGR) Two Tracks to Choose From: 1. Merit-based Incentive Payment System (MIPS) 90%+ providers Fee-For-Service adjusted for Value Metrics. OR 2. Advanced Alternative Payment Models (APMs) Very few providers Requires substantial riskbased payment.

22 MIPS Doesn t have much New Stuff, and some of the Old Stuff got a little Better Quality Cost Advancing Care Information Practice Improvement Came from PQRS Reduced from 9 to 6 Measures Came from VBM No reporting Burden Came from MU Many measures now will give Partial Credit New But lots of options to qualify and attest 22

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24 Primary Care Practice Transformation Patient-Centered Medical Home (PCMH) Advanced Primary Care High Performing Primary Care

25 10 Building Blocks of High-Performing Primary Care T Bodenheimer et al AnnFamMed March 2014

26 CMMI Comprehensive Primary Care Plus (CPC+) Care Management Fee: pmpm payment Performance-Based Incentive Payment: patient experience measures, clinical quality measures, and utilization measures that drive total cost of care. Medicare Physician Fee Schedule: Track 1 traditional FFS Track 2 reduced FFS plus quarterly global comprehensive payment

27 CPC+ What s Wrong With This Picture?

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29 CMMI Accountable Care Communities Initiative

30 Covered CA Policies to Support Primary Care Deductible waived for PC All enrollees (incl in PPOs) must be linked with a PCP Commitment to payment reform along CPC+ model More patients in PCMH practices

31 Safety Net Initiatives Federal-State Partnerships CA public hospital and health system PRIME incentive program Bureau of Primary Health Care CHC initiatives Whole Person Care Etc.

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33 Primary Care Workforce I FPs Family physicians and other primary care clinicians in GREAT demand Key role in traditional FFS care model Key role in population health model

34 Primary care physicians such as family physicians and general internists represent an excellent return on investment, which is one reason they have been our number one and number two searches respectively for the last nine years

35 Growing Number FP Residencies

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37 The Consolidating SF Bay Area Health Care Marketplace

38 Summary Yes, it is complicated. The Zombies are back. Coverage not secure. Real and fake news about affordability Strong momentum towards delivery system reform and movement away from fee for service likely to continue Benefits and potential threats of large integrated delivery systems Heightened role of primary care not a flavor of the month fad But must be matched by investment of resources to support revitalized primary care!

39 Michael Pollan s Guide to Nutrition Eat food Not too much Mostly plants

40 Kevin s Guide to Health Care Get medical care Not too much Mostly primary care