Curry International Tuberculosis Center 1

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1 The Impact of Patient Protection and Affordable Care Act on Tuberculosis Control Christine S. Ho, M.D., M.P.H. Medical Officer Affordable Care Act and Tuberculosis Control National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of Tuberculosis Elimination Objectives Describe: The Affordable Care Act in simple terms The impact of the law on TB control TB programs continued role How programs could strategically leverage opportunities presented by the law to ensure TB services Understanding the Affordable Care Act WHO is covered (and how) WHAT services will be covered WHERE services will be delivered HOW evaluation will take place, inform process 1

2 How Does the Law Affect TB Control? Covered Services Under Affordable Care Act Essential Components of a TB Prevention and Control Program Opportunity To Maximize Population Leverage the Far Larger Personal System to Achieve Population Goals (not to scale!) P. Wortley The Affordable Care Act 6 Adult children 26 and under can be covered by parents plans now 3.1 million newly covered Expands Coverage Uninsured elderly will drop by 20 million in 2015 Medicaid expansion to 133% of FPL (+12 million) Exchanges (+13 million) Employer and nongroup coverage (-5 million) Offers New Consumer Protections and Choice Generally prohibits denial of coverage based on pre-existing conditions children now, adults for plan years starting in 2014 Prohibits rescission (dropping coverage retroactively) Bans lifetime and annual coverage limits, restrictions on out-of-network ER usage Expands consumers rights to appeal denials 2

3 Medicaid Expansion States have the opportunity to expand Medicaid eligibility to adults ages with incomes up to 133% of the Federal Poverty Level (FPL) ($15,282/year for an individual, $31,322/year for a family of 4) 100% federal funding through 2016, 90% thereafter States have no deadline for implementing the expansion One streamlined application for Medicaid and private health plans in the Marketplace Shifts to simplified way of calculating income to determine Medicaid/CHIP eligibility Known as Modified Adjusted Gross Income (MAGI) 8/13/2013 The Insurance Marketplace Million OR CA Who Won t Be Covered? Populations The Size of: PA NY Million CT Million GA FL 8 Bottom line: Significant continuing need for safety net services Prior to healthcare reform, States could add Medicaid eligibility for TB patients States have the option to extend Medicaid eligibility to lowincome persons infected with TB Covered TB-related services include: Prescribed drugs Physicians services (includes outpatient hospital services, rural health clinic services, and Federally Qualified Center (FQHC) services) Laboratory and X-ray services Clinic and FQHC services Case management services Services (other than room and board) designed to encourage completion of outpatient regimens, including services to directly observe the intake of prescribed drugs. 9 States have elected to provide this benefit: (AZ, CA, CT, LA,MN, NY, OK, UT, and WY) Receipt of matching Federal dollars for treating eligible TB patients could alleviate budget difficulties for some states 3

4 Introduction to the Marketplace The Marketplace (or Exchange) Place for qualified individuals and qualified employers to directly compare private health insurance options Known as Qualified Plans (QHPs) Can directly compare on the basis of price, benefits, quality, and other factors 8/13/2013 The Insurance Marketplace Advantages of the Marketplace Helps enhance competition in the health insurance market Increases Affordability through premium tax credits, cost sharing reductions Ensures Quality through QHPs that must meet basic standards, including quality standards, consumer protections, and access to an adequate range of clinicians Makes Costs Clear by providing information about prices and benefits in simple terms consumers can understand, so they don t have to guess about costs 8/13/2013 The Insurance Marketplace What preventive services must be covered under the law? The law requires the following services to be covered without cost-sharing in Nongrandfathered individual and small group plans Medicaid expansion plans United States Preventive Services Task Force (USPSTF) All preventive services with an A or B grade recommendation LTBI screening of high risk persons had an A grade in recommendations deferred to CDC, ungraded Ungraded, LTBI screening not covered without cost-sharing Advisory Council on Immunization Practices (ACIP) and Resources and Services Administration (HRSA)- supported recommendations TB testing for children at high-risk for TB 4

5 All Qualified Plans Will Cover Essential Benefits in These Categories 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care The Insurance Marketplace 101 Essential Community Providers (ECPs) The law requires that QHPs offered through Marketplaces include in their networks those essential community providers, where available, that serve predominately lowincome, medically-underserved individuals. CMS implementing regulations provide that A QHP issuer must have a sufficient number and geographic distribution of ECPs, where available, to ensure reasonable and timely access to a broad range of such providers HRSA identifies ECPs; these include providers eligible for the 340B program TB programs can Be a member of an accountable care organization Identify additional hospitals, clinics, practices that evaluate and diagnose TB suspects and cases Ensure these facilities are designated as ECP Example Urban County A TB Cases Foreign-born cases Mix of newly arrived and settled immigrants or refugees Medical services through the refugee clinic, federally qualified health center (FQHC), or other community providers US-born cases Concentrated in an area with shelters and treatment facilities One FQHC and several non-profit clinics serve this area Options to optimize TB screening and evaluation: Non-profit clinic affiliates with an accountable care organization (academic medical center, consortium) and bill for services TB program partners with FQHC and refugee clinics to do TB screening and evaluation, those clinics bill for services TB clinic gets 340B or FQHC status and bills for services 5

6 Meaningful Use Requirements Examples include: Use of structured fields Use of clinical decision support tools Report clinical quality measures Communicate relevant health information to patients Provide patients ability to view their health information Provide summary of care record for transitions/referrals P. Wortley Clinical Quality Measures Examples from HIV/AIDS Providers will be required to select quality measures to report on New/updated HIV measures in endorsement process: % of patients seen at least once during 12 month period with suppressed VL % of patients seen at least once during 12 month period on ART % of patients with a visit every 6 months over 24 months % of patients with gap in care over 12 month period P. Wortley Clinical Decision Support A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery* CDS can support Retention/re-engagement in care Patient self-care and treatment adherence Data collection and bi-directional reporting and communicating Performance measurement and improvement *Osheroff, Teich, Levick, et. al. Improving outcomes with clinical decision support: an implementer s guide. Second Edition. HIMSS P. Wortley 6

7 Before the Affordable Care Act: Most HD Do Not Bill for Services departments provide services to clients Client care regardless of ability to pay No second or third party billing HD might be paying for some insured patients Results in financial loss for HD, gain for insurance plans Insurance Plans Subhead for Section Myriad Pro, 20pt Option 1: departments bill for services for existing insured patients Option 1: departments (HD) continue to provide clinical services to clients Some clients are insured HD bills those health plans for services Insurance Plans Subhead for Section Myriad Pro, 20pt Additional patients insured through the Affordable Care Act Option 1: HD cares for clients The Law: HD provides client care regardless of ability to pay Second or third party billing to recoup costs, as an ECP or part of an ACO Existing Insurance Plans and QHP Subhead for Section Myriad Pro, 20pt 7

8 Option 2: Insured patients receive services from non-hd providers HD cares for uninsured clients only How does the HD assure quality of services for outside providers? Insurance Plans Subhead for Section Myriad Pro, 20pt Additional patients insured Option 2: HD partners with QHP providers Additional patients now insured HD does not care of insured patients HD partners with QHP to ensure services delivered There are always uninsured patients that still need care Network Providers for Existing Insurance Plans and QHP Billing National Center for Immunization and Respiratory Diseases (NCIRD) American Recovery and Reinvestment Act-funded billing project 2012 NTCA Billing roundtable session CDC and billing activities American Insurance Plan (AHIP) has 3-part billable project to support sites (not known whether this will need MOU or workaround) Contracting Coding Credentialing National Association of City and County Officials (NACCHO) developed a billing toolkit 8

9 Continued Role for Public Populations most at risk for TB non US-born, racial or ethnic minorities, homeless, and persons affected by alcohol or substance abuse, have limited access to health care Ongoing transmission, outbreaks, and drug resistance can result If contacts of infectious patients are not located and provided preventive therapy If persons with TB disease are not treated completely Guarantees for inherently governmental public health services were not the goal of the law Affordable Care Act expansion will not substantially decrease the need for these services by CDC and health department partners Steps to Leverage TB Services in the Community Study Alternative Plan what is and isn t covered Identify health plans that serve populations at highrisk for TB Work with those plans directly to cover TB-related patient services (such as LTBI treatment) Identify providers that serve individuals at high-risk for TB Explore partnership with these providers Capacity, turnover, realistic activities for partnership Explore future education and quality assurance opportunities in these settings Acknowledgements CDC Ann Cronin Victor Balaban Haley Stolp Stuart Berman Pascale Wortley Rozina Kassam Connie Henderson Suzanne Marks Awal Khan Dolly Katz Lydia Ogden George Washington University Naomi Seiler National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention 9