Financing of Care and Its Impact

Transcription

1 The Impact f the ACA Changes t the Delivery and Financing f Care and Its Impact Thmas McAuliffe Directr f Health Plicy Missuri Fundatin fr Health September, 2015

2 Health is mre than health care

3 Hw Can Yu Explain This? Health Care Spending vs Health Outcmes Surce: United Natins Develpment Prgramme Reprt Retrieved frm 3

4 DETERMINANTS OF HEALTH 5-10% 4

5 The REAL Causes f Death

6 Tertiary di l Care Health hcare Medical Pyramid Secndary Medical Care 95%+ Health Care $$ Spent n Acute and Chrnic Care Primary Medical Care Ppulatin-Based Services 10% f Imprvement in Health Status Attributed t Medical Care 90% Attributed t Ppulatin-Based Appraches Adapted frm J. Michael McGinnis, M.D.

7 Ppulatin Health

8 Ppulatin Health An apprach t health that aims t imprve the health hf an entire ppulatin Addresses a brad range f factrs that impact health n a ppulatin level A perspective recgnizing the imprtance f scial determinants f health and the relatively minr impact that medicine and healthcare have n imprving health verall.

9 Individual Vs Ppulatin Health Best utcme fr individual Treat a patient fr gastrenteritis Vaccinating patients Cunseling against smking Treating the cnsequences f besity Treating STD Diagnsing an illness Cmmunity s health Investigating utbreaks, restaurant inspectins, safe water Safety net fr vaccinating medically indigent Advcating fr smke free envirnments Prmting built envirnments cnducive t physical activity Finding andtreating expsed partners Cnducting cmmunity health assessments

10 Health Refrm s Opprtunity t Imprve Public Health Ppulatin Apprach + Clinical Care = Better Health

11 But.. Hw d we g abut getting citizens and legislatrs t care?

12 Health in all Plicies Lks at all public and private sectr plicy making thrugh a health lens Objective is t prmte and prtect the health f the ppulatin Addresses the scial and physical envirnment p y influences n health

13 Integratin f primary care and public health

14 What Is Meant by Integratin The linkage f prgrams and activities t prmte verall efficiency and effectiveness and achieve gains in ppulatin health. Can take many frms Surce: Institute f Medicine. Primary Care and Public Health Explring Integratin t Imprve Ppulatin Health, March

15 Why Integrate Nw? Increase in cst f in health care Imprtance f scial and envirnmental determinants f health Dialgue t understand and address cmmunity level health cncerns ACA presents pprtunities Surce: Institute f Medicine Primary Care and Surce: Institute f Medicine. Primary Care and Public Health Explring Integratin t Imprve Ppulatin Health, March

16 ACA 1) The Affrdable Care Act: Main Themes and Issues 2) Delivery System Refrm: Emerging Mdels Related t the Delivery and Financing f Care 3) Cvering the Uninsured: The Health Insurance Marketplace and Medicaid Expansin 4) Lking int the Future

17 1) What was Refrm REALLY Abut? Expanding Health Insurance Cverage Fcus n Ppulatin Health and Preventin Increasing Quality f Care fr Everyne Signaling that Business As Usual is Over New Mdels f Care Incentive Realignment Insurance Regulatins

18 2) Delivery System Refrms The days f Fee fr Service are cming t an end New mdels that bundle payments and pay fr quality and utcmes Meant t imprve patient care and reign in csts Requires crdinatin and realignment f systems It s scary

19 Innvatin Center Prtfli ACO Suite: Shared Savings Prgram Pineer ACO Mdel Advance Payment ACO Mdel Accelerated and Learning Develpment Sessins Primary Care Suite Cmprehensive Primary Care Initiative (CPCI) Federally Qualified Health Center Advanced Primary Care Practice Demnstratin Multi Payer Advanced Primary Care Practice (MAPCP) Demnstratin Independence at Hme Medicaid Health Hme State Plan Optin Bundled Payment Suite Bundled Payment fr Care Imprvement Dual Eligible Suite: State Demnstratin t Integrate care fr Dual Eligible ibl Individuals id Financial Alignment t Supprt State Effrts t Integrate Care Demnstratin t Reduce Avidable Hspitalizatins f Nursing Facility Residents Medicaid Health Hme State Plan Optin Diffusin and Scale Suite: Partnership fr Patients Millin Hearts Campaign Innvatin Advisrs Prgram Care Innvatins Summit Healthcare Innvatin Challenge Rapid Cycle Evaluatin and Research Learning and Diffusin

20 The Private Insurance Sectr is Fllwing Alng

21 Cst Grwth is Decreasing

22 Quality Financial rewards fr hspitals based n quality and patient utcmes in Medicare Medicare managed care plans 4 & 5 star Medicare private plans 5% bnus Independent payment advisry bard Identify areas f waste and savings fr Medicare Patient Centered Outcmes Research Institute Cmparative effectiveness research Determine best and mst ecnmical treatment f cmmn diseases (n mandates)

23 3) Expanding Cverage t the Uninsured 48 millin uninsured Americans 794,000 uninsured Missurians ACA prvided tw cverage mechanisms: Health Insurance Marketplaces (Exchanges) Mdi Medicaid idexpansin E i d illi f h 48 illi Estimated t cver millin f the 48 millin uninsured in the US

24 Health Insurance Marketplace The Marketplace Is A resurce fr individuals, families, and small businesses t: Learn abut private insurance cverage ptins Cmpare and chse private insurance plans Find ut if eligible fr subsidies/tax credits Open Enrllment Perids (Nv. 1, 2015 Jan. 31, 2016) Special ilenrllment Perids (60 days after life change event) Fund at in 37 states

25 Health Insurance Marketplace Selected Marketplace Features: MustuseMarketplace use Marketplace t receive subsidies Individuals and families with incme between 100% 400% FPL Smallemplyers withfewer than25emplyees Encurages cmpetitin amng private insurance N wrng dr access fr cnsumers Free enrllment assistance it is available Missuri s Prpsitin E

26 Open Enrllment Perid Results Missuri s Federally Facilitated Marketplace Update 1 st Open Enrllment (OE1): 152,335 Missurians enrlled in Marketplace plans Ttal exceeds CMS prjectins by 29% 85% received financial assistance OE2: 253,696 Missurians enrlled 66% increase frm OE1 Over 4% f Missuri s ppulatin 87% received financial assistance

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28 Taking Stck: Missuri Enrllment Numbers enrlled remarkably gd given envirnment Awareness is still a huge issue Need cncerted effrt targeted at hard t reach ppulatins Wid d d f h lthi Widespread need fr health insurance literacy

29 Medicaid Expansin Originally was a mandatry expansin Supreme Curt ruling made Medicaid expansin ptinal Expand Medicaid t 133% (138%) f FPL fr nn Medicare individuals and families 100% federal funding thrugh 2016, steps dwn t 90% in 2020 and later years

30 Current Status f State Medicaid Expansin Decisins i WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI* IA* IL MO AR* MS VT NY MI* PA* OH IN* WV VA KY NC TN SC AL GA ME NH* MA CT RI NJ DE MD DC TX LA AK HI FL Adpted (30 States including DC) Nt Adpting At This Time (21 States) NOTES: Under discussin indicates executive activity supprting adptin f the Medicaid expansin. *AR, IA, IN, MI, and PA have apprved Sectin 1115 waivers. Cverage under the PA waiver went int effect n January 1, 2015, but the newly elected gvernr may pt fr a state plan amendment. Cverage under the IN waiver is set t begin February 1, NH has submitted a waiver t cntinue their expansin via premium assistance. WI cvers adults up t 100% FPL in Medicaid, but did nt adpt the ACA expansin. SOURCE: Status f State Actin n the Medicaid Expansin Decisin, KFF State Health Facts, updated January 27, refrm/state indicatr/state activity arund expanding medicaid under the affrdable care act/

31 2015 Federal Pverty Levels (FPL) 100% f FPL The Pverty Level 1 $11,770 2 $15,930 3 $20,090 4 $24,250

32 Missuri Medicaid Eligibility and Expansin 300% 300% (FPL) 250% Percen nt f Feder ral Pverty 200% 150% 100% 50% 196% 138% 138% 18% 100% 85% 85% 0% Children 0 18 Parents Pregnant Wmen Blind Elderly Disabled Childless Adults

33 2015 Federal Pverty Levels (FPL) 85% 100% 138% 196% 300% 1 $10,005 $11,770 $16,243 $23,069 $35, ,541 15,930 21,983 31,223 47, ,077 20,090 27,724 39,376 60, ,613 24,250 33,465 47,530 72,750

34 Marketplace Subsidies 90% f the currently uninsured have incmes belw 400% f pverty. 66% f the currently uninsured have incmes belw 200% f pverty.

35 What d Refrmers want? Private insurance, nt public prgrams Mre patient persnal respnsibility bl Cst sharing Premiums Incentives fr healthy behavir Use market incentives t keep cst grwth dwn PCMH, bundled payments, shared savings

36 Uncmpensated Care & the ACA 62% f uncmpensated care (UCC) is federally funded Funds cme thrugh Medicaid, Medicare, VHA, IHS, CHC funding, and Ryan White Because the ACA anticipated declines in UCC, the law enacts reductins in the majr existing streams fr UCC Examples Mdi Medicaid iddsh will be reduced db by $17.6 billin by FY2020 Medicare DSH reduced by 75% (Save $22.1 billin between 2010 and 2019) 36

37 In States that Expanded Medicaid

38 4) Where are we headed? On Delivery System Push fr efficiency, transparency and new business mdels will cntinue Will have t address wrkfrce and scpe f practice issues On the Marketplaces Lts f variability in pricing acrss states Lts f issuers jining, sme leaving On Medicaid Expansin Math trumps idelgy, eventually It wuld be wise f Feds t allw many waivers

39 2016 Electin

40 Questins

41 Cntact Infrmatin: Thmas McAuliffe ffh (314)