The Patient Protection Affordable Care Act What Does it Mean for the Orthopaedic Trauma Surgeon? Manish K. Sethi, M.D. Director of the VOI Center for Health Policy Assistant Professor of Orthopaedic Surgery Division of Trauma, Department of Orthopaedics Vanderbilt University Goals Why are we talking so much about healthcare? The PPACA The PPACA and Trauma How will the PPACA shift practice patterns in trauma Why are we talking about this? 1
Healthcare Spending Out of Control The Healthcare Battle of 2010 The 2010 Patient Protection and Affordable Care Act: The Promises Make Health Insurance Affordable and essentially universal Increase Medicaid Funding to States Save Medicare for Seniors Focus on Prevention Decrease Costs Dramatically 2
The Individual Mandate Supreme Court Ruled Mandate Constitutional If no insurance you pay tax Individual mandate takes effect on Jan 1 st, 2014 By 2016 $695 per year up to a maximum of $2,085 per family or 2.5% of household income Employer mandate delayed one year From Jan 1 st, 2015 employers with >50 employees must provide insurance $2000-$3000 penalty/employee The Employer Mandate <25 Employees 25-49 Employees >50 Employees TAX CREDITS FOR SMALL BUSINESSES FINES FOR UNINSURED EMPLOYEES Health Care Insurance Exchanges State Agency Run EXCHANGE will offer one stop shop to buy insurance Will offer to individuals and employers Decided on Feb 15 th, 2013 whether State or Federal Gov. will Build Pay to Play. 4 different categories of plans offered Final agreement for insurance plans sold through federal exchanges delayed from 9/5-9/9 to late September Open for enrollment on October 1 st, 2013 Some states, such as Oregon, may have to delay opening Marketplace coverage begins on Jan 1 st, 2014 3
Health Care Exchanges Medicare and Obama Cutting Costs..ABC s Reduce rates of payment to physicians/hospitals Medicare Parts A and B ($170 Billion) Between 2011-2014 Dramatically Reduce Payments to Medicare Advantage Medicare Part C ($130 Billion) Means Testing for Medicare Part D i.e. for those with incomes above $85,000/individual and $170,000/couple Reduce Payment for Re-Admissions, Infections, etc. Decrease Medicare Fraud Independent Payment Advisory Board (IPAB) and Medicare 15 Individuals Appointed by the President Will Essentially Decide Medicare Payments, etc. Will Guide Future of Medicare These Individuals are not accountable to Congress First proposal may be in January 2014. 4
The Big Cuts American Hospital Association/AMA Backed a $500 Billion Medicare Cut Also supported 100 million/state cut in the Medicaid Disproportionate Share Hospital funding Why Would Hospitals Ever Go For These Cuts? American Hospital Association/AMA Backed a $500 Billion Medicare Cut Also supported 100 million/state cut in the Medicaid Disproportionate Share Hospital funding WHY IN THE WORLD WOULD YOU DO THIS? Dramatic Medicaid Expansion Expand Medicaid eligibility to extend coverage to all individuals with incomes at or below 133% of the Federal Poverty Level HOSPITALS STAND TO MAKE SERIOUS CASH Expand eligibility level for children ages 6-19 from 100% FPL to 133% FPL. Creation of expansive prescription drug plan within Medicaid Planned start date of January 1 st, 2014 5
Dramatic Medicaid Expansion Supreme Court Ruled Medicaid Expansion Unconstitutional Not Everyone Expanding The PPACA and Trauma $224 Million in Federal Funding The National Trauma Center Stabilization Act 200 million Trauma Care Systems and Planning Development Act 24 Million 6
$224 Million Gained but $5.1 Billion Lost Given that the majority of trauma patients are uninsured, Medicaid Expansion is CRITICAL FOR FINANCIAL Survival of Trauma Centers in the face of 1)Medicare cuts and 2) Medicaid Cuts In States Where There Is No Expansion. But as a Nation Can We Afford an Expansion???? 7
Dramatic Changes Will Occur Healthcare Reimbursement Models and Orthopaedic Trauma: Will There Be Change in Management? 35% 33.00% 30% Percent Response 25% 20% 15% 10% 24.00% 21.3% Rates of Transfer to Tertiary Care Centers 19.0% will Rise 20.0% 17.6% 12.00% 5% 0% 0.9% 0.4% Scenario A Scenario B Scenario C Case 1 Case 2 Case 3 It is Time For Orthopaedic Trauma Surgeons to Get Involved The PPACA will impact us unlike any other legislation since the Great Society Right now other players like the insurance companies and hospitals are making their voices heard No one knows healthcare better than you. We are doctors, but more importantly we are citizens. 8
MULTIPLE AVENUES TO GET INVOLVED Trauma Surgeons Involved in Policy-making Patient Care Advocacy OR If We Get Involved We Can Impact the Future Thank you 9