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Practicing Medicine in the Era of Health Reform
Session 16Panel Discussion—
The Affordable Care Act: Evaluating the Rolloutand Discussing Next StepsJames Roosevelt, Jr., Esq.
Jon Kingsdale, PhDDavid Green, MD
August 13, 2015
Tufts Health Care Institute
James Roosevelt Jr., J.D.CEO, Tufts Health Plan
Co-chair, Tufts Health Care InstituteClinical Instructor, Tufts University School of Medicine
Introduction and Overview of the Affordable Care Act
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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
4
The ACA changed four aspects of health care
• Access
• Quality
• Delivery
• Cost
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
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
NOTE: FPL ‐‐ The federal poverty level was $22,350 for a family of four in 2011. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
Coverage of the Nonelderly by Poverty Level, 2011
20%39%
73%90%48%
32%
12%
4%32% 29%
15%5%
<100% FPL 100‐199% FPL 200‐399% FPL 400%+ FPL
Employer/Other Private Medicaid/Other Public Uninsured
Children includes all individuals ages 0-18. Parents are defined as adults with dependent children ages 0-18 and adults without children do not have dependent children ages 0-18. Both parents and adults without children include adults ages 19-64. Data does not total 100% due to rounding. SOURCE: KCMU/ Urban Institute analysis of 2012 ASEC Supplement to the CPS.
The Nonelderly Uninsured Population by Age and Parent Status, 2011
Adults without
dependent children,
59%
Children, 16%
Parents, 25%
47.9 M Uninsured
Majority of uninsured were childless adults
NOTE: The federal poverty level was $22,350 for a family of four in 2011. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2012 ASEC Supplement to the CPS.
Family Work Status
Part-Time Workers,
16%No Workers,
22%
1 or More Full-Time Workers,
62%
Total = 47.9 Million Uninsured
Most uninsured are in working households, 2011
Uninsured Rates Among Nonelderly by State, 2010-2011
<14% Uninsured (13 states & DC)14 to 18% Uninsured (20 states)National Average = 18.2%
SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplement to the CPS (two-year pooled data).
AZ
WA
WY
ID
UT
OR
NV
CA
MT
HI
AK
AR
MS
LA
MN
ND
CO
IA
WISD
MOKS
TN
NMOK
TX
AL
MI
ILOH
IN
KYNC
PA
VAWV
SC
GA
FL
ME
NY
NH
MA
VT
NJ
DE
MD
RI
DC
CT
>18% Uninsured (17 states)
NE
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”
Diagnosis of Late-Stage CancerUninsured vs. Privately Insured
2.9
2.32.22.0
0.0
0.5
1.0
1.5
2.0
2.5
3.0
ColorectalCancer
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 1998-2004.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.
Equal likelihood between
Uninsured and Insured
Ratio of probability of diagnosis of late vs. early stage cancer, Uninsured/private insurance
Barriers to Health Care Among Nonelderly Adults, by Insurance Status, 2009
6%
4%
6%
11%
13%
9%
6%
11%
27%
26%
42%
55%
Could Not AffordPrescription
Drug*
Went WithoutNeeded Care Due
to Cost*
No PreventiveCare
No Usual Sourceof Care
Uninsured
Medicaid/Other Public
Employer/Other Private
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.
Percent of adults (age 18 – 64) reporting:
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
Key Elements of Coverage Reform:“Shared Responsibility”
Individuals:-Mandate-Premium contri-
bution
Government:-QHP Premium assistance
-Medicaid eligibilityexpansion
Employers: > 50 FTEs offer affordable
coverage
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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 2015 16
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
Market Reformsin individual and ESI coverage
– “Essential health benefits”– Adjusted community rating– Guaranteed issue & renewal– No upper limits on coverage– Administrative simplification– Health insurance exchanges
http://aspe.hhs.gov/health/reports/2011/youngadultsaca/ib.shtml
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Health Insurance Marketplace Penetration
How to Offer Consumers Comparable Choice?
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Both state and federal exchanges offer consumersfour coverage levels or actuarial values
BronzeActuarial Value of Essential Benefits:60%
SilverActuarial Value of Essential Benefits:70%
GoldActuarial Value of Essential Benefits:80%
PlatinumActuarial Value of Essential Benefits:90%
But what’s “actuarial value”?
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
Standard Gold Point of Service (POS) Remove from comparison
Apply
Healthy Partner Preferred Remove from comparison
Apply
Anthem Gold DirectAccess Standard ‐cddk
Remove from comparison
Apply
Plan Overview
Estimated Monthly Premium $1031.76
Price after estimated $0.00 tax credit $1060.98
Price after estimated $0.00 tax credit $1144.83
Price after estimated $0.00 tax credit
Health Care Provider Search Providers Search Providers Search Providers
Plan Type POS PPO PPO
Plan Level *Gold *Gold *Gold
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
KISS: Put in County, Age, Household Size & Metallic Level
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?
Adults ages 19–64 who selected a private plan or enrolled in Medicaid through the marketplace
or have had Medicaid for less than 1 year
No34%
Yes60%
Adults ages 19–64 who have used new health insurance plan
Have you used your new health insurance plan to visit a doctor, hospital, or other health care
provider, or to pay for prescription drugs?
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
No62%
Yes36%
Don’t know or refused
2%
Note: Segments may not sum to 100 percent because of rounding.Source: The Commonwealth Fund Affordable Care Act Tracking Survey, April–June 2014.
Prior to getting your new health insurance plan, would you have
been able to access and/or afford this care?
Plan has not yet gone into
effect6%
2005 2010 2012 2014In the past 12 months:
Had problems paying or unable to pay medical bills
23%39 million
29%53 million
30%55 million
23%43 million
Contacted by a collection agency about medical bills*
21%36 million
23%42 million
22%41 million
20%37 million
Contacted by collection agency for unpaid medical bills
13%22 million
16%30 million
18%32 million
15%27 million
Contacted by a collection agency because of billing mistake
7%11 million
5%9 million
4%7 million
4%8 million
Had to change way of life to pay bills14%
24 million17%
31 million16%
29 million14%
26 millionAny of three bill problems (does not include billing mistake)
28%48 million
34%62 million
34%63 million
29%53 million
Medical bills being paid off over time21%
37 million24%
44 million26%
48 million22%
40 million
Any of three bill problems or medical debt34 %
58 million40%
73 million41%
75 million35%
64 million
Adults Reporting Medical Bill Problems Declined in 2014
* 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).
Percent of adults ages 19–64
2003 2005 2010 2012 2014
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 prescription23%
39 million25%
43 million26%
48 million27%
50 million19%
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 problems37%
63 million37%
64 million41%
75 million43%
80 million36%
66 million
The Number of Adults Reporting Not Getting Needed Care Due to Cost Declined in 2014
Source: The Commonwealth Fund Biennial Health Insurance Surveys (2003, 2005, 2010, 2012, and 2014).
Percent of adults ages 19–64
Panel Discussion
The Affordable Care Act: Evaluating the Rollout and Discussing Next Steps
David Green, MD, FACSSr. Vice President Medical Affairs/
Chief Medical OfficerConcord Hospital, Concord, NH
PPACA 3/23/2010• Expand coverage• Control costs
• Improve delivery system
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?
Disruptive Change“As long as an organization continues to facethe same sort of problems that its processeswere designed to address, managing anorganization can be straight forward. Thesefactors also define what an organizationcannot do, and constitute disabilities whenproblems facing a company changefundamentally.”
Christenson 2000
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
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
What is the effect on delivery of care?MSSP
Concord HospitalElliot Health SystemSouthern NH Health SystemWentworth‐Douglass Hospital
What will evolve and change?(It’s not just the PPACA)
• Meaningful Use• ICD‐10• MACRA 2015
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
MACRA(The death of FFS medicine?)
• Track 1– 0.5% annual update 2015‐2019, “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
“…as we know, there areknown knows; there arethings we know we know…
What will evolve and change?
We also know there areknown unknowns; that isto say we know there aresome things we do notknow.”
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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The four aspects of healthcare changed by the ACAAccess
• 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
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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
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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)
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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
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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 2016
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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
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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