The Impact of ACA

Measuring the Impact of theACA and Health Care Reform

The information presented in this Webinar is current as of date of live airing – August 27, 2014

Dan HaleyVP, Gov’t and Regulatory Affairs

Josh GrayVP, athenaResearch

The BIG Question:Is the ACA

Working???

Depends on who you ask…

Evidence is mixed—and selectively invoked

• Increased access!

• Increased enrollment!

• Early bugs fixed!

• Premiums holding steady or falling!

• Rollout disaster!

• Key provisions delayed!

• Cost of care continuing to increase!

• Premiums increasing!

Our BIG Question:

How is the ACA impacting health IT policy, and our care

provider clients?

5

Again, the evidence is mixed


Increased access to insurance = increased access to care!

Lack of information fluidity and transparency means patients and providers cannot shop, so costs continue to rise.


Emphasis on accountable care = increased demand for modern information technology!

Government continues to subsidize closed platforms that do not interoperate.


Health IT standards and deadlines incentivize adoption and use!

Repeated deadline delays and reductions of standards create uncertainty and hamper innovation.

So the verdict is still out, but what do we

KNOW…?

A lot. Our platform and our data give us unparalleled insight

10

Josh Gray, Vice President, athenaResearch (JoshGray_hit)

Update on ACAView

Update onHealthcare

Reform

13

Health care reform rests on three pillars for expanding coverage and

controlling costs

Source: The Advisory Board Company

Fiscal Mechanisms

Slower Medicare cost increases

Disproportionate Share Hospital (DSH) reductions

Independent Payment Advisory Board empowered to reduce Medicare outlays above specified threshold

Delivery System Reform

Bundled payments expanding the episode of care

Shared Savings and ACOs creating total accountability for cost and outcomes

Pay-for-performance programs linking payments to care

Medical homes sharpening focus on high-risk patients

Coverage Expansion

Medicaid expansion broadens eligibility for low-income families• 26 states plus DC

have opted to expand Medicaid

Health insurance exchanges increase coverage options, offer subsidies for low- and middle-income families

Near-Universal Coverage, Sustainable Cost Growth

14

Bundled payments off to a solid start

Source: The Advisory Board Company; Centers for Medicare and Medicaid Services.

Medicare Moving Quickly Private Sector Not Far Behind

Large Employers Exploring Bundling

Major Insurers in Pilot Stage

Partnering with Cleveland Clinic for select cardiac surgeries

Working with five major health systems for high-cost procedures

Offers employees cardiac and bundles at Johns Hopkins

BCBS North Carolina bundling orthopedic services at four sites

United bundling oncology services with Florida oncology clinics

Reimbursing bundled procedures at California orthopedic center

National initiative launched in 2011 by the Center for Medicare and Medicaid Innovation (CMMI)

Offers 48 standardized bundles, including cardiac surgeries, orthopedics, diabetes, and CHF

Covers pre-admission, inpatient, and (in some cases) post-discharge care

350 participating providers

Bundled Payments for Care Improvement

0

100

200

300

400

500

600

700

41 65 81

97

138

146

208

334356

458

479489

606 624

ACOs hitting their stride

15 Source: Leavitt Partners Center for Accountable Care Intelligence.

2010 2011 2012 2013

# o

f A

CO

s

Q4 Q1

Q2 Q3

Q4 Q1

Q2 Q3

Q4 Q1

Q2 Q3

Q4 Q1

• ACOs cover 18 million individuals

• > 50% of US population lives in markets served by ACOs

• 260 ACOs sponsored by medical groups

ACOs in Brief

2014

Two main drivers of coverage expansion

Expanded Medicaid Eligibility

Millions of Newly Eligible Individuals

Health Insurance Exchanges

More Options, with Generous Subsidies

Medicaid Eligibility, % Federal Poverty Level

47%Median State Eligibility, Pre-

ACA

133%States

ExpandingMedicaid

HIX

Primary mechanism for increasing coverage among low-income individuals

Expanded Medicaid eligibility covers individuals up to 133% of the federal poverty level (FPL)

Federal funding pays 100% of additional costs today, dropping to 90% in 2020

20 states have declined expansion, but allowed to participate in future years

National and state-run insurance exchanges link insurers and individuals

Plan tiers defined by actuarial value

Subsidies available to individuals with incomes up to 400% of the FPL

17 states operate own exchanges, 7 partner with federal government, 27 defer to federal exchange

Source: Kaiser Family Foundation, “State Decisions for Creating Health Insurance Marketplaces, 2014.”

17

Enrollment surged in the last few weeks

Source: Kaiser Family Foundation, “Total Monthly Marketplace Enrollment,” whitehouse.gov.

Oct 2013 Nov 2013 Dec 2013 Jan 2014 Feb 2014 Mar 2014 Apr 2014

106k365k

2.15M

3.30M

4.24M

8.02M3 Million+

Exchange Enrollment in Final Month

Jeffrey ZientsDirector of the National Economic Council

Former Director of the OMB, Chief Performance Officer of the United States, and head of HealthCare.gov “tech surge”

Todd ParkChief Technology Officer of the United States

Former CTO of the Department of Health and Human Services, co-founder of Athenahealth

7 MillionOriginal Enrollment

Target

Many states not expanding Medicaid

18

Expanding Medicaid

26 States plus DC

ConsideringExpansion

4States

Not Expanding Medicaid

20States

Source: The Advisory Board Company.

19

Coverage expansion exerting an uneven affect on states

South Dakota

Texas

Virginia

Pennsylvania

North Dakota

Maine

Wyoming

Tennessee

Utah

Wisconsin

Minnesota

North Carolina

New York

Ohio

Connecticut

Rhode Island

Colorado

Arizona

West Virginia

Washington

Significant Variation in the Newly InsuredNewly Insured Individuals per 1,000 Residents

Insured via Exchanges

Enrolled in Medicaid

Source: Centers for Medicare and Medicaid Services, “Medicaid & CHIP: April 2014 Monthly Applications,

Eligibility Determinations, and Enrollment Report,” Charles Gaba, ACASignups.net (various sources).

94

9286

83

6967

6560

5855

2018

1413

119

865

5

8.4 Million

Insured via Exchanges

5.3 Million

Newly Enrolled in Medicaid

Most

New

ly I

nsu

red

Few

est

New

ly I

nsu

red

Introducing ACAView

Overview

21

athenahealth today:

• Businesses: Billing, EHR, Patient Portal, Referral Coordination, Business Intelligence

• Architecture: Single-instance, multi-tenant cloud based application

• Billing: 36K MDs, 14K midlevels, 51M patients

• EHR: 12K MDs, 4K midlevels, 22M Lives

• 50 states and 92 medical specialties

• 2013 (clinicals): 12M patients, 40 M visits

• 2013 (claims): 30M patients, 80 M visits

Office Visit Characteristics: Physician DemographicsAthenahealth ACAView Practices vs NAMCS

Practice Size (Physicians)

12

3-56-10

11+

Census Region

Northeast

MidwestSouthWest

MSA Status Metro

32%12%

25%18%

14%

20%22%

38%21%

89%

18%14%

27%19%22%

22%22%

46%10%

88%

ACAView 20131 NAMCS2

Source: athenaResearch1: 30 million visits to practices active on the athenahealth network before 20112. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

A robust sample: physician demographics

Office Visit Characteristics: Patient DemographicsAthenahealth ACAView Practices vs NAMCS

Age

< 1515-2425-4445-6465-74

75+

Insurance

CommercialMedicare

Medicaid or CHIPMedicare and

MedicaidUninsured

Workers' Compensation

Other

Gender Female

16%8%

20%31%

13%12%

63%25%

14%2%4%1%6%

60%

13%8%

19%30%

15%15%

58%21%

10%5%3%2%2%

59%

ACAView 20131 NAMCS2

Source: athenaResearch1: 30 million visits to practices active on the athenahealth network before 20112. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf

A robust sample: patient demographics

ACA View: Measuring the impact of health care reform

+24

Metrics include…

• Percent of total visits from new patients

• Percent of new patients with chronic disease

• Patient copays

• Bad debt

• Provider reimbursement levels

• Appointment wait time

• Work RVUs per visit

Partnering with RWJF to track the impact of coverage expansion

25

ACCESS PHYSICIAN VOLUMES DELEGATION

▶ New patient visits as % of total visits for PCPs

▶ Days to schedule an appointment

▶ Visits per week for PCPs

▶ Schedule density

▶ Percent of visits where rendering provider is a PA or NP for PCP practices

ACUITY/HEALTH STATUS REIMBURSEMENTPATIENT FINANCIAL

OBLIGATIONS

▶ Distribution of E&M visits by level

▶ Number of dx per visit

▶ % of patients w diabetes dx

▶ % of patients w HBP dx

▶ % of w hyperlipidemia

▶ Referrals per visit

▶ Scripts per visit

▶ Obesity rate

▶ HbA1C values

▶ BP values

▶ LDL values

▶ wRVU per visit

▶ % change in allowables per RVU

▶ Denials

▶ First pass rate

▶ Patient financial obligation ($/visit)

▶ Patient out-of-pocket payments ($/visit)

▶ % of patient obligations paid at 90 and 180 days

▶ Proportion of charges going to collections.

Proportion of Visits from New Patients, By Specialty Category

January through July

30%

20%

10%

0%

PCP Pediatrics OB/GYN Surgery Other

20.5%

18.3%

26.6%

44.0%

34.6%

20.4%19.0%

26.1%

44.4%

33.8%

40.6%2013 2014

Sample: Over 35 million visits to practices active on the athenahealth network before 2011Source: athenaResearch

40.6%

Physicians are so far not seeing more new patients

Work Intensity Metrics for New Patients to PCPs2013 vs 2014, January through July

Work RVUper Visit

Diagnoses per Visit

% of Visits with High

Complexity E&M Code*

2013 2.0 2.4 8.9%

2014 2.0 2.4 8.3%

* E&M code level 4 or 5.Sample: Over 35 million visits to practices active on the athenahealth network before 2011Source: athenaResearch

Complexity of new patients holding steady

2013 2014 % Change

EstablishedPatients

Diabetes 9.5% 9.4% -1%

High Blood Pressure

19.4%

19.6%

1%

High Cholesterol 15.8% 15.2% -4%

NewPatients

Diabetes 5.5% 5.6% 2%

High Blood Pressure

12.7% 12.9% 2%


*% of encounters with diagnosisSample: 430K visits/month, to locations active before 2011Source: athenaResearch

Chronic Disease Rates*, Jan-JulyPCP Visits for Commercially Insured (18-64)

New patients this year have similar rates of chronic

diseases…

Figure 6: Chronic Disease Rates (18-64)*, Jan-MayPCP Visits for Privately Insured, Small Practices, South

Census Region

2013 2014 % Change

EstablishedPatients

Diabetes 10.0% 9.8% -2%

High Blood Pressure 1 22.4% 22.9% 2%


NewPatients

Diabetes 5.1% 5.7% 12%

High Blood Pressure 14.5% 1 15.5% 7%

High Cholesterol 8.6% 8.7% 2%

*% of encounters with diagnosisSample: 50K visits/month, to locations active before 2011Source: athenaResearch

…except for patients receiving care at small practices in the

South

Payer Mix for Adult (18-64) PCP Visits, January through May Medicaid Expansion States vs Non-Expansion States

Sample: 5,000 primary care providers active on athenahealth prior to 2011Source: athenaResearch

Different payer mix shifts depending on Medicaid

expansion status

8.3%

7.3%

10.8%

10.3%

7.7%

7.1%

4.2%

3.8%

69.0%

71.5%

13.8%

15.8%

9.8% 9.8%

4.7%

3.2%

3.6%

3.2%

68.1%

68.0%

2.5%

-1.0%

-0.6%

-0.6%

-0.3%

-0.2%

2.0%

0.1%

-1.5%

-0.4%

16%

12%

8%

4%

0%

Sample: 5,000 primary care providers active on athenahealth prior to 2011Source: athenaResearch

Medicaid is spiking in expansion states, flat elsewhere

Non-Expansion State: UninsuredExpansion State: Medicaid

Non-Expansion State: Medicaid

Expansion State: Uninsured

1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7

2012 2013 2014

Adult (18-64) PCP Visits from Medicaid and Uninsured Patients Medicaid Expansion States vs Non-Expansion States

3.1%4.3%

5.7%

6.1%

6.2%

6.8%

16.0%12.4

%

Confidential – do not distribute. Copyright © 2011 epocrates, inc. All rights reserved.

▶ Patient obligations ▶ Patient out of pocket payments

▶ Referrals per visit

▶ Schedule density ▶ Patient payments as percent of obligations – 90 and 180 days

▶ Scripts per visit

▶ Appointment lag time ▶ Denials – new and exiting patients

▶ Obesity rate

▶ Allowables per RVU ▶ First pass rate ▶ HbA1c, BP, LDL values outside threshold

▶ Proportion of charges going to collections

▶ Percent of visits performed by MDs, NPs, PAs

Just scratching the surface: timeline for future metrics

9/15/14 12/15/14 3/15/14

For more information

SLIDE 33 CONFIDENTIAL – DO NOT DISTRIBUTE. Copyright © 2011 Epocrates, Inc. All Rights Reserved.

Source: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414550

The Impact of ACA

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