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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

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The ACA changed four aspects of health care

• Access

• Quality

• Delivery

• Cost

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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