"the impact of healthcare reform on diabetes care" - patty telgener, diabetesmine...
DESCRIPTION
Patty Telgener of Emerson Consultants gave a keynote talk on the impace of healthcare reform on diabetes care at the 2013 DiabetesMine Innovation Summit at Stanford School of Medicine Nov. 15.TRANSCRIPT
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What Does Healthcare Reform Mean For Diabetes?
What Does Healthcare Reform Mean For Diabetes?
Patty Telgener, RN, MBA
VP of Reimbursement
Emerson Consultants
Current EnvironmentCurrent Environment
“Americans want three things from their healthcare system: Immediate Access Low out of pocket cost High tech medicine “Latest and Greatest”
While it’s easy to deliver two of the three, it may be impossible to have all three”
The former Surgeon General, C Everett Koop
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Is Healthcare Reform Good or Bad?Is Healthcare Reform Good or Bad?
Depends on Who You Ask!
Expanded market share• 32 million potential new customers• Removal of lifetime caps• Coverage for pre-existing conditions • Expanded coverage for preventive services
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What Does Healthcare Reform Mean to Diabetes?
What Does Healthcare Reform Mean to Diabetes?
• People with diabetes will no longer be denied insurance or forced to pay higher premiums
• Focus on prevention and wellness tools • Increase focus on Chronic Diseases• Uninsured people with diabetes will be able to
access insurance through high risk pools specifically created to make insurance available until the provisions banning discrimination are fully in place in 2014
Healthcare Reform Already in Place Impacting Diabetes
Healthcare Reform Already in Place Impacting Diabetes
No pre-existing conditions exclusion for children Prohibited from excluding children with diabetes
from parents insurance No cancelling policies; prohibited from rescinding policies No lifetime limits on benefitsYoung adults can stay on parents plan up to age 26Some preventive services will be free of co-pays and deductibleBeneficiaries receiving a 50% discount on brand name drugs
Benefits Starting in 2014Benefits Starting in 2014
Adults with diabetes can’t be denied coverage
Premiums can’t be based on diabetes or other chronic disease
All plans sold to individuals and small employers must provide “essential health benefits”
Expanded Medicaid eligibility
Copyright Emerson Consultants, Inc.February 12, 2009 7
Focus on Prevention of DiabetesFocus on Prevention of Diabetes
Healthcare reform established the National Diabetes Prevention Program (NDPP) Expand reach of community-based programs to
prevent Type 2
Market Insurance Plans New way for individuals, families and small
businesses to shop for health insurance Plans differentiated based on percentage the plan
pays for covered benefits. Higher premiums, lower out of pocket
Copyright Emerson Consultants, Inc.February 12, 2009 8
Change in Medicare Diabetes SuppliesCompetitive Bidding
Change in Medicare Diabetes SuppliesCompetitive Bidding
Beneficiaries with fee for service Medicare will have two options to purchase their diabetes testing supplies: Beneficiaries can have their diabetic testing supplies
delivered directly to their home by a national mail-order contract supplier (mail-order), or
Beneficiaries can pick up their supplies in person from any Medicare-enrolled supplier of diabetic testing supplies (non-mail-order)
Medicare-approved amount for diabetic testing supplies will be the same regardless of where the supplies are furnished
Competitive Bidding Impact on Patients
Competitive Bidding Impact on Patients
Before competitive bidding, Medicare beneficiaries paid an average of $15.58 a month for testing supplies
Now, average out of pocket is $4.50
Insulin pumps expected to be part of Competitive Bidding starting January 2014
But most likely to have less options!
Copyright Emerson Consultants, Inc.February 12, 2009 10
Change in Drug CoverageChange in Drug Coverage
New law is closing the gap for out of pocket costs under Part D
Donut hole is between $2,870 and $4,750 In 2013, pay 47.5% for brand name. Decrease
to 25% by 2020, then eliminated
Full price count toward out-of-pocket expense For example, $100 is cost of drug, patient pays
$47.50 but $100 counts toward donut holeCopyright Emerson Consultants, Inc.February 12, 2009 11
Free Preventive CareFree Preventive Care
Type 2 screening
Obesity screening and counseling
Nutrition counseling
Blood pressure screening
Gestational diabetes screening May not have copayment or deductible for
preventive screening
Copyright Emerson Consultants, Inc.February 12, 2009 12
Device and Pharma InitiativesDevice and Pharma Initiatives
Device and Pharma companies “Pay to Play” Excise tax of 2.3% applicable to all device
manufacturers regardless of size
Pharma required to give significant discounts on brand names to Part D plans
Increase Focus on Performance Measurements Moving from “Carrot” to the “Stick” Approach
Changes in payment methodologies Moving away from fee-for-service (i.e. Accountable Care
Organizations)
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Paradigm Shift Away from “Build It and They Will Pay”Paradigm Shift Away from “Build It and They Will Pay”
Comparative Effectiveness Research Payers (private and government) are raising the
requirement for level of clinical evidence No longer sufficient to show “superiority over
placebo or standard therapy”, but may now be compared to competitive therapiesAdvance featured insulin pump compared to standard
insulin pump (previously compared to multiple daily injections)
May see increase in registries tracking outcomes
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Why Develop a New Medical Technology?
Why Develop a New Medical Technology?
1. Physician had a great idea (presented on a napkin)2. Engineers can build it3. Marketing says they can package, brand, and create
the need for it4. Sales force says they need it and can sell it5. Board expects it6. Shareholders demand it7. Competition does not have it8. Patients want it (internet blogs told them so)9. Regulatory says it is a 510(k) not PMA10.Clinical says no study necessary, just sell it
Copyright Emerson Consultants, Inc. 2012 15
Better Reasons Better Reasons
The technology will provide substantial clinical improvement over the current standard of care
It will provide an economic advantage to the healthcare system
Solves an unmet medical need – patients want it Improved clinical outcomes provides rationale for
Medicare and payers to cover it Clinical and economic benefit to hospitals and
physicians
Copyright Emerson Consultants, Inc. 2012
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We Pay You – We Pay You Not…We Pay You – We Pay You Not…
Moving ForwardMoving Forward
Healthcare Reform will continue to evolve…stay tuned!
Opportunities for innovative products focusing on preventive services, showing reduction in hospital costs, emphasis on primary care
Expect increased price pressure from physicians. hospitals and physiciansReimbursement must be factored into early product design and integrated with regulatory and market developmentLack of reimbursement can limit market acceptance to innovative technologies despite clinical value
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