The Patient Protection and The Patient Protection and Affordable Care ActAffordable Care Act

[PPACA = ACA][PPACA = ACA]

ASAP MeetingASAP MeetingAustin, TexasAustin, TexasJuly 22, 2010July 22, 2010

Norman H. ChenvenNorman H. ChenvenCEO & FounderCEO & Founder

Austin Regional ClinicAustin Regional Clinic

Dr. George’s Charge:Dr. George’s Charge:

““Give a 20-25 minute talk Give a 20-25 minute talk

on the implications of healthcare reform on the implications of healthcare reform

for the care of patients with chronic disease for the care of patients with chronic disease and/or congenital abnormalities.” and/or congenital abnormalities.”

Problems: American Health Care 2010Problems: American Health Care 2010

45 million Americans uninsured45 million Americans uninsured

Too expensiveToo expensive

Quality is erratic Quality is erratic

Inadequate information systemsInadequate information systems

Lack of “System”Lack of “System”

Shortage of primary care accessShortage of primary care access

What Did We Get?What Did We Get?

The Short Answer:The Short Answer: An expansion of coverageAn expansion of coverage Some health insurance regulatory reformSome health insurance regulatory reform Incentives to improve information systemsIncentives to improve information systems Incentives to reward qualityIncentives to reward quality Pilot projects to:Pilot projects to:

Encourage the development of integrated/coordinated delivery Encourage the development of integrated/coordinated delivery systems.systems.

Encourage transparency with reporting on access, quality, service Encourage transparency with reporting on access, quality, service and cost.and cost.

Reward efficiency and reduce cost.Reward efficiency and reduce cost.

Problem #1: 45 Million Americans UninsuredProblem #1: 45 Million Americans Uninsured

Expand MedicaidExpand Medicaid

Mandates for employers and individuals.Mandates for employers and individuals.

Subsidies for employers and individuals.Subsidies for employers and individuals.

Health insurance exchanges.Health insurance exchanges.

High risk pool mandate.High risk pool mandate.

Residual uninsured: 10 – 20 million (illegal Residual uninsured: 10 – 20 million (illegal immigrants, penalty payers, other).immigrants, penalty payers, other).

Problem #2: Too ExpensiveProblem #2: Too Expensive

Pilot programs to encourage accountable care Pilot programs to encourage accountable care organizations (ACO) and payment bundling.organizations (ACO) and payment bundling.Minimal concessions from the hospital and Minimal concessions from the hospital and pharmaceutical industries for price reduction.pharmaceutical industries for price reduction.A grab-bag of tax increases on insurers, very wealthy A grab-bag of tax increases on insurers, very wealthy individuals, Medicare tax increase, “Cadillac” plan individuals, Medicare tax increase, “Cadillac” plan taxes, etc.taxes, etc.Reduce Medicare Advantage subsidies.Reduce Medicare Advantage subsidies.Tax on sun tanning salons. Tax on sun tanning salons. But, in reality, the ACA does not adequately address But, in reality, the ACA does not adequately address increasing costs.increasing costs.

Problem #3: Erratic QualityProblem #3: Erratic Quality

Supports medical research and comparative Supports medical research and comparative effectiveness research.effectiveness research.

Mandates incentive payments for physicians Mandates incentive payments for physicians and hospitals to measure and report on quality.and hospitals to measure and report on quality.

Various pay-for-performance programs.Various pay-for-performance programs.

Problem #4: Inadequate Information SystemsProblem #4: Inadequate Information Systems

Fiscal Stimulus Bill provided $20 billion to Fiscal Stimulus Bill provided $20 billion to install electronic medical records (EMR) and install electronic medical records (EMR) and develop community based health information develop community based health information exchanges (HIE).exchanges (HIE).

Financial reward for quality reporting which will Financial reward for quality reporting which will require more sophisticated IT systems.require more sophisticated IT systems.

Problem #5: Health Care System is Not a SystemProblem #5: Health Care System is Not a System

Encourages the development of Accountable Encourages the development of Accountable Care Organizations (ACO). Care Organizations (ACO).

Encourages the development of Patient Encourages the development of Patient Centered Medical Homes (PCMH).Centered Medical Homes (PCMH).

Problem #6: Shortage of Primary Care AccessProblem #6: Shortage of Primary Care Access

Increase Medicare and Medicaid payments to Increase Medicare and Medicaid payments to primary care doctors.primary care doctors.Increase payments for behavioral health.Increase payments for behavioral health.Promote Patient Centered Medical Homes Promote Patient Centered Medical Homes (PCMHs).(PCMHs).Fund primary care, Nurse Practitioner & Physician Fund primary care, Nurse Practitioner & Physician Assistant training programs.Assistant training programs.Administrative simplification mandates.Administrative simplification mandates.Encourage and fund medical and nursing school Encourage and fund medical and nursing school expansions.expansions.

Patients with Chronic Disease or Congenital Patients with Chronic Disease or Congenital AbnormalitiesAbnormalities

Prohibits insurance companies from denying Prohibits insurance companies from denying coverage to children with pre-existing conditions coverage to children with pre-existing conditions (Fall, 2010).(Fall, 2010).

Prohibits insurance companies from denying Prohibits insurance companies from denying coverage to any individual with a pre-existing coverage to any individual with a pre-existing condition (Jan, 2014).condition (Jan, 2014).

Limits premium variation to no greater than 3:1…Limits premium variation to no greater than 3:1…except for age, geography, family size to tobacco except for age, geography, family size to tobacco use (Jan, 2014).use (Jan, 2014).

Eliminates lifetime caps on insurance payments.Eliminates lifetime caps on insurance payments.

Patients with Chronic Disease or Congenital Patients with Chronic Disease or Congenital Abnormalities, Abnormalities, cont’dcont’d::

Extends ability of young adults to stay on Extends ability of young adults to stay on parents insurance until age 26 (Fall, 2010).parents insurance until age 26 (Fall, 2010).

Preventive Health Services (U.S. Preventive Preventive Health Services (U.S. Preventive Service Task Force) covered with no cost.Service Task Force) covered with no cost.

Creates state based insurance exchanges and Creates state based insurance exchanges and tax credits for low income individuals.tax credits for low income individuals.

Prohibits insurance policy rescissions unless Prohibits insurance policy rescissions unless well justified. well justified.