What does it mean for internists?
The Affordable Care Act
Joshua Becker MDVII. 2015 Reforms and Beyond
Payment Penalties under Medicare’s Pay-for-Reporting Program Value-Based Payment Modifier
There is a lot in the ACA…
❖ Health Insurance Reforms
❖ Medicare/Medicaid Payment Reforms ❖ ACOs and Value Based Purchasing ❖ Paying for it
Why it came about…
❖ Increasing Healthcare Costs ❖ High Number of Uninsured ❖ Outcomes vs Cost
•
Federally Administered
•Paid via federal payroll
taxes
•
Covers age 65 + and
those with disabilities
•Parts
• A (hospital) • B (medical) • D (prescriptions)
•
State and Federal
Program
•
Covers those with low
income
•
Eligibility and coverage
has varied state by state
Medicare
Medicaid (MA)
•
MN State program
•Covers those with low
income - but more than
previous medicaid
levels
•
Pay premiums and
deductible - sliding
scale
Who Was Covered Prior to ACA Reform
2013
US Population 317 Million Employer Based Insurance 48% Medicaid 16% Medicare 14% Other Private/PublicUninsured
15%
48 Million Americans
How does the ACA address them?
❖Change rules for all private insurance
❖
Expand Medicaid*
❖
Establish Insurance Exchanges (ie. MNSure)
❖
Proved Subsidies for Private Insurance (up to 400% FPL)
❖
The Individual Mandate
Private Insurance Changes
❖
2010 Changes
❖ Coverage for Dependents up to Age 26 ❖ Temporary High-Risk Pools
❖ Pre-existing Conditions Exclusions Banned for Children
❖ Restricting Annual or Lifetime Dollar Limits on Coverage
❖ Prohibiting Coverage Rescissions ❖ Justifying Premium Increases
❖ Covering Core Preventive Services
❖ Medical Loss Ratio at 85% for insurers (rebates)
❖
2014 Changes
❖ Guaranteed Issue and Renewability
❖ Premiums Cannot be Based on Enrollee Health
Status
❖ Universal Prohibition on Pre-Existing Condition
Exclusions
❖ Universal Prohibition on Annual Dollar Limits on Coverage
❖ Eliminate Coverage Waiting Periods ❖ Essential Benefits Package
❖ Parity for Mental Health Benefits
Uninsured
Uninsured
15%
48 Million Americans
Supreme Court Decision about the Medicaid Expansion
•June 2013 - Supreme Court upheld
legality of individual mandate
•But struck down requirement for
states to expand medicare
Medicare “Coverage Gap”
Individual Mandated
Health Insurance
❖
All individuals* are required
to carry health insurance or
pay a penalty
Exemptions from Individual Mandate:
• Individuals and families below a certain income
• People who cannot afford the coverage that is available • Individuals who have been uninsured for less than
three months
• Members of American Indian tribes
• People who do not obtain coverage because of religious
Insurance Exchanges
❖
Ideally to increase competition for insurers -
improve costs
❖
Allowed Gov’t to provide sliding scale subsidies
for those between 137%-400% of the poverty limit
❖
Either Federally or State Run exchanges -
depending on state
❖
Many states and federal site had issues with roll
out in 2013
Minnesota Insurance Exchange
www.MNsure.org
Medicaid and Minnesota Care
Enrollment there as well
Business Enrollment through
SHOP program
Enrollment Nov 15th-Feb15th
How Well is It Working?
❖ Nationally
❖ 2014 - 32 million uninsured, down 9 million
since 2014 (kff) - varying numbers widely
❖ 11.7 Million on Individual Insurance Market
through exchange
❖ 87% received a subsidy
❖ ~10.8 Million new Medicaid Enrollees
❖ Estimate 3 million under expansion of young
(<26) being on parents insurance
❖ Estimate 12 million have insurance out of
What about in MN in 2015?
❖ 325,000 Minnesotans signed up via MNsure ❖ The vast majority landed MA and
MNCare (public insurance covers 20% of Minnesotans)
❖ About 70,000 signed up for private
insurance, about half getting a subsidy
❖ 317,000 Minnesotans (5.8%) remain
uninsured
❖ Nationwide, the uninsured rate fell from
Value Based Purchasing
❖
Medicare withholds some payment and
only gives it back if we meet certain
benchmarks
❖
Started in Hospital Pay in 2012 and
Outpatient 2013
❖
CMS withholds 1-2% of payment - entity
gets it back based on ranking in quality
metrics
❖
Metrics we are graded on change year to
year
Inpatient Metrics
Snippet of 44 page list of metrics for Outpatient Care Score Card
2015 new measures Blood Stream Infections
More Mortality Markers Medicare Spending per
Beneficiary Pt Satisfaction
30-day readmission rates nationally have declined from more than 19.0% to less than 18.0%, equivalent to approximately 150,000 fewer
readmissions annually among Medicare beneficiaries
30 Day Readmission Rates
Changes for Primary Care
❖
Increased need for PCPs
❖ Massachusetts Experience
❖
Pay Primary Care More (relatively speaking)
❖ Medicaid payments increased to 100% of Medicare rates for 2013-2014 (Federal
subsidies to states)
❖ Provide a 10% bonus to PCPs in Medicare from 2011 to 2015
❖
Training more PCPs
❖ Increase scholarship/grants/loan repayments for primary care ❖ Income based repayment in student loans
❖ Increase GME residency slots (via redistribution of unused slots) - pref for primary
care and general surgery
New Funding Models
❖ A group of physicians, hospitals and other health professionals that are
responsible through contracts with payers for providing a broad set of health care services to their Medicare/Medicaid/Private Insured patients.
❖ Different payment model - instead of fee-for-service, groups are paid a
stipend to take care of a population. (Capitated Care)
❖ Incentive is to increase value and savings are shared between payer and
providers
❖ Allina had been 1 of 32 participating preliminary Pioneer ACOs nationwide.
❖ Can operate with Medical Homes - but different from PCMH
New Funding Models
❖ 2 Types in ACA - Pioneer ACOs (2011) and
Medicare Shared Savings (2012)
❖ New CMS ACO - Next Gen ACOS announced
spring 2015 (more risk/more reward)
❖ Other payers doing providing similar payment
models (BCBS, HealthPartners, etc…)
❖ This new arrangement provides flexibility for
participating ACO to utilize services not
normally reimbursable under Medicare (such as phone consultations or telehealth services.)
ACA Cost to the Government
CBO projects $1.36 trillion in expenditures from 2015-2024* Offset by revenues and decreasing health care cost growth - net effect is projected to reduce federal deficit by $109 billion over 10 years (CBO 7/2012)
Largest Revenues in ACA (estimated from 2013-2022)
Annual Fee on Health Insurers: $102 Billion 10% Tax on Indoor Tanning Services: $2.7 Billion
2.3% Tax on Medical Device Sales: $29 Billion Annual Fee on Makers of Branded
Prescription Drugs: $34 Billion High-Cost (“Cadillac”) Health Plan
Whew!….
