INTRODUCTION TO THE HEALTH CARE MAJOR REFORM BILL. Rep. Jim Butler

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1 INTRODUCTION TO THE HEALTH CARE MAJOR REFORM BILL Rep. Jim Butler

2 THE PROBLEM 2

3 ** 2016*** 2017*** 30% State Medicaid Spending as percentage of State GRF 28% 26% 24% 22% 20% 18% 16% 14% MEDICAID CONSUMING INCREASING SHARE OF STATE BUDGET 3 Source: LSC Historical Expenditures by Program, Table 2 and 3 (GRF)

4 FEWER RESOURCES FOR EDUCATION, ECONOMIC DEVELOPMENT, AND PUBLIC SAFETY 4

5 2013 MEDICAID EXPANSION - ADDITIONAL STATE SPENDING PROJECTIONS *(ENROLLMENT IS 34% OVER PROJECTIONS) 5 Sources: (for projections) Health Policy Institute of Ohio, Policy Briefing, March 1, 2013, (for underestimation) Columbus Dispatch, Feb. 12, 2015

6 $9,000 $8,500 $8,000 $7,500 $7,000 $6,500 $6,000 $5,500 $5,000 Per capita Medicaid spending PER CAPITA MEDICAID SPENDING PER CAPITA COSTS INCREASING WHEN ABLE-BODIED, LOWER COST, ADULTS JOINING ROLES OHIO S PER CAPITA COSTS HIGHER THAN NATIONAL AVERAGE FOR LAST TWO DECADES* 6 Sources: LSC, Baseline Forecast of GRF Revenues & Medicaid Expenditures FY 2016-FY 2017 Biennial Budget; Kaiser Family Foundation

7 SOLUTION HAS BEEN TO CUT REIMBURSEMENTS = LESS ACCESS TO CARE 7 Source: National Center for Policy Analysis, An Economic and Policy Analysis of Medicaid Expansion in Ohio, September 19, 2013,

8 1) Significantly lower Medicaid spending, while improving patient health 2) Significantly lower overall healthcare spending, while improving patient health 3) Apply Medicaid savings below current funding levels to pools to care for needy populations THREE GOALS 8

9 1) Skin in the Game - Healthy Ohio Plan 2) Lower Defensive Medicine - Medical Injury Compensation System (MICS) 3) Proper Utilization - ER Diversion 4) Medical Device and Prescription Purchasing Pool 5) Price Transparency Advertising and Cost Estimates 6) Quality Incentives - Value Based Purchasing 7) Cost incentives C bonus and Hospital Network Entry 8) Competitive Marketplace - Reimbursement parity 9) Promote Small Business Health Coverage MEWA Assistance 9

10 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years * Modeled after the Healthy Indiana Plan. Participant contributes $99 ($149 smokers), state contributes $1000. Account used for co-pays etc. Balances carry forward and can be used for future premiums, credits for health outcomes

11 I have a slight headache today after drinking a lot last night. Maybe I have a brain tumor. 11

12 Better ask for a CAT scan to make sure. Why not? It doesn t cost anything 12

13 Reduce Medicaid spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years * Modeled after the Healthy Indiana Plan. Participant contributes $99 ($149 smokers), state contributes $1000. Account used for co-pays etc. Balances carry forward and can be used for future premiums, credits for health outcomes

14 Skin in the Game Enrollees pay yearly premium - $99 adults, $49 children, $149 smokers State adds $1,000 into Health Care Savings Account ( Buckeye Account ) Debit card issued to each participant to use for co-pays and deductibles Encourage cost-consciousness and preventative care - Money in Buckeye Account rolls over to next year and can be used for premiums if patient gets required preventative care Reward healthy outcomes - Bonuses awarded for measurable health outcomes, like lowering blood pressure, losing weight can be used for non-covered services Increased Access to Care Providers paid a much higher Medicare rates, so more doctors will accept Medicaid patients. Mobility up and out of Medicaid Buckeye Account frozen into Bridge Account that can be used for private insurance premiums and other health care expenses HEALTHY OHIO PLAN (HOP) -BASED ON SUCCESSFUL HEALTHY INDIANA PLAN (HIP) 14

15 Okay, a CT scan will cost me, but I have no idea how much. 15

16 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

17 In a recent JAMA study, relative claim payments for searchers on a pricing website were lower for searchers than non-searchers by 13.93% for laboratory tests, 13.15% for advanced imaging, and 1.02% for clinician office visits. Another recent study found an 18.7% savings in diagnostic testing when patients could compare costs. PRICE TRANSPARENCY CREATES COST CONSCIOUSNESS AND LOWER SPENDING 17 Source: JAMA, Association Between Availability of Health Service Prices and Payments for These Services, October 2014; Health Affairs, Price Transparency For MRIs Increased Use Of Less Costly Providers And Triggered Provider Competition, August 2014, wsroom/news/price-transparencyexpiration%2520date%2520=%25206%2520aug%

18 200 Cosmetic Medicine vs. Ohio Overall Healthcare Inflation Cosmetic Surgical Procedure Overall Ohio Healthcare Costs Cosmetic Non-Surgical Procedure SKIN THE GAME AND COST CONSCIOUSNESS MATTER 18

19 He is only 20 years old and just got a headache today (after drinking last night). Probably one in a million chance of a tumor. 19

20 But what if he actually does have a tumor, then I get sued? Better order it. 20

21 Defensive Medicine: the practice of ordering medical tests, procedures, or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits 90 percent of physicians reported practicing positive defensive medicine in the past 12 months 92.5 percent of surgeons indicate they have ordered imaging tests to protect themselves from lawsuits Physicians in other major countries do not practice defensive medicine because they are no personally liable (they cannot be sued). In a recent Gallup survey, physicians attributed 34 percent of overall healthcare costs to defensive medicine Liability reform has been estimated to result in a 5 percent to 34 percent reduction in medical expenditures via a reduction in defensive medicine In Ohio, even a 10 percent reduction in Medicaid costs would save $2.5B/year DEFENSIVE MEDICINE 21 Sources: Costly Defense: Physicians Sound Off on the High Price of Defensive Medicine, Jackson Healthcare, Now, December 2010,

22 Ohio Total Medical Liability Costs (verdicts, settlements and defense costs) $247M 22 Source: Ohio Department of Insurance, 2012 Medical Professional Liability Closed Claim Report, April 2014,

23 Ohio Total Medical Liability Costs (verdicts, settlements and defense costs) $247M $4B to $27B Ohio Defensive Medicine Costs (unnecessary medical tests, prescriptions, procedures, and consultations) 23 Source: 2012 Report from Insurers on Medical Malpractice Claims; Kaiser Family Foundation, 2009 overall health spending $81.6B (5-34%)

24 Significantly Increased Somewhat Increased Not Changed Somewhat Decreased Signifcantly Decreased Physician Survey: How Have the Following Reforms Affected the Practice of Defensive Medicine? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% "I'm Sorry" Law Aggressive Statute of Limitations Joint and Several Liability Attorney Fee Limits Certificates of Merit Pre-trial Screening Panels Pain and Suffering Caps TRADITIONAL TORT REFORM IS INEFFECTIVE AT DECREASING DEFENSIVE MEDICINE 24 Source: Survey Findings: Physicians on Tort Reform, Jackson Healthcare,

25 Defensive Medicine Rates 92% All Physicians 19% DOD Physicians ACTIVE DUTY MILITARY CANNOT FILE LAWSUITS AGAINST DOD PHYSICIANS 25 Sources: Costly Defense: Physicians Sound Off on the High Price of Defensive Medicine, Jackson Healthcare,

26 Reduce Medicaid spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

27 Medical Injury Compensation System (MICS) Current System More patients compensated more often Common Pleas Court Appeals process same as workers compensation Award same as below Trial Preparation/ Motions Trial Post-trial Motions/Appeal Legal standard makes it easier to receive compensation Reviewers must find by clear and convincing evidence that conduct was within standard of care to find medical injury not compensable Patients compensation is quick and easy Because of streamlined administrative process, patients can receive award within a few months instead of years Simpler process makes it easier to navigate and understand Three-member panel Three medical professionals hold hearing each side submits one expert report Award same as below Initial Administrative Review Medical Professional reviews file short hearing possible If compensable, MICS economist calculates award (multiplied by ratio to hold payouts constant with pre-mics total amounts) Administrative claim filed Insurer becomes only party 6 months 2-3 months to award 1-5 years to award 6 24 months 3-9 months Settlement conferences Health care provider(s) file Answer File Complaint Motions for summary judgment Exchange of written information (discovery) Request medical records Take depositions Hire experts, expert draft reports Find lawyer Must have enough damages Children and Seniors have hardest time Eventual lawsuit filed against health care providers

28 MICS Claims automatically forwarded to Healthcare Oversight Board More patients compensated more often MICS Common Pleas Court Appeals process same as workers compensation Award same as below Healthcare Oversight Board Membership made up of board examiners Medical Injury Prevention Database Legal standard makes it easier to receive compensation Reviewers must find by clear and convincing evidence that conduct was within standard of care to find medical injury not compensable Patients compensation is quick and easy Because of streamlined administrative process, patients can receive award within a few months instead of years Simpler process makes it easier to navigate and understand Three-member panel Three medical professionals hold hearing each side submits one expert report Award same as below Initial Administrative Review Medical Professional reviews file short hearing possible If compensable, MICS economist calculates award (multiplied by ratio to hold payouts constant with pre-mics total amounts) Investigates repeated or gross negligence Temporary or permanent suspension of license Similar to Ohio Supreme Court oversight over attorneys All reported medical injuries from MICS and Oversight Board analyzed for improved processes Administrative claim filed Insurer becomes only party Accountability and oversight of healthcare providers Lower preventable medical injuries

29 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

30 Emergency Department Visits 24% 35% Required Emergency Care Required Primary Care Required No Care 41% 65% OF EMERGENCY DEPARTMENT VISITS ARE UNNECESSARY 30 Source: Becker Hospital Report, citing study by Truven Health Analytics, April 25, 2013.

31 $1,400 $1,200 Average Cost Difference $1,316 $1,000 $800 $600 $400 $200 $0 Average Cost of ED Visit $145 Average Cost of Primary Care Visit EMERGENCY DEPARTMENT VISITS ARE NEARLY 10X MORE EXPENSIVE 31 Source: Becker Hospital Report, citing study by Truven Health Analytics, April 25, 2013.

32 Emergency Department Requires Emergency Care Requires Primary Care Requires No Care THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA) IS A FEDERAL LAW THAT REQUIRES ANYONE COMING TO AN EMERGENCY DEPARTMENT TO BE STABILIZED AND TREATED, REGARDLESS OF THEIR INSURANCE STATUS OR ABILITY TO PAY 32 Source: American College of Emergency Physicians,

33 Urgent Care Emergency Department Intake Nurse Requires Emergency Care Requires Primary Care Requires No Care EMERGENCY DEPARTMENT ESCORT SYSTEM: 1) PATIENT REPORTS SYMPTOMS TO INTAKE NURSE 2) IF PATIENT REPORTS OBVIOUSLY NON-EMERGENCY SYMPTOMS, PATIENT IS SEEN IN ADJACENT URGENT/PRIMARY CARE 3) CUSTODY OF PATIENT CONTINUOUSLY MAINTAINED SO NOBODY IS TURNED AWAY 4) IF URGENT CARE DETERMINES EMERGENCY EXISTS, PATIENT TRANSFERRED TO EMERGENCY DEPARTMENT 33

34 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

35 Drugs account for 12 percent of all healthcare costs. Drugs in the United States cost 50 percent more than in any other major country for the same or an equivalent drug. When the drug mix is factored in, the U.S. spends 120 percent more for equivalent drugs. Loose purchasing coalitions have resulted in savings for pharmaceuticals of tens of millions of dollars. A mandatory purchasing pool for pharmaceuticals and durable medical/diagnostic testing equipment has the potential to achieve significant saving for both Medicaid and state and local government plans. Because all providers who contract with the state will be required to use the pool, overall healthcare savings should be significant. MARSHALLING OHIO'S PURCHASING POWER FOR PRESCRIPTION DRUGS AND MEDICAL EQUIPMENT CAN LOWER COSTS 35 Source: Accounting for the cost of US health care: A new look at why Americans spend more; McKinsey Global Institute, December 2008.

36 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

37 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

38 20% bonus Lose Contract $9,000 Per capita Medicaid Costs $8,500 $8,000 $7,500 $7,000 $6,500 $6,000 $5,500 $5, Ohio per capita Expected based on Medicaid inflation Hospital Entry Level POSITIVE AND NEGATIVE INCENTIVES WILL PROMOTE MANAGED CARE COST INNOVATION 38

39 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

40 Source: Medical Economics, Cardiac Stress Test Independent physician office - $2,100 Same office, same test, same patient, but owned by hospital - over $8,000 Office Visit Independent physician office - $20 Same office, owned by hospital - $65 Office visits and echocardiograms Medicare paid $1.5B more than it would have paid had same services been performed by independently-owned office HOSPITAL-OWNED OFFICES GET REIMBURSED SIGNIFICANTLY MORE THAN INDEPENDENTLY-OWNED PRACTICES FOR THE SAME SERVICE 40

41 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

42 MEWAs allow small businesses to pool risk to self-insure and avoid expensive mandates Umbrella Insurance guarantee phased down over five years helps with up front reserve requirements starts at $150,000 Businesses served represented on MEWA Board Must use Reference-based pricing to control costs 120% of Medicare HELP FOR SMALL BUSINESSES TO PROVIDE HEALTHCARE INSURANCE 42

43 Reduce Medicaid Spending Lower overall healthcare costs Ohio has a unique opportunity to take advantage of the recent focus on health care to devise and implement reforms to Medicaid and the healthcare system that substantially curtail Medicaid and overall health care costs, improve health outcomes and provide additional coverage for Ohioans who need it Reduce waste due to defensive medicine Medical Injury Compensation System (MICS) Create cost consciousness skin in the game Ensure competitive marketplace Promote hospital and competition - Quality Promote hospital and competition - Cost Healthy Ohio Plan* 10% limit on reimbursement variation Continuous competition on objective health outcomes (6% Medicaid redistributed) Flat rate reimbursements for acute conditions at state median rates 20% bonus for if beats regional Medicaid cost (lose contract if above) Lower preventable medical errors Divert unnecessary ER visits Encourage free market competition (price transparency) Leverage strong purchasing power Data clearinghouse of errors Escort system Written estimates before nonemergent service Advertising of health costs Published out-of-pocket costs for top 20% of services Central purchasing for everyone accepting state dollars Use savings to benefit Ohioans Negotiate Medicaid waiver to use savings to cover certain pools Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre ACA levels Return additional savings to tax-payers Hospital can run network if price/patient 20% < Promote small business health coverage State umbrella insurance guarantee for 5 years

44 $27,000 Total Medicaid Spending (in millions) $26,000 $25,000 $24,000 $23,000 $22,000 $21,000 $20,000 $3.1B goes to pools in 2017 when pools full, goes back to budget/taxpayers Medicaid Spending (State and Fed) Medicaid Spending After Reform SAVINGS BELOW EXISTING MEDICAID FLOWS INTO POOLS 44

45 Honorably discharged veterans (no access to VA) Severely mentally ill Developmentally disabled Addicted Chronic disease maintenance therapies Parents (90-100%) poverty Childless adults (50-100% of poverty) DSH reimbursement to hospitals to pre-aca levels Return additional savings to taxpayers POOLS FUND NEEDED SERVICES REST OF SAVINGS, BACK TO BUDGET/TAXPAYERS 45

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