1 Massachusetts Health Care Reform and Cancer Care Therese Mulvey, MD Southcoast Centers for Cancer Care February 2010
2 Southcoast Health System in Massachusetts
3 Southcoast Primary and Secondary Markets
4 An Act Providing Access to Affordable, Quality and Accountable Health Care Also known as Chapter 58. Signed into law under a Republican governor and a Democratic state house. Effective April
5 Chapter 58 Four main goals: To use an individual mandate to expand access to near universal coverage. To establish guidelines for employers fair share contribution and involvement. To reorganize insurance markets and manage the distribution and subsidization of new plans through a Connector To establish transparency that will aid in the bill s cost and quality of care.
6 Individual Mandate Expand Access In , ,000 uninsured in MA. EMTALA was considered unfunded safety net. $700 million in the Uncompensated Care Pool. Feds threatening to pull $365 million in matching Medicaid funds for free care provided in MA.
7 Individual Mandate Goal was universal coverage. Community interests to take on cost would come later. Every adult over 18 must have coverage by June Penalty is loss of individual deduction on state income tax in average is $219.
8 Health Care in Massachusetts Medicare, Medicaid, Subsidized and Unsubsidized Private insurance coexist. Massachusetts healthcare reform was signed into law on April 12, 2006, with a goal of providing near-universal coverage of the Massachusetts population. The Health Connector was created to fill the gap for 498,000 individuals that had no insurance. It created complementary coverage programs called Commonwealth Care and Commonwealth Choice. It created an individual mandate which requires adults who can afford health insurance to obtain it, or be assessed a tax penalty. An exception waiver could be granted in certain circumstances. The State also still has a free care care pool, that should become minimal over time.
9 Health Care in Massachusetts First: cover the poor- Commonwealth Care. Automatic enrollment. Next: cover the working who do not have access to employer based insurance- Commonwealth Choice. Penalty if one did not participate. Encourage employer based coverage by allowing new plans- low monthly or annual cost and higher deductibles.
10 Commonwealth Care Commonwealth Care is a subsidized program for adults who are not offered employer-sponsored insurance, do not qualify for Medicare, Medicaid or certain other special insurance programs. Fully subsidized health insurance to adults earning up to 150% of the Federal Poverty Level (FPL). No monthly premiums for individuals earning up to $16,620, or $33,084 for a family of four. Partial subsidies for people earning above 150% and up to 300% of FPL. There are no monthly premiums for the children of adults covered by Commonwealth Care, as the children are covered by MassHealth (Medicaid). Plans are currently available: from $39 a month for an individual earning between $16,261 and $21,672; $77 for an individual earning between $21,673 and $27,096; and $116 if earning between $27,097 and $32,508. Of the 179,000 enrolled in Commonwealth Care 40% contribute toward the monthly cost of premiums, and the remainder receive free coverage.
11 Massachusetts Health Connector
12 Commonwealth Choice Commonwealth Choice is an unsubsidized offering of six private health plans, selected by competitive bidding, and available through the Health Connector to individuals, families and certain employers in the state. The six private plans offer options grouped by level of benefits and cost-sharing at the Bronze, Silver and Gold levels. There is also a special, lower priced Young Adults Plan offering from the same six carriers, exclusively for individuals between the ages of 18 and 26. These plans are offered directly through the Health Connector or directly from the carriers. The change reformed the individual and small-group health insurance markets to effectively lower their price, and offer more choices for individuals purchasing unsubsidized products on their own.
14 Employers and the Fair Share The burden of increased coverage is to be shared among insurers, individuals and government. Employers are deemed to offer fair and reasonable coverage if at least 25% of their full time workers are enrolled in the firm s health plan or the employer offers to pay 33% of the premium of an employed individual. Mass Taxpayers Foundation 2009
15 Employers Small Group Employers with fewer than 11 full-time-equivalent employees are not required to offer health benefits or a Section 125 Plan (which is a pre-tax, payroll deduction plan). Employees can purchase a Commonwealth Choice plan through the Connector. This allows small business employees access to plans similar to those of a large employer with leverage to discount the cost of the plan. Employers of 11 to 49 full-time equivalent employees must make a fair and reasonable contribution toward coverage for full-time employees, or pay a Fair Share Assessment of $295/employee. Employers must offer a Section 125 plan. The Employer is exempt from the penalty only if 25 percent of its employees participate in the company plan, and the employer offers to contribute 33 percent toward an individual s health plan.
16 Employers Large Group Employers with more than 50 full-time employees are limited in what they may offer to their employees through the Health Connector s Commonwealth Choice program. They must offer a Section 125 Plan. Employers with more than 50 full-time employees may not offer the Commonwealth Choice Contributory Plan. The Contributory Plan lets small employers subsidize Commonwealth Choice health insurance options for their employees. Free Rider Surcharge is a surcharge assessed for use of state funded uncompensated care. Triggers after three instances by one employee or five instances by multiple employees. Exempt if employer sets up a Sec. 125 cafeteria plan.
17 Insurance Reorganization The Connector Board set premium levels and copayments for the state subsidized Commonwealth Care Plans. $18/month for incomes 100%-150% of poverty line to $106/month for individuals with incomes 250%-300% poverty line. Two options: higher premiums and lower deductibles and lower premium and higher deductibles. Later expanded to three tiers.
18 Insurance Reorganization Connector provides people with a plan. Risk pools are developed between small businesses and individuals. Cost of the plans is determined by competitive bidding prescription coverage was mandated by the Connector Board for all of the plans participating in the Connector.
19 So what happened? People Almost everyone has coverage. MA has the lowest uninsured in the nation 2.6%. Commonwealth Choice: 30% BCBS 21% HCHP 6% THP 17% FCHP 23% NHP 3% HNE
20 Uninsured Population
21 Expanding Access 160,000 newly insured obtained insurance through their employer at a cost to the employers of $540 million. Penalty for not having insurance is ½ the cost of the plan with the lowest premium available to the individual. Individual making $31,000/yr-$900 MA Dept Revenue 2009
22 So what happened? People January Minimal Creditable Coverage standard- 200,000 residents had to change coverage to comply
23 Individual Mandate MA residents age 18 and over required to have minimum creditable coverage, if deemed affordable. Minimum creditable coverage defined for individuals, with a maximum deductible of $2,000/ $5,000 out-of-pocket Enforced through state tax returns. Appeal process for individuals if one qualifying financial hardship event occurred during year. What Happened in 2007? 95% of adults filing health insurance information with their tax returns have health coverage 2% of adults filing did not have coverage and could afford it according the state s Affordability Schedule, resulting in penalization 2% could not afford insurance according to schedule 1% didn t complete the information required.
24 So what happened- Employer? Estimated that through employer contribution $7.7 million would be raised in In 2008 $2 million raised In 2009 the fair share contribution became more stringent for employers with 50 or more employees to get more money.
25 So what happened- Employer Costs for insurance plans exploded to double digit increases. Health care costs continued to rise unchecked and these costs were passed off to the consumer. Premiums for health care rose 94% between (US Census 2007)
26 Employer Mandates The employers have experienced high increases in plan rates for their employees. Make up for the losses the plans experienced by underbidding for the Connector plans, high risk populations and enrollment distributed across several companies.
27 Health Care Costs Consumes ½ of state expenditures. In 200 acre area of Boston 12 medical institutions, 40,000 employees and 1 million patients per year. (Health Affairs 2009) $5 billion in revenue/year.
28 While the U.S. has the highest health care expenditures per capita among other industrialized countries, MA has among the highest health care costs in the U.S. $7,000 $6,000 Massachusetts $5,000 United States $4,000 France $3,000 Germany Australia $2,000 Canada United Kingdom $1,000 $ Sources: Commonwealth Fund (2008), CMS (2007), U.S. Census (2009). Note: U.S. dollars are current-year values. Other currencies are converted based on purchasing power parity
29 Health Care Costs Rapidly became clear- cost must be controlled if Chapter 58 was to survive. Boston Globe Spotlight series broke Partners Health Care receiving 15-60% more in payments for the same services than elsewhere in MA. There was suspicion of collusion with the largest insurer with the largest health care system, mixed BOD, conflicts of interest.
30 Health Care Costs Health Care Cost and Quality Council formed. In the first meeting- fee for service had to go. Global payments tied to quality care to level to payments independent of site of service. Payments tied to complexity of case and outcomes.
31 What is Next for Massachusetts To control the growth of health care expenditures, the legislature enacted : An Act to Promote Cost Containment, Transparency and Efficiency in the Delivery of Quality Health Care. This created a Special Commission on the Health Care Payment System to investigate reforming and restructuring the payment system. The Special Commission recommends that global payments with adjustments to reward provision of accessible and high quality care become the predominant form of payment to providers in Massachusetts within a period of five years. Government, payers and providers will be required to share responsibility for providing infrastructure, legal and technical support to providers in making this transition.
32 Current Fee for Service Payment System Patient Centered Global Payment System The Problem Care is fragmented instead of coordinated. Each provider is paid for doing work in isolation, and no one is responsible for coordinating care. Quality can suffer, costs rise and there is little accountability for either. The Solution Global payments made to a group of providers for all care. Providers are not rewarded for delivering more care, but for delivering the right care to meet patient s needs. $ $ $ $ $ Primary Care Hospital Specialist Hospital Specialist Primary Care Home Health Home Health
33 Key Components of Recommendations Development of Accountable Care Organizations (ACOs) Participation by all payers - private and public Patient-centered care and adoption of medical homes Patient choice Common core performance measures and cost and quality transparency Appropriately balanced sharing of financial risk between ACOs and carriers Strong and consistent risk-adjustment
34 Oversight Entity The oversight entity will: Define parameters for a standard global payment methodology - but the market will determine global payment amounts. Establish transition milestones and monitor progress, with a focus on the progress to global payments, progress to greater payment equity, and per capita health care costs. Make decisions in an open and transparent manner and seek broad stakeholder input from providers, health plans, government, employers, and consumers. The oversight entity will have authority to assist and intervene, and make mid-course corrections if needed.
35 Chapter 58 and Cancer Care Patients have insurance. Poor working patients have insurance. Prior to Chapter 58 11% patients were uninsured in an average private practice. No show visits declined. Deductibles increased in most on Commonwealth Choice. Copays for imaging, prescriptions, hospital stays increased.
36 Chapter 58 Office E&M rates variable- some up some down. Increased prior authorizations. Increased specialty pharmacies for injectibles: leuprolide, ESAs, grwoth factors. BCBS 10/09 all chemotherapy requires prior authorization.
37 Chapter 58 No quality metrics for cancer care yet. QOPI being discussed. Treatment plans are being encouraged. BCBS pays for treatment plans $200 and uses this for disease management. Cost control has to occur and cancer care will be no exception.?? pathways, EHRs, disease management.
38 Chapter 58 Shift in site of care % all oncology care occurred in single specialty private practice, multispecialty group or community health center. 40% hospital outpatient, largely limited to academic centers in Boston % cancer care in hospital outpatient setting, 40% remains in academic setting. BCBS communication
39 Chapter 58 Site of service shift has implications for payment models, ACOs. Implications for state societies role. Implications for ASCO AESOP Task Force
40 Chapter 58 Quality care and site of service. Metrics in the context of a larger organization. QOPI in a hospital setting. HER in a larger organization.
41 The successes The more obvious ones: 97.4% of Massachusetts Residents are now insured. The uninsured rate is now 2.6%, according to a study conducted by the Urban Institute and is the lowest rate of uninsured residents in the nation. There are now nearly 430,000 newly insured in the Commonwealth of Massachusetts since the outset of healthcare reform. About 190,000, or 44% of the newly insured are in private commercial insurance, purchasing either through the Commonwealth Choice or a private health plan through their employer or directly on their own from private insurance carriers. The not so obvious ones: Individuals needs were put first, not the employer, payer or provider System focused approach to health reform and coverage how insurance is purchased, sold, administered, how public subsidies are delivered
42 The remaining challenges Access: there is a lack of primary care doctors that can accept new patients, so patients still show up in emergency departments. Provider Payments: health care providers have been reimbursed at approximately 75% -90%of cost. Some providers have refused to accept new patients at these rates. Medicaid rates have dropped the fastest. Growth: due to downturn in the economy, more individuals are eligible for partial or full subsidized health care causing the State budget issues. Example is that legal immigrants will receive scaled down benefit package. Services: various benefits have been eliminated due to budgetary constraints. More may come.
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