Healthcare Reform: An Analysis of the Impact on Healthcare Providers

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1 Healthcare Reform: An Analysis of the Impact on Healthcare Providers Background The financial impact from the Affordable Care Act on providers from changes in Medicare reimbursement have been well documented - Market Basket Updates are being reduced, excise taxes are being levied on Pharmaceutical and Medical Device manufacturers, several Value Based withholding programs are coming online but the implementation of Healthcare Exchanges will also impact provider reimbursement. Starting in 2014 all individuals are required to purchase minimum essential coverage, or pay a penalty for not doing so, and the penalties get more and more onerous each year. If an individual does not have access to a qualifying plan through an employer, they can go to the exchange to buy coverage that satisfies their obligation. The exchanges are also set up to calculate and apply the premium and cost sharing subsidies that the regulation provides for eligible low and modest income persons. This system will be a boon for those providers who serve previously uninsured populations of persons living below 133% of the Federal Poverty Level (FPL) in states which elect to participate in the expanded Medicaid program since the government will now provide benefits for these persons.

2 (SOURCE: AMERICAN HEALTH LINE ALERTS) Exchanges will also help the previously underinsured population of person with incomes up to 400% of the FPL get access to more comprehensive coverage, which also will help healthcare providers balance sheets. However, there is also a risk that some employers will terminate their insurance programs and direct employees to purchase coverage on the exchanges (with or without financial contributions from the employer), and that carriers will try and negotiate reduced reimbursement schedules for exchange products than they currently allow for their other commercial products in order to be more price competitive on the exchanges. These scenarios all become important to healthcare providers as they try and assess the impact on their balance sheet from healthcare reform. Providers should also keep in mind that exchanges are already a part of everyday life for most Americans, and they can learn lessons about how to succeed in an exchange environment from organizations such as Amazon, Fidelity, Orbitz and itunes. Assessing the Financial Impact Healthcare providers will need to look at how they think the shift in who funds insurance coverage in their community will play out. The Congressional Budget Office released their analysis when the new regulations were adopted, and that could be a starting place. 2 P a g e

3 Consideration should also be given to the percentage of nonelderly persons in the community with income up to 400% of the FPL who are currently uninsured or purchasing individual coverage as these will be the individuals most likely to end up covered through an exchange. SOURCE: KAISER FAMILY FOUNDATION Once these assumptions are addressed, the healthcare provider should look at its current payor mix and the associated contribution to margin from each source and create a pro forma to determine how the change in these populations will affect their overall margin. In the example below, the ABC Hospital looks at its current Bad Debt, Self Pay, Medicaid, Medicare and Commercial revenue. It then assumes that 40% of the Bad Debt will move to the expanded Medicaid program in their state, and 20% of the Bad Debt sources will move to an exchange program along with 60% of the Self Pay sources (these folks may or may not be getting subsidies). If they further assume 3 P a g e

4 that there will be no appreciable shift away from employer plans into the exchange, they will see their margin improve substantially; by nearly 18%. In the above example, the Hospital also made the conservative assumption that the reimbursement schedule for products under the exchange would be significantly less than their commercial contracts. If the ABC Hospital then performed the same analysis, but assumed that 10% of employers in the community would find a way to move their employees to the exchange, the impact would be significant, lowering the positive impact on margin from lowering the uninsured Bad Debt and resulting in margin improvement of about only 4%. 4 P a g e

5 Creating an Action Plan Organizations such as Amazon, Fidelity, Orbitz and itunes, demonstrate several common characteristics which are necessary to be successful in a price competitive, automated environment such as the Healthcare Exchanges hope to be: Information is updated in real time and is immediately available to consumers They deliver reliable core services and have the ability to tailor them to the individual s taste They provide transparency in price and reviews from other customers They are outcomes focused on delivering to the customer s expectations They continually research customer needs and preferences Errors are promptly addressed and corrected with as little hassle as possible for the consumer The delivery of healthcare is certainly different than the services provided by these other organizations, but the focus on outcomes and the customer experience must not be. Create your action plan to better understand who your customers will be, what they want and how you will deliver outcomes to meet those expectations: Begin communication immediately with State authorities on their plans for Medicaid expansion, and encourage them to do so if no plans are being made Create a marketing and delivery plan on how you will compete for newly insured individuals Create a resource that will help patients better understand all their options for coverage under healthcare reform Get your reporting process together for the new quality measures and for internal success measurement Determine how the organization will make best use of Nurses and PAs to support the higher demand for services Construct a workable approach to reducing variation in clinical practice Determine how the organization will handle coordination of care for better outcomes and reduced readmissions Consolidate and implement plans for EMR and other data sharing resources for better physician alignment Consolidate plans for realigning resources for population health management vs. per encounter payments Determine how you will fill capability gaps in the continuum of care 5 P a g e

6 Summary Healthcare reform is going to change the payor mix, and payors are going to pursue different payment structures that focus on outcomes. Employers will support this evolution, and while most see their insurance programs as an integral part of their overall Total Rewards program, some may opt to get out of the complex business of providing benefits. This new norm will be uncomfortable and scary for healthcare providers, but those which are prepared to understand and help communicate the coverage available to the residents in its service area, prepared to demonstrate outcomes oriented, customer focused service, and are prepared to put resources into marketing their abilities, will find it to be one in which they can be successful and grow market share. Gallagher Healthcare Resources The Gallagher Healthcare Practice Group consists of over 250 sales and service professionals who work with over 1,800 healthcare clients including health systems, hospitals, long term care facilities, physician groups, three state hospital associations and two group purchasing organizations. We provide facilitation, guidance and process management of their business and corresponding benefit plan and liability risk management needs. Our Healthcare Analytics group is made up of actuaries, auditors and analysts who maintain an extensive data warehouse which they apply to cost containment, utilization analysis, physician attribution, patient panel risk adjustment and accountable care contract scorekeeping and payor negotiation. Our extensive partner program includes an effective HealthCAREdge approach to care coordination and case management which has reduced readmissions and claims over $50,000 by up to 40%, as well as a HealthCAREfficiency program which coordinates network alignment and process efficiency for those clients who wish to test the accountable care waters. The practice is coordinated by a full time managing director who identifies hot topics and priorities, develops the tools and resources needed to address this hot issues, coordinates our internal training and continuous education process, and gives back to the community by speaking several times each year at local and national industry events. To learn more about the Gallagher Healthcare Practice Group, and why our client trust and rely on us, please contact: Robin Mancuso, Managing Director, Gallagher Healthcare Practice Group at: Gallagher Healthcare Practice Group. No part of this document may be reproduced without permission. 6 P a g e

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