The Affordable Care Act

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1 The Affordable Care Act What does it mean for internists? Joshua Becker MD 10/14/2015

2 VII Reforms and Beyond Payment Penalties under Medicare s Pay-for-Reporting Program Value-Based Payment Modifier mplifying Administrative Requirements the Health Care System Imposes on Physicians There is a lot in the ACA

3 There is a lot in the ACA What we will talk about Health Insurance Reforms Medicare/Medicaid Payment Reforms ACOs and Value Based Purchasing Paying for it

4 Why it came about Increasing Healthcare Costs High Number of Uninsured Outcomes vs Cost Source: Kaiser Family Foundation - JAMA 9/26/ :12 p.197

5 Medicare Medicaid (MA) MNcare 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 MN State program Covers those with low income - but more than previous medicaid levels Pay premiums and deductible - sliding scale

6 Who Was Covered Prior to ACA Reform Employer Based Insurance 48% Medicaid 16% 2013 US Population 317 Million Medicare 14% Other Private/Public 6% Uninsured 15% 48 Million Americans

7 Uninsured 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 Business Mandate (> 50 employees to provide coverage)

8 Private Insurance Changes 2010 Changes Coverage for Dependents up to Age 26 About 3 million people qualify for this 2014 Changes Guaranteed Issue and Renewability 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) 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

9 Uninsured 15% 48 Million Americans

10 Uninsured 15% 48 Million Americans Old Graphic but you get the idea. :)

11 Supreme Court Decision about the Medicaid Expansion June Supreme Court upheld legality of individual mandate But struck down requirement for states to expand medicare 31 States Expanded (including MN)

12 Medicare Coverage Gap About 4.8 Million People Nationally

13 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 objection

14 Expanding Private Insurance 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

15 Expanding Private Insurance Minnesota Insurance Exchange Medicaid and Minnesota Care Enrollment there as well Business Enrollment through SHOP program Enrollment Nov 15th-Feb15th

16 Costs in Minnesota

17 How Well is It Working? Nationally 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 insurance market

18 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 13.3 percent in 2013 to 10.4 percent last year.

19 Cost Controlling 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

20 Inpatient Metrics Snippet of 44 page list of metrics for Outpatient Care Score Card Pt Satisfaction Scores 2015 new measures Blood Stream Infections More Mortality Markers Medicare Spending per Beneficiary

21 % change in Hospital Reinfection rates from 2010 to Day Readmission Rates 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

22 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 (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 Increased funds for training programs with focus on medical homes

23 New Funding Models Accountable Care Organizations (ACO) 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

24 New Funding Models Accountable Care Organizations (ACO) 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.)

25 ACA Cost to the Government CBO projects $1.36 trillion in expenditures from * 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 ) 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: High-Cost ( Cadillac ) Health Plan Tax - (starts 2018): $34 Billion $111 Billion Sources: Congressional Budget Office; staff of the Joint Committee on Taxation. (5/2013)

26 Whew!. Take away points - Largest change in medical payment reform since 1960s - Refer your patients to MNsure website if they don t have insurance or if they potentially qualify for MA/MN care. - Need insurance by Feb 15th, 2015 to avoid penalties. - Payment based on quality measures is here and continues to evolve.

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