Integrative Health Policy Consortium

Transcription

1 Integrative Health Policy Consortium Implementing the Nondiscrimination Provision of the Affordable Care Act: Expanding Access and Choice for Your Patients Hon. Deborah Senn June 10, 2013

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3 Consumer Demand Eisenberg studies Survey results of over 2000 US households showed 67.6% of respondents used at least one CAM therapy in their lifetime

4 New Law Effective January 2014 A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider s license or certification under applicable State law.

5 New Law (cont.) This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

6 Facts about the nondiscrimination provision Goes into effect January But enrollment in Exchange plans starts October Sponsor and chief supporter of 2706 is Sen. Tom Harkin (D-Iowa) Not effective in states with no licensure

7 Types of health care providers c Naturopathic physicians M.D.s/Osteopaths Chiropractors, Acupuncturists Massage therapists Optometrists Nurse practitioners Licensed or direct entry midwives Podiatrists

8 Types of health plans involved It applies to market-based healthcare plans plans on the health insurance exchanges self-insured plans Self-insured plans (aka ERISA) are generally administered by large companies such as Boeing, Microsoft, Safeway, etc.

9 How it works It basically means that if an insurance company currently covers something, they must cover it in the future regardless of whether the provider is an MD, DO, DC, ND, Nurse Practitioner, Physician Assistant or any number of other qualified healthcare professionals. If it is in your scope of practice and the insurance plan covers it, you should be eligible for reimbursement.

10 Example #1 Suzy Smart comes to you for fatigue and anxiety. You order the usual blood tests, perform a complete physical, and provide diet counseling for managing blood sugar. Since the insurance company covers all these things if performed by another provider, it may not discriminate just because you are for example, a naturopathic physician.

11 Example #2 Suzy Smart-fatigue and anxiety. You order a red blood cell magnesium test and 4 sample salivary cortisol test. You prescribe an adrenal extract, kava kava and cranio electrotherapy stimulation (CES). The insurance company does not cover anxiety, or cover supplements, vitamins, herbal medicines.

12 NOTE Not everything in a scope of practice is covered!

13 Reimbursement Levels Reimbursements not required at same level as MD. ACA does not sets physician or provider fees. Insurers set fees subject to state law.. The nondiscrimination provision is not what is called an every willing provider law. That type of law means that an insurer has to take every qualified provider into its network.

14 Governance Q. Who's in charge of implementing the nondiscrimination provision on a state level? A. This will vary from state to state with the Department of Insurance often taking the lead. This is information that IHPC is researching and will disseminate to each state Association

15 A group health plan offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of provider s license or certification under State law. Every health plan after 1/1/96, shall: Permit every category of health care provider to provide health services or care for conditions included in the BHP services

16 Consumer/Provider Impact Parade of Challenges Whole groups of licensed providers excluded Limitations on number of visits Caps on dollar amount of coverage Inadequate no. of providers. Network adequacy Limiting time:1 hour appt. reduced to 30 minutes Narrowing the scope of practice or utilization Acupuncturists-Anesthesiology/ m.d., nausea, pain, Naturopaths only 3 services

17 Ninth Circuit The benefits conferred by the Act are the expanded treatments available to insureds, and the concomitant spreading of risk, due to the increase in the categories of providers able to provide treatment.

18 2706 Challenges Ca. ESB (Kaiser) excludes chiro and nd s Oregon: alternative services exc. Idaho Wa. Experience

19 HHS Guidance: For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques specified under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider s license or certification, to the extent the provider is acting within the scope of the provider s license or certification under applicable state law. This provision does not require plans or issuers to accept all types of providers into a network.

20 Impact on cost of health care Full implementation of the nondiscrimination provision is likely to reduce, not increase, cost. Many studies demonstrate that care by CAM providers is more cost-effective than conventional medical care.

21 Regence Study: Competition and Cost advantage There is significant potential to control costs with alternative healthcare. There is mounting evidence that practitioners of alternative therapies can be highly costeffective relative to conventional providers at trading several increasingly pervasive chronic and stress related conditions

22 Regence Study (cont.) (savings of 30% and more have been found in recent European outcome studies) such as heart disease chronic pain, respiratory illness, diabetes which are major cost drivers in the health care system and for which conventional medicine has less costeffective treatments.

23 More Recent Studies CAM users averaged $1,420 less in annual health care expenditures than nonusers in patients with the heaviest disease burden Corporate health management programs associated with prevention and wellness showed a 26% reduction in health care costs and a $5.81-$6 returned for every $1 invested 4

24 More Recent Studies (cont.) Median per-visit expenditures were $39.00 for CAM care and $74.40 for conventional outpatient care in Washington. The total expenditures per enrollee were $2,589, of which only $75 (2.9%) was spent on CAM. A systematic review of cost benefit analyses of CAM compared to conventional care revealed 42% of the published studies showed cost savings

25 Political and Legal Strategy