Health Care Reform: The Impact on Practitioners, Patients, and Politicians

1. Health Care Reform:The Impact on Practitioners, Patients, and Politicians Dave Renner Director, State & Federal Legislation Minnesota Medical Association

2. Pre-Quiz PPACA? ACA? ObamaCare? All the same: Patient Protection & Affordable Care Act of 2010

3. Overview • State vs. national context for reform • Reform elements • Insurance Coverage & Reform • Quality Reporting & Improvement • Delivery & Payment Reform • The politics of reform • Discussion/Q&A

4. The Landscape • 2008 Health Reform Act • Bipartisan agreement • Public health investment • Quality reporting and improvement • Payment and delivery reform • Focus on cost containment • Minimal focus on coverage/insurance reform • 2010 Affordable Care Act (ACA) • Bipartisan disagreement • Public health investment • Quality reporting and improvement • Payment and delivery reform (Medicare/Medicaid) • Strong focus on coverage/insurance reform • Minimal on cost

5. Insurance Coverage & Reform

6. Insurance Reform Context • 9% uninsured • History of solid regulatory structure • “Decent” environment for health care stakeholders • Strong non-profit tradition (state-based companies) • 17% uninsured • Variable regulations across states • Variable, but some very contentious environments • Variable, many for-profit, national plans

7. ACA Insurance Coverage • Estimated to provide coverage for 33 million of the 55 million uninsured • 3 specific ways • Individual Mandate • Employer Participation • Insurance Exchange w/ low-income subsidies • Medicaid Expansion

8. 1. Individual Mandate • Effective January 1, 2014 • All US citizens and legal residents • Compliance means you have “qualifying coverage” • A public program plan (e.g., Medicare or Medicaid) • Employer coverage • “Young invincible” plan • catastrophic for those <30 without other insurance • available to those with premiums >8 percent of income • Enforcement penalties • Exemptions • Upheld by SCOTUS: authority to tax

9. 2. Insurance Exchange & Subsidies • One-stop shopping for coverage: “Expedia” • Individual and small employers • Subsidies to all between 133%-400% FPG • Sliding scale premiums: limits cost to 3%-9.5% of income • Subsidies only for coverage bought through Insurance Exchange

10. 2. Insurance Exchange (cont.) • Exchange: An improved “marketplace” for purchase of insurance: individual and small employers (<100) • Administer tax credits • Determine “qualified” health plans that can sell products • Must be fully functional by January 2014 • Can not sell to undocumented immigrants • MN authorizing legislation not advancing • State moving forward with planning efforts • Over $70 million in federal grants to implement • Politically charged

11. Why Do Exchanges Matter to Providers? • Likely venue for insurance buying/eligibility decisions for up to 46% of Minnesotans • Opportunity for increased transparency and improved comparability about health plans/products • Common standards and expectations • Inclusion of quality/cost metrics may impact physicians and network definitions

12. 3. Medicaid Expansion • ACA allowed option for early expansion • Gov. Dayton signed order Jan. 5, 2011 to expand for all Minnesotans <75% FPG • DHS launched March 1, 2011 • ACA: Medicaid eligibility for all < 133% FPG (non-elderly) by 2014 • SCOTUS ruled this optional for states • Today: children, families, pregnant women, elderly • About ½ of newly insured done via expansion • Increased federal $ to states for new enrollees • 90% federal $ first two year.

13. Expansion Implications for MN • Early Medicaid Expansion: eligibility for ~95,000 • 32,000 GAMC • 51,000 MNCare enrollees • 12,000 Other (uninsured) • Expanding to 133% replace MNCare with MA for single adults—save MN $ • Politically charged!

14. 4. Insurance Reforms Key component of federal reform and coverage expansion • 2010: • Dependent coverage for adult children up to age 26 (MN law is up to 25) • Temp. national high-risk pool (thru 2013) • MN opted out of managing pool (MCHA) • No pre-ex for children • Phases in lifetime $ limits

15. 4. Insurance Reforms (cont.) • 2014: • With mandate: guaranteed issue and renewability • Limits on premium variations • Age: 3 to 1 ratio • Geography, family size, tobacco use: 1.5 to 1 ratio • Essential Benefits • 4 benefit packages available (bronze, silver, gold, platinum) • Variable levels of plan-covered costs (60%-90% of costs)

16. Quality Reporting & Improvement

17. Minnesota’s Efforts • Expand MN Community Measurement (voluntary) work statewide • First statewide quality report issued November 2010 (MDH)

18. MN Quality Measures • 2010 Measures (2009 dates of service) • Vascular, Diabetes Care, HIT Use • 2011 Measures • Depression remission, colorectal cancer screening, optimal asthma care • 2012 Measures • Patient satisfaction, C-section rates, early inductions, total knees (2012 services, reported 2014)

19. MN Provider Peer Grouping • Public reporting of cost and quality performance of physician clinics and hospitals • Primary care and multispecialty clinics – “total care” • Endocrinology, cardiology, pulmonology, allergy, orthopedic clinics – “condition-specific care” • MMA: Reliability & validity standards established • Slowed because of methodology challenges • Hosp. release-Dec. 2012? • Clinic release-Feb. 2013? Later? • Original release summer, fall 2011

20. ACA Quality • Medicare PQRS • 2011: Voluntary, 1% incentive for reporting • 2012-2014: 0.5% • An additional 0.5% incentive payment for participating in qualified MOC Program (quality practice-based learning programs through specialty boards) • 2015: 1.5% penalty • 2016+: 2% penalty • 2011: “Physician Compare” Website • Find-A-Doctor feature on Medicare.gov • General information

21. Delivery & Payment Reform

22. Current Payment Models Health Insurance Plan $ $ $ Office Visits ERVisits HospitalStay PhysicianPractice Avoidable Avoidable Phone Calls Lab Work/Imaging ...No penalty or reward forhigh utilizationelsewhere NurseCare Mgr Avoidable No payment for services that can prevent utilization... Source: Miller HD. Network for Regional Healthcare Improvement, Center for Healthcare Quality and Payment Reform, 2010 (used with permission).

23. Health Care Home:Pay for Care Coordination Services Health Insurance Plan $ $ $ Office Visits ER Visits HospitalStay PhysicianPractice Avoidable Avoidable MonthlyCare MgtPayment Lab Work/Imaging Phone Calls Avoidable Care Coordinator $ Payment for care coordination... Source: Miller HD. Network for Regional Healthcare Improvement, Center for Healthcare Quality and Payment Reform, 2010 (used with permission).

24. Proposed Medicare Model:Shared Savings/Risk Health Insurance Plan $ $ $ Office Visits ERVisits HospitalStay PhysicianPractice Avoidable Avoidable Phone Calls Lab Work/Imaging Portion of savings from reducedspending in other areas... NurseCare Mgr $ ...Returnedto physicianpractice aftersavings determined... Avoidable ...but no upfront $for better care Source: Miller HD. Network for Regional Healthcare Improvement, Center for Healthcare Quality and Payment Reform, 2010 (used with permission).

25. Politics of Reform • ACA: First major health reform passed by Congress since Medicare in 1965 • Passed where others had failed • Nixon, Clinton • Success??? • Now the real battles begin

26. Politics of Reform • Very polarizing issue • Candidates running on “Repeal Obamacare” • MN HIE tied up in anti-ACA rhetoric • HIE started as a Republican idea • Market-based health reform • Now can’t be touched by Republican legislators • Nov. elections—referendum on health reform?

27. In What Direction is HCR Headed? • New Congress and President (new?) may repeal?? Modify ACA • Regardless, HCR will move forward • Costs are unaffordable • Purchasers are demanding payment changes • Patients are demanding delivery changes • Everyone wants better/more consistent quality

28. Questions/Discussion Dave Renner 612-362-3750 drenner@mnmed.org

30. CONFLICT OF INTEREST I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.