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The Affordable Care Act and Cardiac Surgery: Update 2014

The Affordable Care Act and Cardiac Surgery: Update 2014. Arie Blitz MD. Proof. Pre-ACA Issues & Challenges. Cost: We spend 17.3% of GDP on health care Coverage: 47 million uninsured Quality: How do we ensure quality while expanding coverage and decreasing cost?. Sources. Outline.

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The Affordable Care Act and Cardiac Surgery: Update 2014

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  1. The Affordable Care Act and Cardiac Surgery:Update 2014 Arie Blitz MD

  2. Proof

  3. Pre-ACA Issues & Challenges Cost: We spend 17.3% of GDP on health care Coverage: 47 million uninsured Quality: How do we ensure quality while expanding coverage and decreasing cost?

  4. Sources

  5. Outline

  6. Introduction • After much political ado, the Affordable Care Act (ACA) was passed in 2010. • Most of the debate has focused on how the ACA improves or threatens healthcare delivery and cost in the U.S. • The effect of the ACA on cardiovascular specialists is not completely clear...

  7. ACA Structure PPACA = patient protection and affordable care act HCERA = health care and education reconciliation act

  8. ACA Themes

  9. The 10 Titles: Effect on Cardiac Surgery Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  10. The 10 Titles: Finances McDonough: Inside National Health Reform. Univ of CA Press 2011

  11. No options Choose not to buy Want but cannot afford insurance Choose not to opt in Choose not to buy Choose not to enroll From census.gov, ncpa.org

  12. Title I: Quality, Affordable Care for All Americans Effects • Change in the character of private HI • Banning of lifetime/annual limits 2010 • No medical underwriting • Guaranteed issue • Mandate • subsidies • HI Exchanges • Gradual elimination of FFS payment mechanisms. • CT surgeons leaving private practice • Favors outpatient over inpatient care • Favors prevention over therapeutic care • Mixed implications for CT surgeons • Diminish inpatient and procedure-based care. Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  13. Title I: Quality, Affordable Care for All Americans Lack of affordability Adverse Selection; free riders McDonough: Inside National Health Reform. Univ of CA Press 2011

  14. Complexity of the Problem Title I: Quality, Affordable Care for All Americans Subsidies Cheap insurance plans no longer available

  15. Title I: Quality, Affordable Care for All Americans Average cost of silver-tiered plan: $4K Individual Mandate Penalties Whichever is higher McDonough: Inside National Health Reform. Univ of CA Press 2011

  16. Title II: The Role of Public Programs “If you have seen one state Medicaid program, you have seen one state Medicaid Program.” Effects • Medicaid Supreme Court preserves state opt-out OH, TX, FL, GA, NC Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  17. Title II: The Role of Public Programs Effects • State-based opt-out of Medicaid • Supreme Court Decision • DSH (disproportionate share hospital payment) cuts • Implications for opt-out states • Safety net hospitals most affected • Requirement of “essential health benefits” • A or B grade by US Preventative TF • Effect of disease screening on cancer and CAD • Effect on CT Surgeons? *Except: OH, TX, FL, GA, NC and others Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  18. Title II: The Role of Public Programs • Expansion of Medicare and Medicaid • On Average: • Medicare pays 81% of private insurance rates • Medicaid pays 56% of private insurance rates • Expansion may paradoxically worsen access

  19. The Medicaid Expansion Paradox Title II: The Role of Public Programs *O’Shea. Ann Int Med, 2006 **Study for Studying Health System Change, 2009 ***Garcia, NCHS Data Brief, 2010 Cost shifting to employees Cost shifting to Insurers

  20. Title III: Improving the Quality and Efficiency of HC Efficiency • HC that is more efficient, effective, and patient-centered • EHR penetration • >50% of all providers • >80% of all hospitals • Effect of health IT EHRs and integration of CV databases • Will this improve quality and costs? • Capture of cases? Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  21. Title III: Improving the Quality and Efficiency of HC Efficiency • IT Challenges • EHR interoperability is mostly lacking • The definition of eMeasures is in its infancy • The ability to extract data from EHRs remains a challenge • The cross-platform interoperability between EHRs and clinical data registries has been difficult to engineer. New incentives necessary? “The Copy-and-Paste” Problem Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  22. Title III: Improving the Quality and Efficiency of HC Efficiency • HER & Physician Practice • Cost $35-50K per physician to set up • Ongoing monthly fees $300-1500 • “Meaningful Use” • Fed reimburse some costs to compliant physicians (at taxpayer expense) • Not all patient care is favorably impacted by EHR • Continued economic pressures on surgeons to leave private practice

  23. Title III: Improving the Quality and Efficiency of HC Efficiency • Medical technology targeted as a primary factor for rising costs • Rising costs are OK if the value is worth it • Progress has been incremental rather than transformative? • E.g., robotics Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  24. Title III: Improving the Quality and Efficiency of HC Effectiveness • Drive to reorganization of care (ACOs and integrated departments) • IPAB (Independent Payment Advisory Board) limitation of spending • Penalties for readmissions and complications • “Robbing Peter to pay Paul.” Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  25. Title III: Improving the Quality and Efficiency of HC • Participate in Accountable Care Organizations(ACOs) • Network that: • Includes primary care providers • Employs evidence-based medicine • Achieves level of integration that include • Sharing patient info; joint governance • ACO must sign 3-year agreement • Must have at least 5000 Medicare beneficiaries • Surgeon can join multiple ACOs

  26. Title III: Improving the Quality and Efficiency of HC • ACA is fueling a drive toward greater collaboration in performance-based, shared savings practice programs • Hospitals under pressure to take greater control of physician’s practices • Incentives and penalties • Insurers will be under pressure to take greater control of physician’s practices • MLR (medical loss ratio) requirements • More risk-sharing with physicians http://www.physiciansfoundation.org/uploadedFiles/Roadmap%20for%20Physicians%20Final%20(2).pdf

  27. Title III: Improving the Quality and Efficiency of HC • IPAB (Independent Payment Advisory Board) • 15 Presidential appointees • Strengthened version of MedPAC (Payment Advisory Committee) • Independent of Congress and HHS • Shifts power from these bodies to IPAB • In order to change IPAB recommendations, Congress needs to have a 3/5 majority resolution. http://www.physiciansfoundation.org/uploadedFiles/Roadmap%20for%20Physicians%20Final%20(2).pdf

  28. Title IV: Prevention of Chronic Disease and the Improvement in Public Health “Money, Mammograms, and Menus” Effects • Promote healthier lifestyles for all Americans • No cost sharing for preventive care • Refocusing HC on prevention of disease, with implications for proceduralists • Cardiac surgeons need to remain vigilant • Must continue to support and strive for the evidence basis for cardiothoracic surgical procedures Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  29. Title IV: Prevention of Chronic Disease and the Improvement in Public Health Favors Prevention over Therapeutics • “Prevention is better than cure.” • “Prevention may be better, but it is not always cheaper” • “The broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.” • Louise Russell: Is Prevention Better than Cure, 1986 McDonough: Inside National Health Reform. Univ of CA Press 2011

  30. Title V: HC Workforce Effects • This commission is designed to analyze and plan for workforce needs • Currently, National HC Workforce Commission not funded • Significant effect on cardiac surgery if not convened Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  31. Title VI: Transparency and Program Integrity Effects • IOM report states that almost 1/3 of HC costs are wasted through inefficient, unnecessary, or illegal spending. • Addressing HC cost inefficiency and fraud • New physician-owned hospitals cannot participate in Medicare • Sunshine provision for physician payment reporting (>$10) • PCORI (Patient-Centered Outcomes Research Institute) support of research on comparative effectiveness • State demonstration program to evaluate alternatives to civil tort litigation. Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  32. Title VII: Improving Access to Innovative Medical Therapies “Biological Similars” • New FDA regulatory pathways • Development • Manufacture • Marketing • Sale • Most profound opportunity is in JIT clinical research based on national databases • CT Surgery has an advantage here Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  33. Title VIII: Community Living Assistance Supports and Services Effects • CLASS was abandoned by the Obama administration on 10/15/13 • Costs Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  34. Title IX: Revenue Provisions Effects • Finances approximately half of ACA • Factors affecting CV are: • new Medicare taxes on high-income wage earners and • new taxes on pharmaceutical and medical technology device manufacturers Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  35. Explicit New Taxes ($569 Billion) Title IX: Revenue Provisions

  36. Title X: Strengthening Quality, Affordable HC for All Americans Effects • Amendments and additions to Titles I-IX, passesd as the Health Care and Education Reconciliation Act (HCERA) signed on 3/30/10 Ferguson & Babb: Seminars in Thoracic and Cardiovascular Surgery. Volume 25, Issue 4 , Pages 280-286, Winter 2013

  37. The Future

  38. The Future for the Provider http://www.physiciansfoundation.org/uploadedFiles/Roadmap%20for%20Physicians%20Final%20(2).pdf

  39. Conclusions • My view: • Hospital employment model will triumph • FFS is dying • Surgeons will have less autonomy • High risk cases may be increasingly turned away

  40. Conclusions • My view: • Surgeons’ value will be determined by indispensability to the hospital and excellent outcomes • E.g., DT certification

  41. Advertisement Attention Surgeon: I’m a perfusionist I’m here to save your ass Not kiss it

  42. Thank You! New Orleans Sign

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