US Health Care System: Its impact on your future practice and patients

1. US Health Care System: Its impact on your future practice and patients Nancy Cooper Coordinator, Health Policy Fellowship March 27, 2014

2. What’s the problem? • Medicine is the #1 industry in the US • We have the best • Technology • Infrastructure • Medical schools • Physicians

3. What’s the Problem? ACCESS50 Million uninsured/10 M underinsured

4. What’s the Problem? COST: $2.6 trillion CMS Office of the Actuary 2011 & Kaiser Family Foundation report, Health Care

5. “The US Government is an insurance company with a large army” White House Office of Management and Budget 2010

6. Half of all children born after 2000 will live to be 100 One in three will develop Type II diabetes The Lancet Oct 1, 2009 and National Diabetes Fact Sheet, Jan 26, 2011

7. What’s the Problem? QUALITY • Emphasize acute care over wellness and prevention • Fee for service payment encourages quantity over quality • Health disparities among racial and ethnic minorities • Outcomes are poorer than countries which spend much less

8. Inefficient and Expensive "In the United States today, we give you all the care you can afford, whether or not you need it, as opposed to all the care you need, whether or not you can afford it." Arthur Kellerman, MD, MPH, Emory Medical School

9. Understanding the US Health Care System(s): Evolution or Intelligent Design?

10. Access to Insurance Equals Access to Care 250 Million Americans 50% Private Insurance Employer-based group insurance or Single policy or Out of Pocket

11. 50% State and Federal Government Insurance Medicare (elderly) Medicaid (destitute) Children’s Health Insurance Program (CHIP) Veterans Affairs Indian Health Service Federal Employees Health Benefit Program

12. Safety Net for 60 M Uninsured/Underinsured Urban Institute: Health Care Spending Under Reform: Less Uncompensated Care and Lower Costs to Small Employers 1/2010 http://findahealthcenter.hrsa.gov/Search_HCC.aspx • Emergency rooms • Public hospitals • Federally Qualified Health Centers (FQHCs) 145 OR • Migrant worker health centers $61 B per year in uncompensated care

13. Government InsuranceHealth and Human Services $880 billion budget Medicare $524 B Medicaid $243 B fed$ Total CMS $ 767 B www.hhs.gov Kaiser Family Foundation 3/17/11

14. Medicare Centers for Medicare and Medicaid Services (CMS) • Serves 47 million people over age 65 • >650,000 in CO • Four Parts • Part A: Hospital costs • Part B: Physician Services • Part C: Medicare Advantage • Part D: Rx www.hhs.cms.gov Kaiser State Health Facts/Medicare/Oregon. Accessed 10/13

15. Centers for Medicare and Medicaid Services (CMS) • Also pays $9B for Graduate Medical Education (GME) • – med school enrollment increasing but cap on federally-funded residency slots

16. Where the Money Goes

17. Happy Birthday Boomers! "You’ve got . . . 10,000 new seniors, baby boomers, becoming eligible for the entitlement programs" . . . everyday for the next 18 years. Rep. Cantor, R-VA House Majority Leader Representative Eric Cantor, April 27, 2011, PoliticFact, Richmond Times Dispatch 4/27/11

18. The Silver Tsunami . . . Enrollment will increase from 47 million to approx 74 million – number of beneficiaries over age 80 will triple. Congressional Budget Office 2/1/12

19. MedicaidCenter for Medicare and Medicaid Services (CMS) 3 out of 5 kids are born on Medicaid • Health care for 60 million eligible poor > 133% FPL • Pregnant women, children, moms • Medically needy (aged, blind, disabled) and nursing home care • 618,000 in CO (2010) • $343 billion per year – • 2/3 is federal match (FMAP) • 1/3 paid by states Kaiser State Health Facts/2009 data

20. Medicaid’s Fiscal Challenges Takes up >25% of most state budgets Increases in unemployment = increases in eligibility (but decreased state revenue) Fairly generous benefits (mental health, dental and vision) but access problems due to low reimbursement

21. Changing the SystemHealth Care Reform

22. Values Affect Policy: Is Healthcare a Right or a Responsibility?

23. Interest Groups and Stakeholders Impact Policy

24. Politics Affect Policy • Separation of powers • Senate and House: Checks and balances • Reactive rather than proactive • Compromisethe key to passing policy • Congress is currently highly partisan • Change is slow and incremental

25. Even Congress Hates Congress Approval rating: 9% “It’s so bad sometimes I tell people I’m a lawyer,” Senator Lindsey Graham (R-S.C.). “I don’t want to be associated with a body that in the eyes of your fellow citizens seems to be dysfunctional.” “We’re below sharks and contract killers,” added Rep. Trey Gowdy (R-S.C.). Politico, October 26, 2011/January 2012

26. Limited Resources Affect Policy US Government Income and Outlay, based on historical tables from the White House Office of Management and Budget (Table 1.1). *2012 is estimated by OMB. http://www.whitehouse.gov/omb/budget/Historicals

27. Change is painful and slow “I love change except for the part about doing things differently” anonymous “There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order.” Machiavelli Rule of Reform

28. What’s in thePatient Protection and Affordable Care Act?

29. 1. Will the health reform law require nearly all Americans to have health insurance by 2014 or else pay a fine? • Yes • No • Don’t know

31. 2. Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare? • Yes • No • Don’t know

32. "The America I know and love is not one in which my parents or my baby with Downsyndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care.” Sarah Palin 8/7/09

33. 3. Will the health reform law cut benefits that were previously provided to all people on Medicare? • Yes • No • Don’t know

35. 4. Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children? • Yes • No • Don’t know

38. 5. Will the health reform law provide financial help to low and moderate income Americans who don't get insurance through their jobs to help them purchase coverage? • Yes • No • Don’t know

39. 6. Will the health reform law prohibit insurance companies from denying coverage because of a person's medical history or health condition? • Yes • No • Don’t know

40. 7. Will the health reform law require all businesses, including small businesses, to provide health insurance for their employees? • Yes • No • Don’t know

41. 8. Will the health reform law provide tax credits to small businesses that offer coverage to their employees? • Yes • No • Don’t know

42. 9. Will the health reform law create a new government run insurance plan to be offered along with private plans? • Yes • No • Don’t know

43. 10. Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance? • Yes • No • Don’t know

44. Health Care System: Before the ACA Dual Eligibles Retiree Benefits Medicare 65 Health Care “On Demand” Employer- Provided Managed Care Underinsured Medicaid Uninsured Age 18 CHIP Very Poor Near Poor Work. Poor Middle Class Upper-Mid Class Very Rich Income Adam Sheingate, Professor, John Hopkins University Political Science Department, August 2012

45. Health Care System: After ACA Dual Eligibles Retiree Benefits Medicare 65 Health Care “On Demand” Employer- Provided Managed Care HealthExchanges MedicaidExpansion Uninsured Underinsured Medicaid Age Circa 2012: Medicaid Exp., Health Exch. 18 CHIP Very Poor Near Poor Work. Poor Middle Class Upper-Mid Class Very Rich Income Adam Sheingate, Professor, John Hopkins University Political Science Department, August 2012

46. Good News for the Uninsured • Cover up to 35 million more people • Individual Mandate (SCOTUS considers the fine a “tax”) • Employer Mandate • Insurance Regulation • Kids covered on parents policy to age 26 • No exclusion for pre-existing conditions • Health Insurance Exchanges and subsidies • Changes to Medicaid • State can choose to include adults > 137% of FPL

47. Good News for Seniors Fill in donut hole in Medicare Rx Reduce Hospital readmissions Reduce Medicare premiums Increase Medicare preventive services Increase access to Medicaid services Increase access and quality for dual eligibles

48. Carrots and Sticks for Providers • Incentive payments for Patient Centered Medical Home • $44,000 bonus payment for adoption and “meaningful use” of HIT • 10% bonus to primary care physicians and surgeons working in Health Profession Shortage Areas (HPSAs) • Accountable Care Organizations responsible for quality and costs; can earn “shared savings” • Cut reimbursement to Medicare providers • No payment for preventable readmissions • Reduce payment updates for hospitals, home health and SNFs • Value-based purchasing performance and quality • Bundled payment for an episode of care • Cut reimbursement to Medicare Advantage (MA) plans • Independent Payment Advisory Board to reduce rate of spending

49. Get Involved • Invite speakers on key issues • AOA Dept Gov. Relations • AACOM Dept Gov. Relations • Former HPF and TIPS Fellows • Educate yourself • Monitor, analyze and advocate for issues • Educate elected officials about key issues • Attend DO Day on the Hill – or Visit State Capitol • AACOM Health Policy Internship • Training in Policies Studies Program OGME II and III

50. Generate Discussion