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

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Presentation on theme: "Health Care Reform: The Impact on Practitioners, Patients, and Politicians Dave Renner Director, State & Federal Legislation Minnesota Medical Association."— Presentation transcript:

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 4

5 Insurance Coverage & Reform 5

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 6

7 ACA Insurance Coverage Estimated to provide coverage for 33 million of the 55 million uninsured 3 specific ways 1.Individual Mandate a)Employer Participation 2.Insurance Exchange w/ low-income subsidies 3.Medicaid Expansion 7

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 8

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 9

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 10

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 11

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. 12

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! 13

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 14

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) 15

16 Quality Reporting & Improvement 16

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

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) 18

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

20 ACA Quality Medicare PQRS – 2011: Voluntary, 1% incentive for reporting – : 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 20

21 Delivery & Payment Reform 21

22 Current Payment Models ER Visits Lab Work/ Imaging Hospital Stay Health Insurance Plan Physician Practice $$ Avoidable Office Visits Nurse Care Mgr Phone Calls $ No payment for services that can prevent utilization......No penalty or reward for high utilization elsewhere Source: Miller HD. Network for Regional Healthcare Improvement, Center for Healthcare Quality and Payment Reform, 2010 (used with permission). 22

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

24 Proposed Medicare Model: Shared Savings/Risk ER Visits Lab Work/ Imaging Hospital Stay Health Insurance Plan Physician Practice $$ Avoidable $ Portion of savings from reduced spending in other areas......Returned to physician practice after savings determined......but no upfront $ for better care Office Visits Nurse Care Mgr Phone Calls $ Source: Miller HD. Network for Regional Healthcare Improvement, Center for Healthcare Quality and Payment Reform, 2010 (used with permission). 24

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? 26

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 27

28 Questions/Discussion Dave Renner

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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.


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