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Mass. healthcare reform and CHA David Bor MD Cambridge Health Alliance Harvard Medical School.

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Presentation on theme: "Mass. healthcare reform and CHA David Bor MD Cambridge Health Alliance Harvard Medical School."— Presentation transcript:

1 Mass. healthcare reform and CHA David Bor MD Cambridge Health Alliance Harvard Medical School

2 Disclosures No financial conflicts of interest Doctors are the natural attorneys for the poor because within the examination room or on the wards we are forced to confront the stark and painful reality that inequality contributes to our patients' illnesses and early mortality. Rudolph Virchow

3 Agenda What’s new? Our setting: –CHA: –Romnicare CHA experience with Romnicare The future?

4 The safety net If you’ve seen one, you’ve seen one Health centers and public hospitals Serve uninsured & low income persons Special services –trauma, burns, psychiatric care, interpreters Special locales: –Inner-city, rural Special roles: –train future work force –Innovators in delivery, public health –contribute to advocacy

5 Our setting: CHA An Island of Sanity –Integrated academic healthcare system –Covenant with the Commonwealth –Free care pool & DSH funds Romnicare The Recession Three World Series Championships

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7 Cambridge Health Alliance, 1996…

8 The covenant with CHA’s communities Develop Neighborhood Health Centers Rescue mental health and addictions care Rescue secondary care hospitals Provide for special needs: –seniors, homeless, house-bound, victims of violence, immigrants, those with addictions and mental illness Program public health functions: –, TB, HIV, School health, disaster preparedness

9 Romnicare: Massachusetts healthcare reform –Expand access, reduce disparities through insurance: –Funding Mandate insurance with minimal penalties Repurpose disproportionate care funds & FCP Share costs with beneficiaries –Cost controls - Cost sharing Restrain Medicaid growth Experiment with incentives Triage by inconvenience –Unregulated market ACO consolidation

10 Impact of Romnicare on CHA Financing formula fractures safety net –It’s a revenue problem Challenge to/of “underserved” –Health care system –Social care system Market culture infects CHA

11 Mass Hospital Margins FY 2012 Statewide median (65)2.8% Teaching (18)5.0% Community (47)2.5% DSH (20)1.3% Non-DSH (36)3.4% MGH9.7% BIDMC5.3% U Mass memorial-0.4% BMC-0.3% CHA-5.4%

12 CHA financial performance pre and post reform Net revenue $ 414 $ 473 $ 475 Net income $ (14) $ (37) $ (29)

13 CHA financial performance pre and post reform Net revenue $ 414 $ 473 $ 475 Revenue as "support" 47%32%29% Bad debt $12.5$26 Net income $ (14) $ (37) $ (29)

14 Medicaid payment to cost trends Massachusetts Hospitals (CHA gets ~60% NPSR from low income public payer)

15 Medicare payment to cost trends Massachusetts Hospitals CHA gets about 20% NPSR from Medicare c/w 29% mean

16 Unregulated “marketplace” Relative payments by commercial insurers 2012 AetnaBC/BSHPHC B&W BIDMC Hallmark BMC CHA

17 The patient experience: Insurance hassles: –Lapses – in and out of insurance –Tiered insurance: –Eligibility determination hassles –No retroactive coverage Underinsurance: –More no-shows –Inability to fill scripts –Deferred care

18 The patient experience New health care barriers –Hospital requires payment at PCP visit –Long waits, esp. for psychiatric and SA care –Lost access to post-acute care New social care barriers –Don’t qualify for the ride –Restricted housing assistance –Psychiatric day programs, drop in centers

19 MD experience Attempting to predict out-of-pocket costs Attempting to arrange alternate care Attempting to conform to: –Clinical speedup –Perverse financial incentives –Micromanagement –Consultants New ethical considerations: –OK not to serve uninsured? –OK to send poor to collection?

20 CHA going forward... New compact with Commonwealth Transition toward ACO/PCMH Tertiary affiliation Expand population served National model –Population health –Advocacy Austerity

21 ... Still Best place to work, Best place to innovate Best setting from which to advocate –Restore DSH … fully fund Medicaid –End P4P –Restrain/regulate consolidation –Single Payer ! “ Power concedes nothing without a demand. It never did and it never will”. Frederick Douglass

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