Transcript Understanding Health Care Reform

Why Health Care Reform
Should Matter to You
Preparing for practice in an evolving health care
system
THE STATUS QUO OF THE
U.S. HEALTH CARE SYSTEM
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A Typical Month of Health Care in
the United States
Adapted from Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J
Med 2001;344:2021-5.
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Current U.S. Health Care System
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A non-system
Uncoordinated
Fragmented care
Emphasizes intervention, rather than prevention
and comprehensive management of health
• Unsustainable costs that are rapidly increasing
• Access is declining
• Quality is far from ideal
Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American
Academy of Family Physicians, 2008. Accessed August 30, 2013.
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WHAT A “HEALTHY”
HEALTH CARE SYSTEM
WOULD LOOK LIKE
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Triple Aim
• Better patient experience of care
• Better health outcomes
• Lower Cost
Health Insurance Coverage
+
Access to Usual Source of
Care =
Improved Health Outcomes
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“Right care, right time, right place,
every time”
Source: Nowak NA, Rimmasch H, Kirby A, Kellogg C. Right care, right time, right place, every time. Healthc Financ Manage 2012
Apr;66(4):82-8.
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Key Elements of a High-functioning
Health Care System
• Health care coverage for all, including catastrophic
protection
• Patient-centered medical home for every patient
• Health care a shared responsibility of:
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Individual
Employers
Government
Private and public sectors
Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American
Academy of Family Physicians, 2008. Accessed August 30, 2013.
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What Does This Mean for Me As a
Medical Student?
• You are training at a pivotal time
• You have a responsibility to be change
agents for a system that will deliver better
care
• Your patients will look to you as a guide
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Health Insurance Coverage
+
Access to Usual Source of
Care =
Improved Health Outcomes
DeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance
coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.
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50 Million Uninsured
• Approximately equals the population of OR,
OK, PR, CT, IA, MS, AR, KS, UT, NV, NM,
NE, WV, ID, HI, ME, NH, RI, MO, DE, SD,
AK, ND, DC, VT, WY combined
Or
• The population of Sweden, Austria,
Switzerland, Denmark, Finland, Norway,
and Ireland combined
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Insurance Coverage Alone Is Only
Part of the Solution
• Giving people coverage alone is like giving
everyone a bus ticket and not having
enough buses.
• Improved health outcomes must also
address workforce needs
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Health Insurance Coverage
+
Access to Usual Source of
Care =
Improved Health Outcomes
DeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance
coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.
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Primary Care Health Professional
Shortage Areas
Primary Care Health Professional
Shortage Areas (2006)
Primary Care Health Professional
Shortage Areas, Family Physicians
Removed (2006)
Source: Interact For Health and the American Academy of Family Physicians. Health Landscape
Primary Care Atlas (healthlandscape.org), 2006 – 2013.
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Improved Health Outcomes When the
Usual Source of Care Is Primary Care
• Increase accessibility
• Promote prevention
• Proactively support patients with chronic
illness
• Engage patients in self-management and
decision-making
Source: Health care for all: a framework for moving to a primary care-based health care system in the United States.
American Academy of Family Physicians, 2008. Accessed August 30, 2013.
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States That Rely More On Primary
Care Have…
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Lower Medicare spending
Lower resource inputs
Lower utilization rates
Better quality of care
Dartmouth Medical School Center for the Evaluative Clinical Sciences. The Care of Patients with Severe Chronic
Illness. Trustees of Dartmouth College, 2006. Accessed August 30, 2013.
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Key Changes Needed
• Reinvigorate the primary care infrastructure
in the U.S.
• Redesign the manner of primary care
delivery
• Re-emphasize the centrality of primary care
Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American
Academy of Family Physicians, 2008. Accessed August 30, 2013.
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WHAT IS THE PATIENT
PROTECTION AND
AFFORDABLE CARE ACT AND
HOW DOES IT ADDRESS THE
EQUATION?
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Health Insurance Coverage
+
Access to Usual Source of
Care =
Improved Health Outcomes
DeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance
coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.
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What is the Patient Protection and
Affordable Care Act?
• Comprehensive health reform
• Signed into law March 23, 2010
• Includes measures to:
– Cover at least 30 million of the 60 million Americans
projected to be uninsured by 2022
– Increase access to affordable care
– Improve care quality and lower cost
• Sound familiar? Echoes the three key elements of a highfunctioning, primary care-based health system
Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American
Academy of Family Physicians, 2008. Accessed August 30, 2013.
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Year-by-Year: 2010
• New funding for scholarships and loan repayments for
primary care physicians working in underserved areas
• Tax incentives for primary care physicians working in
underserved or health professional shortage areas
• Increased payments for rural health care providers
• New funding for community health centers
• Creation of $15 billion Prevention and Public Health Fund
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2010
Patients can
Insurance companies can’t
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Compare coverage options online
Appeal insurance company decisions
Access customer assistance from
their states for enrollment, education,
and appeals
Stay on parents’ insurance until age
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Access preventative care services
such as mammograms and
colonoscopies without charge
Retire early and receive coverage
Receive coverage through Medicaid
expansion
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Deny coverage of children based on
pre-existing conditions
Rescind coverage for an error or
technical mistake
Impose annual limits or lifetime dollar
limits on coverage
Unjustifiably hike rates
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2011
• For seniors:
– Prescription drug discounts
– Free preventative care
– Improved post-hospitilization care and
coordination
• Funding for home and community-based,
rather than institutional, care for disabled
covered through Medicaid
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2011
• Testing of new care delivery models that
highlight care quality, cost control, to
propose a new national strategy
• Regulations to control insurance premiums
and overpayment
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2012
• Payment linked to quality outcomes through the
Value-Based Purchasing Program in Traditional
Medicine.
• Incentives for creation of Accountable Care
Organizations (ACOs) to coordinate patient care.
• Standards for billing and electronic health record
(EHR) use
• Increased information gathering on health
disparities
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2013
• Increased Medicaid payments for primary care
doctors
• Open enrollment in Health Insurance
Marketplace begins
• Payment bundling to incentivize provider
coordination and improve quality of care
• New funding for state Medicaid to cover
preventative services
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2014
• Establishment of the Health Insurance
Marketplace
• Expanded Medicaid (in states that choose)
• Uninsured Americans who are not exempt pay a
fee to help offset the costs of caring for uninsured
Americans
• Tax credits for middle class to afford insurance
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2014
• Prohibit insurance discrimination due to preexisting conditions or gender
• Eliminate annual limits on insurance
coverage
• Ensure coverage for individuals
participating in clinical trials
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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Year-by-Year: 2015
• New provision to tie physician payments to
care quality.
Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed
August 30, 2013.
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What Are the Insurance Marketplaces
(Exchanges)?
• Federally run, state-run, or partnership
exchanges.
• Composed of private insurance plans and
federal plans, including Medicaid and the
Children’s Health Insurance Program.
• Allow Americans to compare, find, and
enroll for health insurance coverage in one
place, with one application.
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Options for Saving
• Based on income level and family size,
patients can qualify for:
– Reduced premiums or co-pays through a plan
in the Marketplace
– Expanded Medicaid programs for people who
make up to 133% of the federal poverty level
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Gaps in Coverage
• Some American’s won’t qualify for Medicaid or
reduced-cost insurance through the Marketplaces
– In states that chose not to expand Medicaid coverage
– Income level too high for Medicaid coverage, but
– Income level too low for Marketplace cost reductions
• These patients can
1. Pay full price for coverage through the Marketplace, or
2. Go uninsured and qualify for exemption from the
fee, fitting into the gap and remaining uninsured.
Source: healthcare.gov
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Covering the Gap
• Primary Care stepping up to the plate
• Community health centers providing
essential care in states that choose not to
expand Medicaid to cover uninsured
patients
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WHAT DOES THIS MEAN FOR
FAMILY MEDICINE?
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More Patients Will Need Family
Physicians
• Insurance marketplaces and expanded coverage
will create a new insured patient population
– This is good for patients and for physicians
(access and reimbursement)
• Patients entering this population want a family
doctor. They want a shepherd to navigate their
personal health care and the system.
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Market Forces Will Drive Demand
For Family Physicians
• Demand for family physicians will increase
steeply, highlighting undersupply of family
physicians
• Programs and policies both new and
already in development will focus on
producing more family doctors
• Care will focus on prevention and disease
management, saving cost
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Family Physicians in Demand
• “Primary care physicians remain at the top
of the wish list for most hospitals, medical
groups and other health care
organizations.”
• The most recruited specialty in 2012; at
the top of the list for 7 straight years
Source: 2012 Review of physician recruiting incentives. An overview of the salaries, bonuses, and other incentives
customarily used to recruit physicians. Merritt Hawkins, 2012. Irving, Texas.
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What Is the Future of Family
Medicine?
• Patient-centered medical home
(PCMH)
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Population health
E-visits and online appointments
Web-based patient education
Group visits
Team approach to care; systematic
approach to care
– Chronic disease management
– Joy in practice through innovation
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Resources on Health Care Reform
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Healthcare.gov
CMS.gov
HHS.gov/healthcare
Familydoctor.org
Health Care for All: A Framework for
Moving to a Primary Care-Based Health
Care System in the United States