Transcript An Update in Healthcare Reform Albert Heuer

The ACA Five- Years Later—An
Update on Health Care Reform
Al Heuer, PhD, MBA, RRT, RPFT
Professor & Program Director
Rutgers School of Health Related Professions
Learning Objectives
Summarize Key Facts about Our Health
Care System
 Review the History & Legislative Process of
Health Care Reform
 Summarize the Some Major Features of the
Law.
 Describe the Reality of It’s Impact on:

 Us as Clinicians and Consumers
 Health Care Organizations
Review Future Implications
 Furnish Additional Resources

US Health Care System—The Best
& the Worst

Strengths:
 Strong Investment in Technology & Research
 Safety Net for Elderly, Disabled & Disadvantaged.

Weaknesses:





Cost
In 2010. 47 mil. (16%) of Americans were Uninsured
Unequal access to care
Uneven clinical outcomes
Health catastrophes are leading cause of U.S.
bankruptcies.
 Inefficient use of services


ER as primary care
Futile Care—We don’t know how to say “no mas”!
Health Care Systems of
Other Countries
• US Health Care cost twice that of other
developed countries; approximates 6th largest
national GDP.
• Universal Health Care - Canada-national public
policy provides disincentives for using private
health insurance.
* National Health Care-England-National Health
Service founded in 1948. Co-lateral private
health insurance is allowed.
* Germany spends approx. 10% of it’s GDP on
Health Care; 5-6% for many European countries
Initial Attempts at Reform
FDR wanted national health care to be
included in the 1935 Social Security Act.
 President Truman attempted to initiate a
national health care insurance program.
 Was on Jimmy Carter’s agenda.
 1993 Hillary Clinton —Ultimately
unsuccessful, largely due to insurance
industry opposition.

Contentious Political Process for This Law
President Obama’s 2010 budget set aside $600 Billion for
Health Care reform.
 July 15, 2009 - Senate Health Committee passes its bill.
 August/Sept. - White House loses control of the debate.
 November 2009 - Dems introduce new Senate bill,
including an increased payroll tax on the wealthy.
 December 2009 - 25 day debate in the Senate.
 February 2010 - Bi-Partisan summit with Obama.
 March 2010 - To avoid a Senate Republican filibuster,
House passes the Senate version with “sidecar” of fixes.
 Final Votes: House 228-207; Senate 56-43.
 Signed into Law March 23, 2010. (974 pages long)

Features of the Bill – Impact
Many Stakeholders
Individuals
Small
Businesses
Insurance
Companies
Hospitals,
Doctors &
Clinicians
Initial Features of the Bill
- Individuals
Mandates that all Americans have Health
Insurance.
 Creates Health Insurance Exchanges for

 Uninsured
 Self-employed
 Subsidies for low-income individuals/families
(133% to 400% of the poverty level).
Expands Medicaid coverage.
 Prescription “Donut Hole” Rebate, Fills some
of the limits for prescriptions under Medicare.

Initial Features of the Bill Individuals (cont.)

Must cover preventative care, including
checks ups with no deductible.
 Asthma management
 Smoking cessation
Coverage for adults with pre-existing
conditions.
 Young adults can continue on parents plan
until age 26.
 Mandated Coverage: Penalty of $695/Indiv. in 2016.

Features of the Bill - Small
Businesses
Creates similar exchanges for smallmedium sized businesses.
 Small Business tax Credits – 50% of
health ins. premiums applied as credits
for businesses with less than 50
employees.
 Companies with 50 or more employees
must cover 95% of full-time employees
by 2016.

Initial Features of the Bill - Insurance
Companies





End of Rescissions-Insurance Co’s can’t cut someone
when he/she gets sick.
Insurance Company Transparency-Must reveal amount
spent on overhead.
Higher loss-ratio requirements (now 85%) for insurance
companies to take advantage of tax benefits.
Customer Appeals-Any new plan must implement an
appeal process for coverage determinations and claims.
40% tax on insurance companies offering Cadillac H.I.
Plans.
Initial Features of the Bill –
Hospitals & Doctor’s Practices
Decreases Medicare coverage but
Temporarily increased reimbursements
for general practice
physicians/surgeons.
 Medicare pay’t protections extended to
rural hospitals.

ACA Re-Emphasizes
Emerging Themes
What Does Value over Volume
Mean to an RT?
Old Philosophy – If a patient stays on a
ventilator longer or has a stay, that’s is
good for our Job Security!
 New Philosophy - Fewer Vent Days,
shorter LOS and Happier patients are
Rewarded!
 How does this work?

The Answer: – The ACA’s ValueBased Purchasing Provision
Value Based Purchasing Program (VBP)
 Begin to pay hospitals for their actual
performance
 Requires a portion of Medicare
reimbursement to be withheld and returned
in proportion to how the Hospital performs,
Initially in 3, Now in 4 Categories.

FY 2016
CMS - Value-Based
Purchasing (VBP) Program
17
Soooo, VBP Can Reward Clinicians for
Contributing to Better Outcomes!
Patient weans off ventilator sooner.
 Shorter LOS.
 Better clinical outcome and happier
patient means higher VBP performance.
 Better VBP performance means more $
reimbursement to the hospital.
 More reimbursement means more $ for
resources, including staff, equipment…

Another Form of Pay-for
Performance – The Hospital
Readmission Reduction Program
(HRRP)
Conditions Covered Under
HRRP
Initial 2013
Conditions
 Acute Myocardial
 Infarction (AMI)
 Heart Failure
 Pneumonia
2015 Expansion
 COPD
 Coronary Bypass
Surgery‐
 Coronary
Angioplasty
 Other Vascular
Conditions
Shhh! Don’t Say “Frequent Flyer”!, HRRP Rewards
Less Frequent Flying …and Here’s How!






Patient is admitted but gets enrolled in a Readmission Reduction Protocol
Patient gets educated about their condition and
the importance of adhering to their Tx. plan.
Potential barrier to successful discharge are
addressed and post discharge follow-up done.
Patient stays out of the hospital.
Better HRRP performance means more $
reimbursement to the hospital.
More reimbursement means more $ for resources,
including staff, equipment, etc.
Changing Reimbursement—Pay-For-Performance
Payment Reform for Hospitals
Fiscal Year
Value Based
Purchasing
Hospital Readmission
Reduction Program
Hospital
Acquired
Conditions
Total
2013
1.00%
1.00%
0
2.00%
2014
1.25%
2.00%
0
3.25%
2015
1.50%
3.00%
1.00%
5.50%
2016
1.75%
3.00%
1.00%
5.75%
2017
2.00%
3.00%
1.00%
6.00%
.
Alexander, K.,LHA Legislative & regulatory Update. LA Assn for Healthcare Quality Annual Education Conference,
April 2012
2013 (Interim) Reimbursement Penalties—The
Facts

2,211 American hospitals received reimbursement
penalties for high readmission rates
 Together they will forfeit about $280 million in
Medicare funds over next year

According to Medicare, 2 out of 3 hospitals
evaluated failed to meet its new standards for
preventing 30 day readmissions.

Hence, more hospitals lost $ than gained.
Five years Later-- Public
Remains Divided on ACA
Late June 2015

Favorable: 43%

Unfavorable: 40%
Other Realities -- ACA--Five Years
Later Health Ins. Coverage
15 million Fewer uninsured individuals
since 2010
 But, 35 million Individuals still without
insurance

 Most
gains are from expanded
Medicaid expansion

12 million More people enrolled in
Medicaid since 2010.
Health Ins. Coverage - Reality
* 5.8 million people gained coverage in the
individual market.
* 4.9 million individuals lost employer
coverage during the same period.
* In other words, for that period in which raw
data are available, almost 90% of coverage
gains were in the Medicaid program.
Fewer Adults Without Health
Insurance:
Why do we Care About
Medicaid Expansion???
Positive:
• More Americans are Covered!!!
• All adults up to 133% of the FPL will gain Medicaid coverage.
• Should promote healthier life styles--Example
• Starting in 2014, Medicaid programs that provide prescription drugs
must cover tobacco cessation medications.
• Those who are low-income and uninsured are more likely to use
tobacco.
• These enrollees will now have access to six cessation counseling
sessions a year.
Negative:
* Possible Influx of Insureds with poor health.
* Incentives to Primary Care Physicians to Accept Medicaid are
running out.
* Cost of expanded Medicaid passed onto tax payers?
ACA—Positives Five Years
Later - Individuals
2.3 million young adults gained
coverage from 2010 through Sept. 2013
by staying on their parents' plan.
 11 million Individuals have insurance
through a state or federal exchanges.
 7.7 million Individuals receiving tax
subsidies for coverage through an
exchange.

ACA—Negatives Five Years
Later - Individuals
900,000 Americans’ individual or employersponsored health policies were cancelled for 2015
because they did not comply with the ACA.
 Individual Premiums have increased dramatically.
 1 in 2 Number of American households eligible for
a premium subsidy in 2014, paid some money
back to the government in 2015 because of
income changes…

 $794 Estimated average payment these households
will owe the government in 2015.
ACA--Five Years Later Large
Corporations
Group Health Insurance Premiums have
Skyrocketed.
 Corporations with 50 Employees must provide
Health Insurance to 95% of emplyees
 Both of the Above have caused Corporations to:
 Be cautious in hiring
 If they do hire, keeping hours below 30/wk.
 Sent more job overseas
 Future uncertainties have curbed other forms of
corporate spending

Accountable Care Organizations
(ACO’s)
In section 2706 & 3022 of the ACA
 An ACO is a network of physicians,
hospitals, and other health providers that
collaborate to improve care and reduce
costs for Medicare participants.
 The ACA, created a shared savings
program, providing incentive payments for
improving quality and reducing cost.
 A Pioneer ACO--one which has experience
in coordinating care across settings.

Accountable Care Organizations
(ACO’s)- The 2014 Results
1. 97 ACOs qualified to share in savings by meeting quality and cost benchmarks
* earned a total shared savings of more than $422 mil.
2. The results indicate ACOs improve over time: 37 percent of the ACOs that
launched in 2012 generated shared savings
• compared to 27% in 2013
• and 19 % in 2014.
3. ACOs also improved on quality compared to 2013. ACOs that reported in both
preceding years showed improvement in 27 out of the 33 quality measures:
Clinician-patient communication
Patient ratings of physicians
Tobacco & Blood Pressure Screening
EHR use
4. The program is still receiving strong interest and CMS plans to announce new and
renewing ACOs.
ACO’s-Why Should you Care?
May explain increased emphasis on
interprofessional collaboration between
and among disciplines/care settings.
 Better coordination = better outcomes.
 If your organization is receiving shared
savings, there’s more $ for staffing,
supplies, equip. & education.
 Can counteract reductions elsewhere,
from VBP, Short-term Re-admit
penalties, and reimburse. reductions.

Meaningful Use & the ACA
Health Care Organizations receive
incentives and beginning in 2015 penalties
for demonstrating that they are
meaningfully using Electronic Health
Records (EHRs).
 Meaningful Use was Actually Created by
the Health Information Technology for
Economic & Clinical Health (HITECH) Act
(2009), not the ACA.
 Grants and other $ incentives are in the
ACA to promote health information
technology enhancements.

EHRs & Meaningful Use

Stage 1 -- 2011-2012
 Electronic capturing of health info.
 Initial reporting of clinical quality measures.
 Using information to Track Clinical Conditions.

Stage 2 – 2014
 Increased requirements for e-prescribing and
incorporating lab results.
 Electronic transmission of patient care summaries across
multiple settings

Stage 3 – 2016
 Improving quality, safety, and efficiency, leading to
improved health.
 Patient access to self-management tools.
Meaningful Use Financial
Incentives



Through 2014, $44K-$66K per physician in
financial incentives meeting the criteria.
Approx. 50-60% of health care facilities fail to
show that they are using the system in a
“meaningful way” 1-2% reimb. penalty
Penalties for Failing to Demonstrate Meaningful
Use:
 2015 & 2016 -- 1-2% reimb. penalty
 2017-- 3% reimb. penalty
 2018 -- 4 %
 2019+ -- 5%
Meaningful Use —Why Should Clinicians Care?
Explains changes to Elec. Health
Records (EHR) and Computer Physician
Order Entry (CPOE) at your institution.
 If you organization is receiving $
Incentives (or avoiding penalties), they
will have more $ for staffing, equip…
 May have a positive Impact of other
Measures – Patient Satisfaction
 Can counteract reductions elsewhere
(e.g., VBP, S/T Re-admit penalties, etc.

Meaningful Use —Why Else Should
Clinicians Care?

Meaningful Use (Stage 3) promotes
Telemedicine and Digital Resource
Development and other similar

Stage 3 Criteria: “Outcomes for Improving quality,
safety, and efficiency, leading to improved health
outcomes.”

Applications in Respiratory Care
 Virtual Pulmonary Rehabilitation Progs.
 Digital Disease Management—COPD, Asthma
 Computerized Educational Resources
 Care Plan Compliance Monitoring
 Smoking Cessation Aids
Original Projections:
Paying for the Plan

Increased Medicare Tax for Singles earning
> $200K and Couples > $250K. (Beginning 2013)
 From 1.45% to 2.35% on earned income
 New 3.8% tax on interest, capital gains.
 W-2 reporting of employer H.I. Premium value.
○ Will this lead to future taxing of those benefits?

Reductions for Medical Expense Itemization.
 From expenses over 7.5% earned income to
over 10% earned income.

Medicare Reductions.
Original Claims -- The ACA
Would be A Deficit Reducer
Actually President and congress claims
it will!
 OMB estimates savings of $138 Billion
over 1st 10 years & $1.2 Trillion over
next 10 years….
 Reality is Appearing Different.

Reality--Paying for the Bill
Claim
1.
Health reform would
reduce the typical family's
healthcare costs by
$2,500 a year
2.
The law is a deficit
reducer.
3.
Health Exchanges will
increase competition and
lower premiums
Reality
1.
2.
3.
Consumers have
experienced sharp,
double-digit premium
increases, combined with
breathtaking increases in
their deductibles.
The law locks in massive
entitlement spending, last
estimated at $1.7 trillion
over the next 10 years.
Exchanges are 21.5%
less competitive (offer
few choices)
Other Looming Concerns…
Many provisions didn’t activate until 2013-15.
 Little to no mention of Tort Reform, governing
Med-Mal Lawsuits.
 Some only apply to “new” insurance
companies.
 Originally was to tax cosmetic surgery, but
due to apparent lobbying efforts, will tax
tanning shops instead.

The Future of the ACA?
U.S. House of Representatives has
voted 50 times to repeal the entire law.
 Public remains divided on law.
 President Obama works to shore up his
legacy.
 Will ACA be a 2016 presidential
campaign issue?

Take Home Notes
There are many facets to the Health Care
Reform and the ACA.
 The public remain relatively uninformed.
 Pluses:

 Increased the number of those with insurance
 More emphasis on prevention/community care.
 Coverage for pre-existing conditions.
Big Minuses: Cost and No Public Option.
 Changes/amendments are Likely.
 Get informed…Keep informed!

Selected Resources
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http://www.healthreform.gov
https://www.cms.gov/cciio/resources/FactSheets-and-FAQs/index.html
http://www.whitehouse.gov/issues/health-care
http://voices.washingtonpost.com/health-carereform
http://www.nytimes.com/2010/02/23/health/poli
cy/23health.html
Longest, BB; Health Policymaking in the US;
ed 5, 2009