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And other Health Care Insights from America’s Greatest Contemporary Songwriter And other Health Care Insights from America’s Greatest Contemporary Songwriter

And other Health Care Insights from America’s Greatest Contemporary Songwriter - PowerPoint Presentation

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And other Health Care Insights from America’s Greatest Contemporary Songwriter - PPT Presentation

For the Times They Are A Changin How ACP Is Helping Internists to Start Swimmin so You Dont Sink Like a Stone Bob Doherty SVP Governmental Affairs and Public Policy American College of Physicians ID: 796770

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Slide1

And other Health Care Insights from America’s Greatest Contemporary Songwriter

For the Times They Are A’ Changin’How ACP Is Helping Internists to Start Swimmin’(so You Don’t Sink Like a Stone)Bob Doherty, SVP, Governmental Affairs and Public PolicyAmerican College of Physicians Nebraska Chapter, ACPOctober 18, 2013

Slide2

If your time to you,

Is worth savin'Then you better start swimmin'Or you'll sink like a stoneThe times they are a-changin’The Times They Are A-Changin’ 1963

Slide3

Swim or sink?

Will physicians, medical schools, and hospitals be able to successfully participate in new payment/delivery models?

Slide4

Swim or sink? Are you ready to:

Be accountable for outcomes, quality and cost?Accept more financial risk?Acquire best practices and information systems?

Slide5

Swim or sink?

Are you ready to collaborate with others?No one can do it alone: physicians will need to collaborate with other physicians and health care professionals in their own communitiesNo one can do it alone: policymakers, physician membership organizations, other stakeholders will need to advocate for pay stability, incentives, innovation and flexibilityNo one can do it alone: team-based care will replace “silos” of practice

Slide6

Swim or sink? Will the ACA . . .

Deliver on its promise of providing affordable care to nearly all Americans?Will the marketplaces work as expected?Will premiums be affordable or cost too much?Will the states expand Medicaid?Will there be enough doctors?Or will political opposition, complexity, and misunderstanding cause it to fail?And will physicians help it “swim” . . . or sink?

Slide7

Payment and Delivery System Reforms

The Medicare SGR and the Future of FFSValue-based paymentsAlternative Models

Slide8

Light at the end of the SGR tunnel?

CBO has lowered the “score” for SGR repeal: $138 billion over 10 yearsMay 10 letter from Senate Finance Committee sought input from ACP, ACR, and others “as we develop a more viable alternative to the SGR that will provide stability for physician reimbursement and lay the . . . foundation for a performance-based system.”House Energy and Commerce committee unanimously reported a bipartisan bill to eliminate SGR and reform physician payments

Slide9

How does the bill propose to transition physicians to new payment models?

Recommended featuresHouse BillRepeal SGRYESPositive baseline updates for five years for all services. YES, 0.5% annual FFS updates for five years. But

does

not include higher updates for E/M codes.

Process and timetable

to transition to new payment/delivery models

YES

Transitional

value-based FFS updates above “baseline” updates with graduated payment structure

YES

Positive incentives for Care Coordination and Patient-Centered Medical Homes

YES

Improve accuracy of RVUs

Yes, but takes savings out of the physician

pay pool

Slide10

Starting in 2019, Medicare FFS update will be

completely based on new quality update program Physicians self-select a clinical “cohort” for their specialty and type of practice Creates process for CMS to approve “weighted” measures for each cohortMeasures would address care coordination, patient safety, prevention, patient experienceMeasures would be harmonized to extent possiblePhysician scored on a 1-100 scale depending on how well they do each year on the measures for their cohort

Slide11

Quality Incentive Program FFS Updates, starting in 2019

Physician’s Annual Quality ScoreTotal Annual FFS Update (0.5% plus/minus quality adjustment)67-100PLUS 1.5%34-66PLUS 0.5%

1-33

MINUS 0.5%

Physician does not successfully report any quality

data

MINUS 5.0%

Slide12

But there is another pathway

! Join an Alternative Payment Model (APM)CMS will hire a contractor to consider/evaluate APM proposals from physicians and othersAPMs must show that they can improve quality without increasing costs, or lower costs without decreasing quality Two-types of APMs will be selected: those for which strong data already exist on their effectiveness (e.g. PCMHs)those that have a high potential but less data on effectiveness

Slide13

Alternative Payment Models

Initial APMs selected within one year of enactmentAPMs would not participate in the FFS quality update program (but would considered to have met the reporting requirements—and applicable update for their FFS payments?)APMs would be paid by Medicare under the payment rules applicable to them

Slide14

How

might physicians in APMs be paid?Patient-Centered Medical Homes:Per patient per month risk-adjusted payments +FFSWith opportunity for shared savingsLinked to measures of outcomes, effectiveness. patient experiencePatient-Centered Medical Home Neighbors (specialty practices)Enhanced FFS payments or separate care coordination fee, linked to having structural capabilities and formal arrangements for care coordination with primary care physicians

Slide15

Authorizes payment for coordination of complex chronic illnesses, starting in 2015

Physicians in practices that have achieved independent certification as a PCMH, or as a PCMH specialty practice (PCMH-neighbor), would be eligible to bill and be paid for new chronic care codesTracks closely with CMS proposal rule to begin paying for such codes in 2015

Slide16

CMS proposes to pay for chronic care management, defined as:

Complex chronic care management services furnished to patients with multiple (two or more) complex chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; GXXX1, initial services; one or more hours; initial 90 days GXXX2, subsequent services; one or more hours; subsequent 90 days

Slide17

To qualify, CMS proposes that practices must:

Have a Certified, practice-integrated EHR that meets meaningful use; members of the team must have access to the patient’s full electronic medical record, even when the office itself is closed Employ at least one APN or PA for care of patients who require complex chronic care management. Demonstrate use of written protocolsProvide 24/7 accessProvide continuity of care with a designated practitioner or member of the care team

Slide18

How could the CMS proposal be improved?

Create pathway for practices that are not certified PCMHsEliminate overly prescriptive hiring mandatesAlign more closely with new CPT codes for CCM

Slide19

Slide20

“I want to highlight the letter from the American College of Physicians. They gave us concrete examples, down to how Medicare could incentivize physicians to use guidelines that help them decide when to order tests and perform procedures. This would encourage doctors to provide the care seniors need, and avoid unnecessary care

that might cause harm. I’m not saying we will accept all of their suggestions, but their comments help us see different angles ofpotential policies.”Senator Max Baucus, June 10, 2013 http://www.finance.senate.gov/imo/media/doc/07102013%20%20Baucus%20Statement%20on%20Improving%20the%20Flawed%20Medicare%20Payment%20System1.pdf

Slide21

What happens next?

SFC bill expected to be released soon (followed by “mark up?” and Senate vote)?House Ways and Means committee may modify Energy and Commerce bill, and then the two House bills would have to be reconciled and passed by the HouseAnd then House and Senate will have to reconcile their bills, followed by a vote on an identical billBut we are running out of time! (If not completed this year, a short-term patch into 2014 is likely, allowing Congress more time to complete action on the bills)

Slide22

How ACP is helping internists

swim . . .Advocacy for better models (PCMH, PCMH-N, ACOs, other)Advocacy for better pay—FFS (transition of care management, chronic care codes) and in new models Resources to help you make changes in your practice (e.g. Practice Planner, PQRS Wizard)New principles on team-based care

Slide23

Slide24

Team-based care: definitions

ACP adopts the Institute of Medicine (IOM) definition of primary care: “The provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Slide25

Team-based care: definitions

Primary care encompasses various activities and responsibilities. It is simplistic to view primary care as a single type of care that is uniformly best provided by a particular health care professional. The diverse activities that are often considered under the rubric of primary care often extend into what may be better considered “secondary” or even “tertiary” care.

Slide26

Principles:

leadership and responsibility within teamsACP reaffirms the importance of patients having access to a personal physician who is trained in the care of the “whole person” and has leadership responsibilities for a team of health professionals, consistent with the Joint Principles of the Patient-Centered Medical Home.

Slide27

Principles:

matching the patient to most qualified team memberAssignment of specific clinical and coordination responsibilities for a patient’s care within a clinical care team should be based on what is in that patient’s best interest, matching the patient with the member or members of the team most qualified and available at that time . . .

Slide28

Another Dylan insight

“How does it feel, how does it feel, to be without a [medical] home, like a complete unknown, like a Rolling Stone.”Like a Rolling Stone, 1965

Slide29

Prediction: rapid growth in # of PCMH practices

Gateway to reimbursement for chronic care management codesGateway to being paid better than the maximum 1.5% Medicare FFS updates (under House SGR bill)But we know you will need our help!

Slide30

Slide31

The ACA (Obamacare) and the Future of American Medicine

What can you expect over the next six to twelve months? When it is finally fully implemented over the next decade?

Slide32

Obamacare implementation will:

Be highly disruptive to insurance markets, employers and “providers” (as it was supposed to be)Political resistance and headlines on “chaos, confusion, and problems” will make it especially challenging (critics are “rooting for failure”)Will be confusing and not go smoothly on day one, but this is nothing new, same was true for Medicare Part D and original Medicare

Slide33

New York Times, April 23, 1966http://www.washingtonpost.com/blogs/wonkblog/wp/2013/05/17/when-medicare-launched-nobody-had-any-clue-whether-it-would-work/Source: Sarah Kliff, Washington Post, When Medicare Was Launched, Noboday Had Any Idea It Would Work, May 17, 2013

Slide34

ACA Milestones: next 12 months

Date

Milestone

October 1, 2013

Open enrollment period begins to buy coverage from marketplaces

December 15, 2013

Last date to sign up to be eligible for tax credits, subsidies on 1/1/14

January 1, 2014

Marketplace coverage and tax credits go into effect

January 1, 2014

Medicaid plans can enroll persons with incomes up to 138% of FPL (participating states only)

January 1, 2014

Consumer protections implemented for all insurance plans (no lifetime limits, no pre-existing condition exclusions, community rating)

Slide35

ACA Milestones: next 12 months

Date

Milestone

March 31, 2014

Open enrollment period closes, except for persons who have life changes that make them eligible to buy coverage later. Persons without qualified coverage in 2014 subject to tax penalty equal to $95 or one percent of taxable income,

whichever is greater

January 1, 2015

Employers with 50 or more FTEs must provide coverage that meets federal requirements or pay a penalty (delayed by one year from initial 1/1/14 deadline)

Slide36

Premiums, cost-sharing in the marketplaces

Average of 53 qualified health plan choices in states where HHS will fully or partially run the MarketplacePremiums before tax credits will be more than 16 percent lower than projected. Premiums tend to be lower in states where there is more competition and transparencyAfter taking tax credits into account, fifty-six percent of uninsured Americans may qualify for health coverage in the Marketplace for less than $100 per person per month, including Medicaid and CHIP in states expanding Medicaidhttp://aspe.hhs.gov/health/reports/2013/MarketplacePremiums/ib_marketplace_premiums.cfm

Slide37

Qualified health plans: cost-sharing levels

Plan% of actuarial cost of required benefitsBronze60%Silver70%Gold

80%

Platinum

90%

Catastrophic plan for under

age 30

$6350 deductible

All plans cover same essential benefits. No cost-sharing for USPSTF screening tests.

Maximum out-of-pocket expenses for all plans: $6350 for individuals, $12,700 for family of four . Individuals and families with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 250 percent ($58,875 for a family of four) are eligible for cost-sharing reductions (or CSRs) if they are eligible for a premium tax credit and purchase a silver plan through the health insurance marketplace in their state. People with lower incomes receive the most assistance.

Slide38

What about so-called “premium shock?”

Some will pay more (healthy and younger) but many will pay less (older, less healthy)Even those who pay more can’t be turned down and will be getting better coverage (lower cost-sharing, better benefits) than usual plans in small and individual insurance marketAffects very small percentage of the population in small group and individual market

Slide39

Premium “shock and joy”

Reinhardt,

Reinhardt, Premium Shock and Joy under the Affordable Care Act,

http://economix.blogs.nytimes.com/2013/06/21/premium-shock-and-premium-joy-under-the-affordable-care-act

/

Traditionally, the

premium in the

nongroup market can be expressed as

Pi-premium

quoted to individual

Xi-expected outlays

for covered health

benefits for that

Individual

L is a ‘loading factor’

added to cover the

cost of marketing and administration, as well as a target profit margin

Slide40

Premium “shock and joy”

“Less frequently noted in commentaries about the law — certainly among its critics — is that the law is likely to bring what I call ‘premium joy’ to individuals and families with health problems. Many such people simply could not afford the high, medically underwritten premiums they were quoted in the traditional nongroup market. This joy will be shared by high-risk applicants who were refused coverage by the insurer, along with people now in high-risk pools.”Uwe Reinhardt, Premium Shock and Joy under the Affordable Care Act, http://economix.blogs.nytimes.com/2013/06/21/premium-shock-and-premium-joy-under-the-affordable-care-act

Slide41

100

88

77

66

47

29

14

Medicaid

73

64

55

39

24

12

Medicaid

100

100

53

46

40

28

18

8

Medicaid

100

37

32

28

20

12

6

Medicaid

Source: The Henry J. Kaiser Family Foundation.

Percentage of premium paid by family

Percentage of premium covered by subsidy

*For families of four purchasing coverage in the exchange, not through an employer; numbers reflect standard plan for coverage

ACA: A Closer Look

Family Health Insurance Premium Obligations Vary

by Age, Income

Percentage of Premium Paid by Family of Four vs. Covered by Subsidy

Policyholder Age

450%

400%

350%

300%

250%

200%

150%

100%

20

40

60

50

30

100

97

85

73

52

32

15

Medicaid

Family Income as % of Poverty Level

Analysis

A family of four is eligible for Medicaid at 133%, the same percentage below the poverty level as an individual

A family of four buying coverage in new state-based health insurance exchanges will be eligible for federal subsidies if their joint income is below 400% of the poverty level; above 400%, families pay full cost

Slide42

Nebraska: premiums and subsidies: 40 plans in marketplace

Second lowest Silver Plan, before tax creditSecond lowest Silver Plan, after tax creditLowest Bronze plan before tax creditLowest Bronze plan after tax credit

Second lowest Silver Plan, before tax credit

Second lowest Silver Plan, after tax credit

Lowest Bronze plan after tax credit

$206

$145

$159

$98

$744

$282

$113

27 yr old, $25 K income

Family of 4, $50K income

For the purposes of this analysis, a family of four is defined as one 40-year-old adult, one 38-year-old adult, and two children under the age of 18.

After tax credits, bronze premiums for a family of four may be below those for a single individual. This occurs because the tax credit is calculated as the difference between the cost of the second lowest cost silver plan premium and the maximum payment amount determined by income. Because premiums for older individuals and families are higher than those for younger individuals, tax credits are larger for older individuals and families. Therefore, using tax credits to purchase a bronze plan may yield lower bronze premiums for older individuals and families than for younger individuals

http://aspe.hhs.gov/health/reports/2013/MarketplacePremiums/ib_premiumslandscape.pdf

Slide43

But technical problems with government hub are a major barrier to enrollment

Slide44

Obamacare implementation is facing

unprecedented political headwindsOrganized political effort to discourage people from signing upFailed effort to defund the law, tied to resolution to fund the government and/or debt ceilingState opposition to expanding Medicaid, setting up exchanges and helping people enrollIn most extreme cases, state opposition is bordering on nullification

Slide45

States Split on Participation in Medicaid Expansion

Source:

Status of State Action on the Medicaid Expansion Decision,

Kaiser Foundation, July 1, 2013.

Updated

9/4/13

Analysis

The Supreme Court

s ruling on the Affordable Care Act allows states to opt out of the law

s Medicaid expansion, leaving this decision with state governors and legislatures

Governors of states participating in Medicaid expansion cited support for increased coverage for residents as reason for opting in; governors of non-participating states cited high cost of expansion as reason for opting out; governors of undecided states weighing costs of expansion before opting in or out

OH

WV

VA

PA

NY

ME

NC

SC

GA

TN

KY

IN

MI

WI

MN

IL

LA

TX

OK

ID

NV

OR

WA

CA

AZ

NM

CO

WY

MT

ND

SD

IA

UT

FL

AR

MO

MS

AL

NE

KS

VT

NH

MA

RI

CT

NJ

DE

MD

DC

AK

Working to Implement (24+DC)

Not Working to Implement (21)

Debate ongoing (5)

HI

MA

RI

CT

NJ

DE

MD

Slide46

P

hysicians should want Obamacare to swim, not sinkWill provide coverage to tens of millions of uninsured and better consumer protections for everyone elseState resistance to Medicaid expansion will result in 2 out of 3 poor and near-poor going without coverageCoverage associated with better outcomes and fewer preventable deathsIf Obamacare fails, nothing good will replace it

Slide47

Slide48

Slide49

Slide50

Slide51

Another Dylan insight

There must be some way out of here said the joker to the thief, There's too much confusion, I can't get no relief.All Along the Watchtower, 1967

Slide52

“Too much confusion”

E-Rx, PQRS, Meaningful use, rewards and penaltiesICD-10Transitional Care Management CodesAnd many more!

Slide53

The Timeline can be found under “Running a Practice”

Items can be viewed by quarter

Items with timeframes that run over one quarter are shown in “Ongoing Items”

Newly added and highlighted resources can always be found here at the top

Overview of the Physician & Practice Timeline

Slide54

The current quarter is

open by

default

You can then click on one of these colored badges for more information on that program

Overview of the Physician & Practice Timeline

Slide55

Another Dylan insight

“I’m on the pavement, thinking about the government.”Subterranean Homesick Blues, 1965

Slide56

Appropriations and debt ceiling

Two-week government shutdown resulted in CDC, NIH, FDA suspending key programs to protect public health and support medical researchBut did not stop ACA marketplaces, funded by mandatory dollars, from opening 10/1/13

Slide57

Debt ceiling/federal funding deal

Government funded through 1/15/14 at sequestration levelsHouse-Senate budget conference must report by 12/15/13 with long-term spending planDebt ceiling extended to 2/27/13; automatically increases unless majority of House and Senate vote to disapproveDemocratically-controlled Senate won’t vote to disapprove, and Obama could veto bill to disapprove, meaning that the ceiling will be increased either wayNo changes in Obamacare except requirement to verify income eligibility for subsidies

Slide58

More from Bob Dylan

You don’t need a weatherman to know which way the wind blowsSubterranean Homesick Blues, 1965

Slide59

Which way is the wind blowing?

Away from pure FFS to new models that put physicians (potentially) in more control in patient-centered systems of care, but with more risk and accountabilityFrom a health system that leaves tens of millions without coverage to one that insures “nearly” everyone (even if it takes longer than originally planned) with better protections for all

Slide60

Another Dylan insight

How many times must a man look upBefore he can see the sky?Yes, ’n’ how many ears must one man haveBefore he can hear people cry?Yes, ’n’ how many deaths will it take till he knowsThat too many people have died?The answer, my friend, is blowin’ in the windThe answer is blowin’ in the windBlowin’ in the Wind, 1963

Slide61

3

Dorn, Uninsured

and

Dying

Because

of

It:

Updating

the

Institute

of

Medicine

Analysis

on

the

Impact

of

Uninsurance

on

Mortality,

Urban Institute, 2008

Age

U.S.

population

(millions)

Percent

uninsured

within

age

group

Total

deaths

Uninsured

excess

deaths

).

:

2000

2001

2002

2003

2004

2005

2006

Total:

21,000

23,00

Year

Number of deaths due

to uninsurance

2000

20,000

2001

21,000

2002

23,000

2003

24,000

2004

24,000

2005

25,000

2006

27,000

Total

165,000

Why is it important to get Obamacare successfully implemented?

Because too many people have died.

Dorn, Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on Mortality, Urban Institute, 2008

Slide62

A Final Dylan Insight

Everything passesEverything changesJust do what you think you should doTo Ramona, 1964