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
Slide2If 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
Slide3Swim or sink?
Will physicians, medical schools, and hospitals be able to successfully participate in new payment/delivery models?
Slide4Swim or sink? Are you ready to:
Be accountable for outcomes, quality and cost?Accept more financial risk?Acquire best practices and information systems?
Slide5Swim 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
Slide6Swim 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?
Slide7Payment and Delivery System Reforms
The Medicare SGR and the Future of FFSValue-based paymentsAlternative Models
Slide8Light 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
Slide9How 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
Slide10Starting 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
Slide11Quality 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%
Slide12But 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
Slide13Alternative 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
Slide14How
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
Slide15Authorizes 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
Slide16CMS 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
Slide17To 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
Slide18How 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
Slide19Slide20“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
Slide21What 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)
Slide22How 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
Slide23Slide24Team-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.”
Slide25Team-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.
Slide26Principles:
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.
Slide27Principles:
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 . . .
Slide28Another 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
Slide29Prediction: 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!
Slide30Slide31The 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?
Slide32Obamacare 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
Slide33New 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
Slide34ACA 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)
Slide35ACA 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)
Slide36Premiums, 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
Slide37Qualified 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.
Slide38What 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
Slide39Premium “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
Slide40Premium “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
Slide41100
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
Slide42Nebraska: 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
Slide43But technical problems with government hub are a major barrier to enrollment
Slide44Obamacare 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
Slide45States 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
Slide46P
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
Slide47Slide48Slide49Slide50Slide51Another 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!
Slide53The 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
Slide54The 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
Slide55Another Dylan insight
“I’m on the pavement, thinking about the government.”Subterranean Homesick Blues, 1965
Slide56Appropriations 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
Slide57Debt 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
Slide58More from Bob Dylan
You don’t need a weatherman to know which way the wind blowsSubterranean Homesick Blues, 1965
Slide59Which 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
Slide60Another 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
Slide613
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
Slide62A Final Dylan Insight
Everything passesEverything changesJust do what you think you should doTo Ramona, 1964