An Update of Healthcare in the United States - PowerPoint Presentation

1. An Update of Healthcare in the United StatesAntonia Coello Novello, M.D.,M.P.H., Dr.PH Course Directors: Co-Course Directors:Asher A. Chanan-Khan, M.D.Robert B. Diasio, M.D. Suzanne M. Brown, B.S.N., C.N.R.N., S.C.R.N.W. David Freeman, M.D. Christina Smith, A.R.N.P.Betty Kim, M.D., Ph.D.Alfredo Quiñones-Hinojosa, M.D.Joon H. Uhm, M.D.SEPTEMBER 7-9, 2017Four Seasons Resort Orlando at Walt Disney World® ResortOrlando, FL

2. Healthcare in the United StatesThe nine most terrifying words in the English language are. “I’m from the government and I’m here to help.” - Ronald Reagan

3. The Future of Healthcare in the United StatesTimeline of Healthcare in the US1912 – President Theodore Roosevelt made Universal Coverage part of his presidential campaign1940 – President Truman proposed healthcare benefits to all Americans – unsuccessful1965 – President Lyndon B. Johnson signed Medicare and Medicaid legislation1970’s – Presidents Richard Nixon and Jimmy Carter, along with Senator Ted Kennedy, tried to enact reform of national healthcare unsuccessfully1993 – President Bill Clinton attempted to institute universal health insurance coverage – it was defeated

4. The Future of Healthcare in the United StatesHistoric Timeline of Organized Healthcare2010President Barack Obama signs the Healthcare Reform Bill

5. The Future of Healthcare in the United StatesThe bill passed 219-212 after the White House issued an Executive Order clarifying the bill’s ban on federally funded abortions. This was brought by Rep. Bart Stupak (D-Mich) and eight other anti-abortion democrats on board. In the final vote, 34 democrats voted against the bill; republican opposition was unanimous

6. The Future of Healthcare in the United StatesPPACA Legislative Summary1965 - The most expansive social legislation since Medicare and Medicaid Law passed March 23rd on a partisan basis through reconciliation processThe initial stated objective was to improve accessibility and affordability of care to Americans. The final bill, however, focused primarily on accessibility and insurance market reform with little emphasis on cost Cost is estimated at $1.2 trillion over the next ten years - the Congressional Budget Office projected in 2010 an additional $10 to $20 billion in administrative costs to federal agencies carrying out the lawBill will be phased in over a several year period beginning in 2010, with major provisions including exchanges and mandates being effective in 2014SOURCE: Beacon – United Benefit Advisors, LLC

7. The Future of Healthcare in the United StatesWhat PPACA Does Not DoDoes not insure every “person in the country” 23 million will remain uninsured: undocumented, those cycling on/off coverage, those exempt from or willing to pay individual penaltiesDoes not create a single payer systemMedicaid, Medicare, employer-provided, Medigap, and State exchange-based insurance will coexistDoes not fundamentally reform MedicaidDoes not fundamentally change the large group health insurance marketDoes not reform medical malpractice Does not fix Medicare Doctor Pay (SGR)Does not restructure the delivery of health care, but sets in motion potentially significant changes

8. The Future of Healthcare in the United StatesWhat PPACA DoesOverall, will insure 32 million uninsured AmericansAdds 20 million to Medicaid rolesNew federal regulation of health insurance with substantial impacts on individual and small employer marketsCreates State health benefit exchanges that will insure 30 million AmericansSubstantial Medicare provider cuts, revamps Medicare Advantage, makes Part D more generous, implements IPABExpansion of quality, innovation and efficiency effortsEmphasis on primary care, community health, public health, wellness and preventionExtensive new “fraud, waste, abuse & transparency” provisions

9. The Future of Healthcare in the United StatesWhat PPACA really is: Insurance Market ReformEstablish mandate for most legal residents to obtain health insuranceCreate insurance exchanges through which certain individuals and families may receive federal subsidies to substantially reduce the cost of purchasing health insuranceExpand eligibility for MedicaidImpose an excise tax on certain health insurance plans with high premiumsEstablish penalties on certain employers who do not provide minimum health benefits to their employees

10. The Future of Healthcare in the United StatesHealthcare SpendingMedicare and Medicaid are expected to grow more rapidly than private insurance as the baby boomer generation agesBy 2025, government at all levels will account for nearly half of healthcare spending – 47%About 5% of the population accounts for nearly half the spending in a given year. Of the total $3.35 trillion for this year:32% - hospital care20% - doctors and other clinicians10% - prescription drugs5% - nursing care facilitiesTotal national health expenditures as a percent of GDP – 18% - 2015

11. The Future of Healthcare in the United StatesHealthcare’s Share of GDP is Projected to Grow from 16.7% to 20.2% by 2019SOURCE: Center for Medicare and Medicaid Services, Office of the Actuary, and the U.S. Office of Management and Budget.

12. The Future of Healthcare in the United StatesHealthcare SpendingAccording to CMS, our national healthcare expenditure is projected to hit $3.35 trillion this year. It will surpass $10,345 per person and for the first time, healthcare spending will grow at a faster rate than the national economy over the next 10 years Growth projected to average 5.8% from 2015 to 2025The driving trends are:Stronger economy – Mergers Faster growth in medical prices and equipmentAging population

13. The Future of Healthcare in the United StatesU.S. Spent $3,205.6 Billion on Healthcare in 2015: Where did it go?SOURCE: Center for Medicare and Medicaid Services, Research, Statistics, Data and Systems

14. How much has the ACA Cost?The non-partisan office estimates that the program will cost the federal government 1.34 trillion over the next decade, an increase of 136 billion from the CBO’s prediction in 2015. In 2016, the ACA will cost a total of 110 billion.

15. The Future of Healthcare in the United StatesHealthcare Reform Timeline2011 Uninsured with pre-existing conditions able to purchase affordable insurance in the marketplace Children may remain on their parents insurance plans until the age of 26Tax credits to small businesses to purchase insurance for employeesLimited help for Medicare patients2011 Insurance companies required to spend ≥ 80% of premiums on actual medical services2013Increase the Medicare Part A (hospital Insurance) tax rate on wages by 0.9% (from1.45% to 2.35%) on earnings over $200,000 for individual payers and $250,000 for married couples filing jointly and impose a 3.8 tax on unearned income for higher-income taxpayers 2014Health insurance required for most Americans – or pay a penaltyState exchanges availableBusinesses with ≥ 50 employees required to provide coverage or pay a penalty2018 Expensive employer-provided insurance benefits ($27,500 per family or $10,200 single coverage) subject to 40% tax2020Phase down the beneficiary coinsurance rate in the Medicare Part D coverage gap from 100% to 25%

16. The Future of Healthcare in the United StatesObamacare TaxesThere are 20 new or higher taxes on American families and small businesses - 500 billion over the next 10 yearsSurtax on Investment Income – 3.8% surtax earned in households making $250,000 and married, $200,000 and singleHike in Medicare Payroll Tax – 86 billion - it was 1.45% and under Obamacare it is 2.35%Individual Mandate Excise Tax and Employer Mandate Tax – from 1% ($95) to 2.5% ($695)Tax on Health Insurers – 60 millionExcise Tax on Comprehensive Health Insurance Plans – 32 billion. ”Cadillac” health insurance plans – 40% excise tax

17. The Future of Healthcare in the United StatesObamacare Taxes, cont’dTax on Innovator Drug Companies – 22.2 billion - relative to share of sales made that yearTax on Medical Device Manufacturers– 20 billion - imposes a 2.3% excise tax. Exempts less than 100 itemsMedicare Cabinet Tax– 5 billion - unable to use HAS, FSA or health reimbursements to purchase over the counter medicinesExcise Tax on Charitable Hospitals– $50,000 per hospital - if they fail to meet new “community health assessment needs

18. The Future of Healthcare in the United States (Employer Mandate)CBO projects that 59% of uninsured will obtain coverage (32 million)

19. The Future of Healthcare in the United StatesSmall Companies Dropping Health Benefits

20. The Future of Healthcare in the United StatesSmall Companies Dropping Health BenefitsA survey by the International Foundation of Employee Benefit Plans found that 15% of large employers (50 or more employees) and 20% of smaller employers had plans to adjust hours so that fewer employees qualify for full-time medical insurance under the ACA.September 12, House and Rules Committee – save American Workers Act (HR 3798) will be voted on after November midterm elections. Establishes 40 hour work week.

21. The Future of Healthcare in the United States (Individual Mandate)Penalties for the UninsuredEffective January 1, 2014, citizens and legal residents must maintain “minimum essential coverage” or pay a penalty if without coverage for more than 3 months in a yearExemptions: religious objectors, prisoners, undocumented immigrants, individuals with income below the filing threshold ($9,350 for an individual in 2009), members of Indian nations, those where plan exceeds 8% of incomeFine equals greater of fixed amount or percentage of income over filing threshold:2014: $95, or 1%; 2015: $325 or 2%; 2016: $695 or 2.5% Example: individual grossing $40,000 w/out minimum essential coverage pays penalty of $766 in 2016 ($40,000 - $9,350 x 2.5%) SOURCE: Holland & Knight

22. The Future of Healthcare in the United StatesACA ExemptionsDifficult Life Hardship Exemptions:HomelessnessBankruptcy filing in the last 6 monthsRecent domestic violenceRecent death of close family memberShut-off services, i.e., utilities companyEviction, or foreclosure within 6 monthsSubstantial property damage, natural or human disastersCancellation of current insurance policyInability to pay medical expenses (24 mos.)Unexpected increase in expenses (caregiver)Ineligible for Medicaid (state opted out)Unspecified hardship

23. The Future of Healthcare in the United States$1.2 Trillion, 2010-2019SOURCE: Greater New York Hospital Association

24. The Future of Healthcare in the United StatesHow the ACA covers 32 million UninsuredSOURCE: Greater New York Hospital Association2019 ProjectionIncreasing Private Coverage

25. The Future of Healthcare in the United StatesInsurance Reforms: Insurance ExchangesSOURCE: Greater New York Hospital Association

26. The Future of Healthcare in the United StatesAffordable Insurance ExchangesThey must offer a comprehensive package of items and servicesThese services are known as “Essential Health Benefits”These benefits must include at least 10 categoriesThey must be defined using a benchmark approachStates will have the flexibility to select a benchmark approach that reflects the scope of services offered by a typical employer planStates will have the flexibility to select the plan that best meets the needs of their citizensAbortion coverage cannot be part of the essential health benefits package

27. The Future of Healthcare in the United StatesEssential Health BenefitsAmbulatory patient servicesEmergency servicesHospitalizationMaternity and newborn careMental health and substance-abuse disorders including behavioral healthPrescription drugsRehabilitative and habilitative services and devicesLaboratory servicesPreventive and wellness services and chronic disease managementPediatric services including oral and vision careGeneral categories of benefits that the health law considers essential that could trigger debate:

28. The Future of Healthcare in the United StatesHealth Exchange UpdateSOURCE: Center on Budget and Policy Priorities; Avalere Health201839 states use HealthCare.gov12 states based Exchanges11.8 million consumers re-enrolled: 8.7 million in 39 states, 3 million in state exchanges27% - new consumers63% - selected silver plans29% selected bronze plans7% selected gold plans

29. The Future of Healthcare in the United StatesMedicaid Eligibility Expansion (S.2001)January 2014 – all individuals under age 65 with incomes below 133% of FPL eligible for Medicaid (children, pregnant women, parents and adults with dependent children):Mandatory Medicaid eligibility for kids 6-19 increases to 133% FPL (from 100%) Mandatory Medicaid eligibility for parents increases to 133% (from varying levels in different states) Mandatory Medicaid Eligibility created for non-pregnant childless adults up to 133% of FPL (no current requirement) Feds cover 90% of the costMust provide Medicaid “benchmark equivalent” coverage to newly-covered essential benefits, prescription drugs and mental health services at actuarial equivalenceSOURCE: Holland & Knight

30. The Future of Healthcare in the United StatesSupreme Court DecisionThe Supreme Court of the US upheld the healthcare law as constitutional in a 5-4 decision, lead by Chief Justice John G. RobertsThe federal government does not have the power to order people to buy health insurance. It does have the power to impose a tax on those without health insurance.The healthcare law had to allow states to choose between participating in the expansion while receiving additional payments, or foregoing the expansion and retaining existing payments. Medicaid expansion is now optional for the states

31. The Future of Healthcare in the United StatesA 50-State Look at Medicaid Expansion: 2017SOURCE: Families USA analysis using data from the U.S. Census Bureau, American Community, Kaiser Family Foundation, State Health Facts, Medicaid Expansion Enrollment

32. The Future of Healthcare in the United StatesNew Medicare Payment ModelsMedicare readmissionsValue-Based Purchasing (VPB)Hospital acquired conditions

33. The Future of Healthcare in the United StatesMedicare Readmissions

34. Quality Cuts

35. Study: Medicare Readmission Penalties Need to Weigh Socioeconomic FactorsIn general, risk-standardized readmission rates calculated using the socioeconomic factor–enriched models increased toward the mean for hospitals with low rates and decreased toward the mean for hospitals with high rates. Source: The National Center for Biotechnology Information

36. The Move to Value-Based PaymentsIn 2015, HHS announced its goal to have 90% of Medicare fee-for-service (FFS) payments linked to quality by 2018, with specific targets as follows:All FFSCategories 2 - 4 90%Categories 3 – 450%Category 1Category 2Category 3Category 4FFS w/ no link of payment to qualityFFS w/link of payment to qualityAlternative payment models (APMs) built on FFS (shared savings or 2-sided risk)Population-based model (capitation)VBPFinancial Risk

37. Federal VBP ModelsBundled PaymentsAccountable Care Organizations

38. ACA provided funding for CMS to develop new payment & delivery modelsEpisode-based bundled paymentsAccountable Care Organizations (ACOs)Voluntary: BPCI Models 1-4, Oncology Care Model, ESRD ModelMandatory: CJR, SHFFT, AMI, CABGMedicare Shared Savings ProgramNext Generation ACO

39. Bundled Payments

40. Overview of Bundled Payment ModelsGoal:Reward quality of care instead of quantity servicesPayments are bundled for a single illness or course of treatmentPayment arrangements include financial & performance accountabilityProviders incentivized to collaborate across specialties & settingsSuccess measured by improved patient outcomes & lower costs to Medicare

41. AMI and CABG bundles can qualify as Advanced Alternative Payment (APM) models in 2018 under MACRAHowever: Hidden CABG disrupt bundle payment systems – specifically postoperativelyExample: CABG average uncomplicated cost - $36,580 CABG one major complication cost - $64,542CABG two major complications cost - $111,239CABG three major complications cost $194,043Note: Cost of CABG outspaced the CMS health care specific inflation rate

42. Cost of Complications within 30d following CABG

43. AMI and CABG bundles can qualify as Advanced Alternative Payment (APM) models in 2018 under MACRACMS: Announced its intention to cancel two reforms – Bundle payments for MI and Bypass surgery as well as incentives for cardiac rehabilitation. Changes that had been in the works since Summer 2016 and scheduled to begin Jan. 1, 2018.

44. Bundle Payment for Comprehensive Care for Joint Replacement ModelCJR: A quality measurement for an episode of care associated with hip and knee replacement. Implemented April 1, 2016. Will run until Dec. 31, 2020As of Feb 1, 2018 – 465 IPPS Hospitals and 67 MSA’s are participating In 2014 – 400,00 procedures – 7 billion paid for hospitalizations aloneQuality and cost varies across providers more than 3 times higher at some facilitiesAverage cost for hospitalizations and recoveryRanges from 16,500 to 33,000 across geographical areas

45. Bundle Payment for Comprehensive Care for Joint Replacement ModelNote: CMS dialed back but did not cancel CJR. Its geographic scope has been window down from 67 MSA’s to 34 and participation is now voluntary.Moving forward, CMS expects to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment model efforts. CMS – Aug. 15/17

46. CMS Voluntary Initiatives – Bundle Payments for Care – Model 1-4There are 48 clinical episodes that participants are able to choose from: 18 cardiacAcute Myocardial InfarctionAtherosclerosisAutomatic implantable cardiac defibrillation on padCardiac Arrhythmia Cardiac Defibrillator Cardiac valveChest painCongestive Heart FailureCoronary artery bypass graft surgeryMajor cardiovascular procedureMedical peripheral vascular disordersOther vascular surgeryPacemakerPacemaker Device replacement or revision Percutaneous coronary intervention Stroke Syncope and collapse Transient Ischemia

47. The Future of Healthcare in the United StatesCreated in 1997 - SGRThe Sustainable Growth Rate (SGR) system to control Medicare physician spending

48. Between 2003 and 2014 there were 17 doc fixes addressing the SGRIn 1997, Congress created the SGR (the formula set an annual budget target – most important factor – that it would not exceed the growth in GDP)The plan was not to incentivize excessive or unnecessary care and instead foster the judicious use of medical resources, since physicians directed the care that constituted the lions share of total Medicare spending.In 2014, Medicare paid doctors and other clinicians around 138 Billion – 22% of total Medicare spending up from 59 Billion in 2000.

49. Cont. In 2002, SGR yielded almost 5% decline in feesBy 2015 – If that build up would be allowed, it would have led to an untenable 21.2% reduction in physicians fees. Macra then in 2015 became the vehicle to repeal SGR and replaced the formula with a new medicine physician payment system.

50. MACRA

51. The Future of Healthcare in the United StatesMedicare Access and CHIP Reauthorization Act (MACRA) of 2015The alternative to SGRTwo new payment plans that Medicare pays clinicians by establishing 2 new payment tracks.The Merit Based Incentive Payment System (MIPS)Alternative Payment Model (APM)

52. Implementation Timeline - MACRAJuly 2015 through December 2015: Medicare physician payments increase by .5%2016-2019: Physicians payments increase by 0.5% each year2020 through 2025: Medicare physician payments remain at 2019 levels with no updates.

53. Physician Updates Under MACRA

54. MACRA TRACK 1: MIPS

55. Clinicians Subject to MIPS

56. Track 1: MIPS Begins in 2019, Based on Performance in 20172. Cost (0%)Replaces value Modifier (VM) programMedicare spending per beneficiary for episodes of care (claims based)

57. The Future of Healthcare in the United StatesThe new Reimbursement Strategy – Quality Payment Program (QPP)Based on their performance in these four categories, physicians and others will receive a payment adjustment. This adjustment will be capped at ±4 in 2019 rising to ±9% in 2022 and subsequent years. Additionally for 2019-2024, the Secretary will designate a threshold for “exceptional performance” on MIPs and may spend up to 500 million each year on separate bonus payments to top performing providers. In reality, poor performers receive negative adjustments to their Part B reimbursement rates, high performers receive upward adjustments.

58. Some Problems With MIPsIncentives for clinicians to reduce the provision of services are very weak, and some features create incentives to do more rather than less. There is ample opportunity to obtain rate increases without substantially lowering Medicare spending. Inadequate risk adjustment also establishes incentive for providers to attract lower risk patients (favorable selection) diverting attention and resources way from improving the health of existing patients.

59. Additional Problems with MIPsWhat measures are policy makers taking to limit the unintended consequences of MIPs and attain its intended goals?Encourage the growth of Medicare Advantage (MA) and APM’s such as ACO’s which together cover half of the Medicare population.

60. MACRA TRACK 2: APM

61. The Future of Healthcare in the United StatesAlternative Payment Model (APM) – Exempt from MIPsAimed toward larger, more technological and advanced practicesParticipants would have to join a generation ACO model track 2 or 3 or an approved patient – centered medical home, or programs focusing on primary care, renal, or oncology care Incentive bonus payment up to 5% of their current reimbursement from 2019 to 2024Payment tied to performance must be 25% of a doctor’s or group practices Medicare revenue in 2019, increasing to 75% in 2022. Starting in 2026, physicians in APM will receive an annual across the board fee increase of .75%. Physicians in MIPs will get 0.25% annual increase.

62. WHAT DOES MACRA MEAN FOR PHYSICANS AND HEALTH

63. The Future of Healthcare in the United StatesSmall Practices and MACRACMS is giving “Pick your own pace” so that small practices will participate in MACRABy doing this, they will avoid any negative payment adjustments related to MIPS If nothing is done, practices will be hit with a 4% pay penaltySmall practices have fewer reporting requirements in Advancing Care Information (ACI), Improvement Activities (IA) and quality categoriesLarge practices – must report 3 medium-weighted activities to receive credit for IASmall practices – only 2 reporting activities

64. The Future of Healthcare in the United StatesSmall Practices and MACRACMS aiming to make APM’s easier for small practices to join. Some of these APM’s would get a 5% payment bonusCMS give $20 million to aid small practices to prepare for MACRAIt awarded around $20 million this year to 11 organizations to assist practices with fewer than 15 clinicians to prepare for MACRA and CMS will award additional $80 million from 2018-2021Although small practices unite and create “virtual groups” that would be evaluated under MIPs, there has been little interest in this option

65. The Future of Healthcare in the United StatesCMS believes that a number of doctors participating in APM will double next year (180,000 - 245,000) because of doctors participating in ACO’s and primary care modelCMS estimates when the rule is finalized in 2020 that providers could collectively receive up to 1.4 billion in quality bonus payments in APM and MIPs

66. Challenges for Success: Significant Infrastructure Required

67. ACOsGaining will be easier for better resources provider with more sophisticated information systems and analytic capabilities, potentially exacerbating disparities further.

68. Medicare ACO (MSSP) Results - 201631% of Participants received a bonus, 56% saved relative to benchmarkCharacteristics of successful ACOsEven among those earning bonuses, magnitude varies widelyNo real differences in quality between ACOs earning bonuses and notHighlights need for real delivery system reform to achieve successHigher financial benchmarksMore experience (i.e. earlier cohorts)Physician-led (as opposed to hospital led ACOsSmaller

69. Challenges for ACOsOpportunity for shared savings may be too little to incentivize real change

70. Calculating Savings and GainsCMS Administrator Verma seeks to accelerate pace at which ACOs share downside riskCMS proposal to reform MSSP program: “Pathways to Success”:ACOs allowed to participate in program for maximum of two years before taking on risk (down from six years in current MSSP)

71. Accountable Care Organizations and MACRAOnly a few Medicare ACO’s will actually be able to participate in Advanced Alternative Payment Models under MACRA but the rest will need to take part in Merit-Based Incentive Payment Programs (MIPs)Worries about ACO’s:Concerned about Value Based Payments such as Bundle PaymentsWorry about the cost of running an ACO and the significant number of ACO’s ready to leave the Medicare shared savings program, MSSPFunding barriers in connecting their providers with social service/programs

72. Next Generation ACO ModelOffers:A new opportunity in accountable care- one that sets predictable financial targetsEnables providers and beneficiaries greater opportunities to coordinate careAims to attain the highest quality standards of careThere are 51 ACO’s participating in the Next Generation ACO Model

73. This New Model of ACOIs an initiative for ACO’s that are experienced in coordinating care for populations of patients. It allows them to assume higher levels of financial risks and reward, higher than the ones under current pioneer or shared savings program. Goal is to test whether strong financial incentives coupled with tools to support better patient engagement and care management can improve health outcomes, and lower expenditures for original FFS beneficiaries.

74. Next Generation ACO Model – Participating in Florida 2018Accountable Care Options – LLC Boynton BeachBest Care Collaborative – Fort MyersPrimary Care Alliance – Mt. DoraSteward Integrated Care Network, Inc. – BostonUniPhy ACO, LLC – Doral, FL

75. The Future of Healthcare in the United StatesMedicare Access and CHIP Reauthorization Act (MACRA) of 2015Realities:Population health is no longer optionalIt is a reality for everyoneYou succeed or fail as a teamLarge practices will fare better Penalties higher for smaller practices Larger bonuses for larger practicesPractice like everyone is watchingData available to public on the Physician Compare website. Hospitals looking for better practices with demonstrated success in MIPS

76. The Future of Healthcare in the United StatesWhen will this happen?As of January 1, 2017, clinicians will have to begin recording data in regards to patient outcomes and use of technology in their practiceFor APM program, clinicians can begin providing care and collecting data right away For MIPS, clinicians will need to send in the data or have technology used in their clinical practice – due March 2018In 2018, Medicare will give doctors feedback on their dataIn 2019, performance based MIPS payment adjustments and a 5% incentive payment for APM participants will commence

77. What’s Next?3 years of complex MACRA rulemaking lie ahead amid a still entrenched fee for service system, continued political rancor over ACA, and a change in administrations and a new Congress. The trajectory of healthcare spending over the next few years could also affect the urgency and design components of MACRA implementation. Big Question is: Will MACRA success at improving quality, reducing unnecessary care, and lowering cost growth where past efforts have lagged or outright failed?

78. ACA UNDER PRESIDENT TRUMP

79. The Future of Healthcare in the United States Reasons Why ACA’s Future was Uncertain under Pres. TrumpRising insurance costIncreasing out-of-pocket costsReduced insurance competitionNegative impact on jobs growthOverall healthcare cost curve trending upwardTax increases on America’s middle classPayment cuts in Medicare threatening seniors’ access to careIncrease deficits and debtArbitrary rules and costly mandates

80. The Future of Healthcare in the United States Prognosis for RepealCurrently, for millions of middle-class Americans, paying their health insurance bills is now equivalent to taking out a second mortgageCompetition among insurers is declining precipitously in the individual marketMore Americans are left with fewer choices, narrower network of doctors

81. Insurance Companies Leaving ACA 201737 states opt out of ACA40 countries projected to have no ACA insurers – 20181,332 counties are projected to have just one insurer next year, or 40% of all counties nationwide containing 2.4 million customers of ACA exchanges. Average premiums have increased by 21.6% between 2016 and 2017, while carrier participation has declined by 31.2% since 2015Most carriers hikes premiums substantially for 2018 in an anticipation of elimination of cost sharing subsidies.

82. The Future of Healthcare in the United StatesAffordable Care ActIf ACA remains unchanged – The United States would face steadily and increasing federal budget deficits and debts over the next 30 years – reaching the largest, highest level of debt relative to GDP ever experience in this country

83. The Future of Healthcare in the United StatesProposed ACA Repeal Legislations

84. H.R. 1628American Health Care Act (AHCA)Approved by the House of Representatives May 4, 2017, as plan to repeal and replace ACAConvert Federal Medicaid Assistance Percentage funding to a per capita allotment. Limit Federal Growth beginning in 2020. Provide state option for Block Grant. Add state option to require work as a condition of eligibility for non-disabled, non-elderly, non-pregnant Medicaid adults. Prohibit federal funding for Medicaid Planned Parenthood Clinics.

85. The Future of Healthcare in the United StatesBetter Care Reconciliation Act (BCRA) – Senate BillStrengthen MedicaidFlexibility to states without jeopardizing the ones currently enrolledAllows states to chose between Block Grants and per capita allotments beginning in 2020Allow states to impose work requirement on non-pregnant, non-disabled, non-elderly receiving MedicaidEliminate individual and employer mandate penaltiesImprove affordability of health insuranceHealth savings Accounts – Tax FreeRepeal ACA taxes and cost sharing subsidies Empower states through waivers

86. The Future of Healthcare in the United StatesSkinny Repeal Amendment ActWould repeal Obamacare’s mandatesRepeal Medical Device TaxDefund Planned ParenthoodEliminate the Prevention and Public Health FundEliminate additional commitments to Community Health CentersSkinny repeal could simply be a vehicle to get enough votes to pass the bill and then get the bill to conference committeeMcCain gave the decisive vote - NO

87. President Trump and ACA – Chronology January 2017HHS pulls funding for outreach and advertisement for last days of 2017 enrollmentFebruary 2015/2017New rules backed by Insurance Companies cutting the 2018 open enrollment period in half, making it more difficult for people to buy insurance outside the six week period. June 2017Uncertainty about ACA is having an impact on the Market. Anthem pulls out of Ohio, Humana, Aetna, Wellmark in Iowa, and Blue Cross and Blue Shield in Kansas City.

88. President Trump and ACA – Chronology July 2017BRCA 2 defeated by 1 vote – McCain’sMcCain’s vote defeats the Skinny Repeal (repeal individual and employers mandate, and give broad authority to states to waive key sections of ACA).November 2017Penalty for not having health insurance is eliminatedApril 2018CMS reports 11.8 Million people bought 2018 coverage on the ACA federal and state based exchanges during the shortened enrollment period. 27% were new customers

89. President Trump and ACA – Chronology October 2018Executive Order – allows small business owners, their employees, sale proprietors, and others to join together to buy or promote insurance in the large group market through association health plans. They will not be able to deny coverage or charge higher rates to individual employees with pre-existing medical conditions. They might not have to after all the essential health benefits.

90. ACA and President Trump - Although not successful in repealing ACA he has weakened it considerablyLimited support for open enrollment, halted up to 5 million in ACA Advertisement (90%)Cut in half the time consumers had to sign up on the federal exchange – six weeks instead of 3 monthsReduced federal support by 40% for counselors who helped people navigate the enrollment. Killed the cost sharing subsidies of roughly 6M lower income ACA enrollees, however, many consumers benefited from higher premiums subsidies that allowed them to buy 2018 plans on the exchange for less money. Middle class Americans without subsidies had to cope with full hikes.

91. ACA and President Trump (cont.)Eliminated the Individual Mandate starting in 2019 – IRS stopped looking into Tax ReturnsGave states more control over Medicaid programs – Work? Change premiums? Limit benefits? Proposed allowing small businesses and some self employed folks to band together and buy health insurance (association plans based on location and industry) - Coverage across state lines?Encouraged the sale of short term health plans

92. Under President TrumpWeakened the Contraceptive Mandate. Companies no longer required to provide contraceptives if they have sincerely held religious beliefs. Tightened the rules for consumers seeking coverage, while loosening them for insurersConsumers must pay any back premiums before signing again. Enrollment during special periods – must provide documentation proving their eligibility.

93. The Future of Healthcare in the United StatesCost-Sharing Reduction (CSR)CSR is used to reduce deductibles and co-payments for individuals who make less than 250% of FPL. The Federal government pays this directly to the insurance companies to subsidize this groupCSR is an additional layer of financial assistance designed to reduce the out of pocket cost burden than ACA places on the near poor (people 400% FPL)They raise the bottom line to health insurers in a considerable way7 billion last year, 10 billion expected this year, 130 billion expected by 2026 MONEY MUST BE APPROPRIATED BY CONGRESS FOR THE EXECUTIVE BRANCH TO SPEND ITObama Administration began disbursing CSR subsidies to health insurance firms under ACA, even when the funds were in the law but not appropriated by Congress

94. CSR – Under President TrumpIntroduced by ACA to offset the cost to insurers of offering affordable plans to poor AmericansThe payments of CSR were illegal once they were being appropriated by the Executive Branch instead of Congress which never authorized them. President will consider cost sharing reduction payments.

95. CSR – Cost Sharing Reduction Until late 2017, this subsidization was directly provided by the federal government (7 Billion in 2018), since then the cost of CSR has been added to premiums in most states, driving the cost of coverage, and thus resulting in larger premium subsidies, which continue to be directly provided by the federal government.

96. CSR – Under President TrumpCSR, currently are automatically incorporated into silver plans when eligible pts shop for plans through the exchanges. Although the Federal Government is no longer reimbursing insurers for the cost of providing, CSR, the availability of the benefits themselves, has not changed. Anyone that is eligible for cost – 250 of the FPL $30,350 for a single person and $62,750 for a family of 4.

97. Currently - 2018CMS reports that subsidized marketplace customers are paying less out of pocket than everMore than four in five enrollees received premium subsidies to help pay for coverage – Average cost was $89/month – down from $100 in the past 3 yrs. Nearly 9M people selected marketplace plans in the 39 states using Healthcare.gov during open enrollment – only ½ million lower than prior yearNumber of Marketplace Insurers for 20181 Insurer – 23%2 Insurers – 24% 3 insurers – 16% 4 or more – 37%

98. Five changes in the insurance market coming in 2018Silver plans are pricier – soar by 37% average Gold policies will be more affordable for some, rising only 19% - Average deductible: $1,320There will be a new expanded bronze plan. They will have lower premiums, but higher out of pocket. Enrollees can skip Healthcare.gov and enroll directly through third party websitesEnrollment period is shorter – only until Dec. 15 not till January. Not enrolled on time – will stay in previous one – unable to switch to another policy.

99. Under President Trump, CMS Guidance on Hardship Exemption: 2018 and Beyond – Different from previous guidance Live in counties with only one or no health plan insurers. Experience other circumstances that impede the purchase of health insurance. Only have access to plans that provide coverage for services to which they object on religious grounds. Must complete hardship application to determine eligibility. Three safe harbors – as proxies for defining affordability: W-2 wages formEmployees rate of payUse of Federal Poverty Line

100. Essential Health Benefits – Future Plans 2018Adopt another state benchmark planReplace essential health benefits categories from its plan with one or more from a new state. Develop a new plan that stays within ACA’s parameters. The burden of determining the scope of EHR’s shift from the Federal Government to the States.

101. Affordability Requirements The plan is affordable if the Self-only coverage health care plan costs no more than 9.5% of an employees total household income. Threshold of affordability for 2016 changed to 9.66% of household income.

102. Employer Mandate PenaltyIf employer does not provide minimum essential coverage or have an adequate health plan – employer can be penalized. No penalty is triggered unless an employee receives a tax credit for that purchase of health insurance in a state exchange. The plan does not provide minimum essential benefits. Required contribution for self-only exceeds employees household income. Employer pays for less than 60% of the benefits. Penalties:2015: $2,080 x number of FTE’s in excess of 80 employees2016: $2,160 x number of FTE’s in excess of 30 employees$3,120 in 2015$3,240 in 2016Per full time employee that procures coverage from an exchange who receives a premium tax credit enabling them to purchase coverage through exchanges

103. Employer Mandate Penalty (cont.)Congress passed legislation to improve health outcomes for patients on Medicare with chronic conditions. Chronic Care Act expands telehealth services and a program for seniors to receive specialized care at home. It also provides greater flexibility for Medicare Advantage plans covering chronically ill seniors. Implementation of the 21st Century Cures Act Increases funding (10.5B) for biomedical Innovation, Cancer, and Genomic, mental health and substance abuse treatment, and promotes consumer protections with respect to electronic medical records.

104. Next Steps in Payment Reform: Trump Administration & Regulatory Changes Continued funding for CMS Innovation CenterPreference for voluntary bundled payment modelsMore opportunities for physician led modelsUnclear whether Trump will adhere to Obama’s VBP commitments

105. 12 Healthcare Issues that will define 2018:The continued uncertainty and risk the healthcare industry will face in 2018, will motivate healthcare organizations to boost their efficiency across functions, demanding the attention and innovation of healthcare C-suite executives, clinicians and other healthcare professionals.

106. Artificial Intelligence Business executives will need to be able to automate tasks such as: Routine paperwork – 82%Scheduling – 79%Timesheet entry – 78%Accounting – 69% Investment in AI machine learning predictive analysis – 39%Only 20% businesses had technology to thrive in Artificial Intelligence

107. Health Reform: Not over – just more complicated The overarching trend has been toward State autonomy in health care policy. Healthcare organizations, especially ones doing business in multiple states, should strengthen compliance, and local advocacy efforts.

108. Medicare Advantage – Swells in 2018Organizations need to inform older adults about Medicare Advantage before they hit 65, only 28% of consumers ages 50 to 64 surveyed said they were familiar with Medicare AdvantageThe Feds are ramping up reviews of Medicare Advantage plans – to avoid penalties, health insurers should manage risk by focusing on members, particularly to services such as timely notifications, an adequate network, and up to date providers directories.

109. Healthcare Endangered MiddlemenHealthcare intermediaries may evolve. They could boost pricing transparency and take charge of more of the value chain, and that means holding manufacturers responsible for drug efficacy, combing pharmaceutical and clinical data, and assisting individual patients in better managing their care.

110. Opioid CrisisKeeping close eye on patients and discovering social factors that sway their behavior could help stop new opioid addictions. The use of care management programs from other areas -i.e. cancer – could help manage at risk opioid patients.

111. Securing the InternetThere will be more cyber security breaches and hospitals and health systems must be prepared. The financial and reputational cost of a breach affecting patient health care can far exceed the lost revenue from business disruption. While 95% of provider executives believe their organization is protected against cyber security attacks – only 36% have access management policies and just 34% have cyber security audit process.

112. Strategic Patient Experience It has been shown that there have been major improvements in patient experience measures after conducting programs that engage employees in the mission of caregiving. Organizations need to educate both: patients and clinicians on how to use available tools and integrate them into care, then administer and integrate the data they generate.

113. Price Transparency With a sharp eye on value and their individual brand, and with regulations varying from state to state, businesses need to make pricing decisions carefully and strategically.Manufacturers and payers should track each states requirements so they can navigate regulations, strategically.They must decide which environments to do business in, and figure out whether legal responsibilities allows flexibility.

114. Social Determinants of Health Come to the Forefront States are pushing for value based reimbursement models for Medicaid amid probable funding changes in 2018. In the next 5 years, 84% of provider executives say they do not have true data to recognize patients social needs. While clinicians do gather standard demographic information in EHR, this information is spottier.

115. Real World Evidence – Challenge for PharmaBusinesses need to seek partners that already have broad patients consent to share data – many health systems have invested in data infrastructure and aim to use this as a market differentiator.

116. Disaster Preparation Healthcare organizations need to go the extra mile with disaster preparedness. Keep virtual backup to traditional services understanding that virtual care can provide medical assistance in the event of damaged facilities.Disasters can cause population shifts so consider capital planning carefully. Consider market share loss after significant damage.Consider the impact of a credit rating downgrade, should a facility population make up change after a disaster. Combat bad or false information on social media during and after disaster, as patients and employees may be scared off.

117. Tax ReformFinancial reporting systems will have to be updated to capture different information as new tax provisions go into effect. Businesses based on any final tax reform will need to audit their systems to determine required changes.

118.

119. Thanks!

120. Finally….Food for Thought

121. What about us Doctors, and the future of Medicine?

122. The Future of Healthcare in the United StatesNot So Good for DoctorsFlawed Medicare Physician Payment Formula (SGR) – uncertainty of MACRANO TORT REFORM New Technology – Cognitive OverloadShort supply of physicians and specialistsMust return overpayments to the government – 10 years look back periodRetaining payment beyond the 60 days deadline could constitute a false claim, and fineDoctors must post speaking fees, five star meals and other compensations from pharmaceutical or medical device companies on the web Solo practitioners at risk with implementation of ACOs and MACRA

123. The Future of Healthcare in the United StatesDemoralized Doctors and Degraded CareUndercurrent of deep disappointment almost demoralization with what medical practice has becomeIncessant interference with their workA deep erosion of their autonomy and authorityTransformation from physician to “provider”Never ending attack on the profession from government, insurance companies and lawyersProgressively intrusive and usually unproductive rules and regulationsElectronic medical records mandate producing only billings and legal documents

124. The Future of Healthcare in the United StatesCumulative Toll on PractitionersWorking a median of 50 hours a week – satisfaction with work/life balance is lower than of others (36% to 61%)More than 7% of employed physicians between 29-65% reported having considered suicide within the past year, around 400 doctors commit suicide each yearDoctors who coveted their independence and authority now work under a microscopeEmotional exhaustion triggers medical errorsDoctors compartmentalize off their humanity in order to make decisions that profoundly affect patientsCaring for patients who don’t take care of themselves can be frustrating

125. The Future of Healthcare in the United StatesMedical Malpractice StatisticsBetween 1992 and 2003, the total amount of payouts increased from $3 billion to $4.8 billionAccording to the AMA, in 2011 nearly 30 states had implemented malpractice capsSix states represented more than 50% of total malpractice payouts in 2011 (California, Florida, New Jersey, New York, Illinois & Pennsylvania)New York has the highest payout amount, $677 million, followed by PennsylvaniaThe highest average payout per claim is Hawaii at $686,509. The lowest in Indiana at $122,297

126. The Future of Healthcare in the United StatesMalpractice Risk According to Physician SpecialtySOURCE: New England Journal of Medicine, 2011

127. Florida – 1 paid medical claim for every 100 physicians – Florida ranks #7Total non-economic damages recoverable from all plaintiffs against practitioners shall not exceed $1,000,000Cap of 1 million on wrongful death – found to be unconstitutional under Florida’s Constitution (March 2014)Statute of Repose – under NO circumstances may a healthcare provider be sued for medical malpractice more than 4 years after the date of the actual incident of malpractice (unless fraud, concealment or misrepresentation. 90% of Medical Malpractice cases are settled out of court. Average court settlement - $425,000Average jury award tops 1 Million

128. Florida – 1 paid medical claim for every 100 physicians60% of cardiologists have been named in a lawsuit. 12% - they were the only person named Reasons for lawsuits:36% - complications from treatment/surgery25% - wrongful death21% - failure to treat/delayed treatment20% - failure to diagnose/delay18% - poor outcomes5% - poor documentation of patient instruction and education4% - abnormal injury4% - failure to follow safety procedures2% lack of, or improperly obtaining informed consent. Hours spent on defense – 42% - more than 40 hrsAdvice: Do not volunteer information21% cardiologists settle before trial

129. Cont.What have they learned after being sued?27% - better chart documentation13% - more time with patient and family11% - not taking patient on9% - careful on how you phrase things to patients5% - review chart more carefully5% - ordered more appropriate tests4% - referred to other physician 4% - obtained 2nd opinion

130. Most Effective Ways to Discourage Lawsuits53% - Place caps on non-economic damages50% - Have medical panel screen cases for merit47% - Make plaintiff responsible for attorney and legal fees of every party involved if they lose. 24% - Try cases before health courts

131. The Future of Healthcare in the United StatesProjected Supply and Demand, Physicians, 2008-2020SOURCE: Healthcare Reform Magazine

132. The Future of Healthcare in the United StatesIOM Report – There is no Physician ShortageSystem is not undermanned – it’s inefficientProblem is how we reimburse doctors for careMoney – financial largest factor driving doctors’ specializationTherefore we can do things:Train more doctors or allow more doctors to immigrate to the USImprove ratio by which physicians enter specialties or primary care, through changes in training slots or how we pay physiciansMake ACA more efficient by distributing resources more effectivelyIncrease the use of midlevel practitioners through changes in regulations or licensing

133. The Future of Healthcare in the United StatesACA and Primary CareMedicare 10% Bonus for Primary Care/General Surgery ProvidersIn 2013-2014, increase Medicaid payment rates to internists, pediatricians, and primary care physicians for E&M care no less than 100% of Medicare rateTo entice providers to accept more Medicaid recipients, Obamacare required that states with federal dollars raised primary care physician payments rates for Medicaid to parity with Medicare rates for 2013 and 2014January 1, 2015, the mandate and the federal funding for the parity payment expired

134. The Future of Healthcare in the United StatesWould Incentives for Primary Care Work?Paying doctors financial rewards to meet targets for improving the care of patients made no discernible difference to the health or treatmentPhysicians that received the bonus:37% said that it made a small difference5% said it made a bid difference48% said it made no difference at allEven after allowing for variations, the study showed no impact on incidence of strokes, heart attacks, renal failure, heart failure or death in patients who started treatment before pay-for-performance targets were launched or those who started treatment after the targets were in placeSOURCE: British Medical Journal on the Orlando Sentinel, January 27, 2011

135. The Future of Healthcare in the United StatesACA and Doctors in TrainingMore medical students will be driven toward primary care specialties and general surgeryThe possibility of more medical schools closing the shortage gap, while simultaneously, residency slots are diminishing.There are 18 new medical schools in various stages of accreditation and development11 have opened since 2007, enrollment in allopathic and osteopathic medical schools has expanded

136. The Future of Healthcare in the United StatesACA and Doctors on Training - DownsideLarger number of medical doctors will compete for the same number of residenciesA large number of US medical graduates could find themselves unmatched after graduation2017 Match – 1,177 of the 1,279 unfilled positions were offered during Supplemental Offer and Acceptance Program (SOAP) 2018 Match - 1,177 of the 1,279 unfilled positions were offered during SOAP.

137. The Future of Healthcare in the United StatesRealities of TodaySOURCE: New England Journal of Medicine

138. Doctors, Burnout, Depression and Suicide

139. Doctors Suicide RateOne doctor commits suicide in the U.S. every day, the highest suicide rate of any professionNumber of doctor suicides – 28 to 40/100,000 More than twice that of the general population and higher than among those in the militaryFemale doctors attempt suicide far less than women in general population, their completion rate exceeds that of the general population by 2.5 to 4 times. Stigma is a major obstacle to seeking medical treatment. Female physicians reluctant to seek professional help because of the fear of stigma.

140. Most Common Means of Doctor Suicide Poisoning and hangingAccess to potentially lethal substances account for the higher rate of suicide completion in doctors. Psychiatry – near the top in suicide rates.

141. Physician Depression12% Males19.5% FemalesEven more common in medical students and residents: 15 – 30%National Physician Burnout and Depression Report15,000 physicians – 29 specialties reported

142. Which Physicians Are Most Burnt OutCritical Care – 48%Neurology – 48%Family Medicine – 47%OB/GYN – 46%Internal Medicine – 46%Emergency Medicine – 45%General Surgery – 43%Cardiology – 43% Pediatrics – 41%Nephrology – 40%Oncology – 39%Psychiatry – 36% Public Health – 36%Orthopedics – 34%Pathology – 32%Dermatology – 32%Plastic Surgery – 23%

143. Depression and BurnoutOB/GYN – 20%Public Health – 18% Neurology – 17%Critical Care – 16%Surgery – 15%Orthopedics – 14%Cardiology – 13%Oncology – 13% Emergency Medicine – 12%Pediatrics – 11%Plastic Surgery – 10% Dermatology – 9%Psychiatry – 8%14% of all physicians surveyed said the are both burnt out and depressed. More Females – 48%Less Males – 38% Burnout

144. What contributes to Physicians Depression – On a scale of 1 to 7 Highest – for both men and women was their job – 5.6 for each2nd – Finances next highest at 2.9 men and 3.7 for women

145. What contributes to Burnout?Too many bureaucratic tasks (charting, paperwork) – 56%Too many hours at work – 39%EHR’s – 24%Insufficient Compensation – 24%Lack of autonomy – 21%Lack of respect from patients – 15% Maintenance of certification requirements – 12%

146. What Would Reduce Your Burnout?Increased compensation to avoid financial stress – 35%More manageable work schedule/ call hours – 31%Decreased government regulations – 27%Increased control – 23%Greater respect from colleagues employer’s – 23%More time off – 23%Greater flexibility in schedule – 20%More supportive spouse/partner – 5%

147. How Do Physicians Cope with Burnout?Exercise - 50% Sleep – 42%Isolate myself – 36%Music – 36%Junk Food – 33%Drink alcohol – 22%Binge – 20%Use prescription drug – 2%Marijuana – 1%Women: Discuss with family – 55%Men: Exercise – 52%Women: Junk food – 39% Sleep – 46%

148. AdvicePhysical activity is good for you, but keep in mind the following activities do not count as exercise:Jumping to conclusionsBending over backwardsRunning around in circlesPutting your foot in your mouth

149. Seeking Professional HelpWomen: 58% No13% YesMen:66% No 9% Yes40% Psychiatrists – more likely to seek professional help17% Cardiologist – least likely to seek helpHappiest at WorkOphthalmology – 37% Extremely happy at work Cardiology – 21% Lowest percentages

150. The Future of Healthcare in the United StatesRealities of TodayFor all specialty categories, physician retirement decisions are projected to have the greatest impact on supply, and more than one third of all currently active physicians will be 65 or older within the next decadeMedical doctors between 65-75% account for 10% of active workforceMedical doctors between 55-64 make up nearly 26% of active workforce

151. The Future of Healthcare in the United StatesMean Age of Retiring Physicians (age 50+)SOURCE: Association of American Medical Colleges, April 5, 2016

152. The Future of Healthcare in the United StatesRealities of TodaySOURCE: American Association of Colleges of Nursing (AACN) and National Organization of Nurse Practitioner Faculties (NONPF) Annual Surveys

153. The Future of Healthcare in the United StatesRealities of TodaySOURCE: National Commission on Certification of Physician Assistants “Certified Physician Assistant Population Trends”

154. The Future of Healthcare in the United StatesRealities of TodayThe ratio of medical doctors to APRN’s and PA’s is projected to fall over time as the APRN and PA supplies grow at faster rates than physician supplyPhysician to PA ratio will fall from:7.2 : 1 in 20153.5 : 1 in 2030Physician to APRN ratio will fall from:3.6 : 1 in 20151.9 : 1 in 2030Would these ratios be sustainable or to what extent these shifts will affect the demand for physicians?Achieving population health goals may actually raise demand for physicians in the long-term

155. The Future of Healthcare in the United StatesQuestions on What Needs to be DoneHow will telemedicine and digital technology affect demand for physician services, physician productivity, physician career satisfaction, access to care, patient care utilization and outcomes?Will a saturation point be reached and if so when?To what extent APRN’s and PA’s displaced physicians in some specialties?To what extent are they providing previously unfilled services and expanding access to care?Might market saturation be reached for hospitalists?

156. 2018 Challenges for Medicine1. Burnout2. Time demands of EHR data entry3. Growing number of uncompensated tasksLoss of revenue at least $50,000 per yearAs much as 20%, prior authorizations, EHR data entry, non-clinical paperwork, request and questions from family members4. Third party interference in patient care5. Patient adherence to medication regimen6. Managing quality measures incentives7. Rapidly changing reimbursement landscape8. Patient disrespect toward physicians9. Value Based – the rising cost of compliance has forced doctors to join larger MD groups, or sell practice. 10. Changing insurance marketplace

157. The Future of Healthcare in the United StatesQuestions to AskWill medical schools and residencies be able to keep up with demand of training more doctors? Would doctors leave medicine, retiring early?Would doctors only see patients that pay cash (concierge medicine)? Would nurse practitioners overtake the field of Primary Care from MDs?Would doctors deny care to Medicare and/or Medicaid patients?Would solo practices disappear? Would emergency Rooms become the extension of primary care offices? Would doctors unionize?

158. AMI and CABG bundles can qualify as Advanced Alternative Payment (APM) models in 2018 under MACRACABG most frequent complications were: -Postoperative Atrial Fibrillation – 18.4% -Prolonged ventilation for longer than 24 hrs. – 9%At a cost of: -Prolonged Ventilation – 59 Million -Post Operative Atrial Fibrillation – 27 MillionSource: Virginia Cardiac Surgery Quality Initiative

159. CMS Voluntary Initiatives: Bundled Payments for Care Initiative (BPCI) Model 1Hospital receives discounted IPPS rate for inpatient staysPhysicians receive FFS paymentsModel 2Retrospective bundleEpisode includes inpatient stay +90 days post-discharge Model 3Post-acute retrospective bundleTriggered by hospitalization Model 4Prospective bundleAll services in acute care hospital stayPhysicians paid out of bundleApr. 2013 – Dec. 2016Awardees participated in all MS-DRGsOctober 2013-201648 clinical episodes to choose from; risk is phased in

160. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)Introduces the Medicare Physicians sustainable growth rate (SGR) formulaCreates new framework for rewarding health care providers for better care, not just more care. Combines existing quality reporting programs into one new system.CMS requires CMS to implement a two track payment system: The Quality Payment Program (QPP) for physicians and other eligible clinicians.

161. Track 2: Advanced APMs Overview Incentives to participate in Advanced APM TrackExempt from MIPs!Receive 5% bonus payment (Medicare Part B revenue)Opportunity to receive bonus payments from APM arrangement Minimum payment and/or patient thresholds:Eligibility criteriaFinancial risk, quality measures comparable to MIPs, use certified EHRs, required to refund Medicare if spending under model exceeds a projected amount.

162. Qualifying Medicare APM Models

163. Employer Mandate Penalty (cont.)Congress failed in 2017 to reauthorizeThe children’s Health Insurance Program – covers 9M childrenCommunity Health Centers Program – covers 1 in 19 AmericansThough Congress provided short term support into the new year – the lack of long term funding creates uncertainty