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US Health Care System:Its impact on your future practice and patients
(Your name here)
What’s the problem?Medicine is the #1 industry in the US
ACCESS50 Million uninsured/10 M underinsured
COST: $2.9 trillion
National Health Spending In 2013: Growth Slows, Remains In Step With The Overall Economy. CMS Office of the Actuary. Health Affairs. Dec. 2014.
“The US Government is an insurance company with a large army”
US Treasury and OMB/2012
Half of all children born after 2000 will live to be 100
One in three will develop Type II diabetes
The Lancet Oct 1, 2009 and National Diabetes Fact Sheet, Jan 26, 2011
QUALITYEmphasize acute care over wellness and prevention
Fee for service paymentrewards quantity over quality
Health disparities among racial and ethnic minorities
Outcomes are poorer than countries which spend much less
Understanding the US Health Care
System(s):
Evolution or Intelligent Design?
Access to Insurance Equals Access to Care for 250 Million Americans
HALF have Employer-based group insurance
or
Single policy
or
Out of Pocket
Half have State and Federal Government Insurance
Medicare (elderly)
Medicaid (destitute)
Children’s Health Insurance Program (CHIP)
Veterans Affairs
Indian Health Service
Federal Employees Health Benefit Program
Safety Net for 60 M Uninsured/Underinsured
• Emergency rooms• Public hospitals• Federally Qualified Health Centers (FQHCs) NY has > 60• Migrant worker health centers
$61 B per year in uncompensated care
Urban Institute: Health Care Spending Under Reform: Less Uncompensated Care and Lower Costs /2010http://findahealthcenter.hrsa.gov/Search_HCC.aspx
Government InsuranceHealth and Human Services
HHS Budget:$967 B
Medicare $597B Medicaid $254B (fed)
Total CMS $851 B
www.hhs.gov CBO Medicare Baseline May 2013
Medicare
Serves 47 million people over age 65 3,093,591 in NY
www.hhs.cms.govKaiser State Health Facts/Medicare/NNY Accessed 3/5/15
B
Medicare Reimbursement• Reimburses at 80% of “customary and reasonable charge”
• Resource Based-Relative Value Unit - RUC
• Fee for Service
• Sustainable Growth Rate (SGR)
• Physician Quality Reporting System
– Currently voluntary – earn 2% of Part B fees
– Mandatory in 2015: Part B payment will be ‘adjusted’ for not submitting quality data
CMS.gov Affairshttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/PQRS/
CMS pays $9B for Graduate Medical Education (GME)
– med school enrollment increasing but cap on federally-funded residency slots
Happy Birthday Boomers!"You’ve got . . . 10,000 new seniors, baby boomers,
becoming eligible for the entitlement programs" . . . everyday for the next 18 years.
Rep. Eric Cantor, R-VAFormer House Majority Leader
Representative Eric Cantor, April 27, 2011, PoliticFact, Richmond Times Dispatch 4/27/11
. . . Enrollment will increase from 47 million to approx 74 million – number of beneficiaries over age 80 will triple.
Congressional Budget Office 2/1/12
The Silver Tsunami
MedicaidHealth care for 60 million eligible poor > 133% FPL
5,161,400 in NY
Kaiser State Health Facts (2012 Data). Accessed 3/5/15
50%FMAP 50% NY state dollars
Medicaid’s Fiscal Challenges• Takes up >25% of most state budgets• Increases in unemployment = increases in eligibility• Fairly generous benefits but access problems due to
low reimbursement – pays 70% of Medicare’s 80% rate
Changing the System
Values Affect Policy: Is Healthcare a Right or a Responsibility?
Stakeholders Impact Policy
Approval rating: 9%
Politics affect Policy: Even Congress Hates Congress
“It’s so bad sometimes I tell people I’m a lawyer,” Senator Lindsey Graham (R-S.C.). “I don’t want to be associated with a body that in the eyes of your fellow citizens seems to be dysfunctional.”
“We’re below sharks and contract killers,” added Rep. Trey Gowdy (R-S.C.).
Politico, October 26, 2011/January 2012
Limited Resources Affect Policy
“We can’t keep filling infinite need with finite resources.”Former four-term Colorado Governor Richard Lamb
“I love change except for the part about doing things differently” anonymous
“There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order.”
Machiavelli Rule of Reform
What’s in thePatient Protection and Affordable Care Act?
1. Will the health reform law require nearly all Americans to have health insurance by 2014 or else pay a fine?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
2. Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
"The America I know and love is not one in which my parents or my baby with Down syndrome will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care.” Sarah Palin 8/7/09
3. Will the health reform law cut benefits that were previously provided to all people on Medicare?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
4. Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
Yes and No
5. Will the health reform law provide financial help to low and moderate income Americans who don't get insurance through their jobs to help them purchase coverage?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
Don’t Know Yet
King vs. Burwell: Subsidies for people in state AND federally run exchanges?
6. Will the health reform law prohibit insurance companies from denying coverage because of a person's medical history or health condition?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
7. Will the health reform law require all businesses, including small businesses, to provide health insurance for their employees?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
8. Will the health reform law create a new government run insurance plan to be offered along with private plans?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
9. Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance?
1. Yes2. No3. Don’t know
1 2 3
33% 33%33%
65
18
Health Care“On Demand”
Very Poor
Near Poor
Uni
nsur
ed
Dual Eligibles
Und
erin
sure
d
Medicare
Med
icai
d
Work. Poor
Very Rich
Middle Class
Upper-Mid Class
Retiree Benefits
CHIP
Employer- Provided
Managed Care
Health Care System: Before the ACA
Age
IncomeAdam Sheingate, Professor, John Hopkins University Political Science Department, August 2012
65
18
Health Care“On Demand”
Very Poor
Near Poor
Dual Eligibles Medicare
Work. Poor
Very Rich
Middle Class
Upper-Mid Class
CHIP
Employer- Provided
Managed Care
Health Care System: After ACA
Age
Income
Med
icai
d
Hea
lth
Exc
hang
es
Med
icai
d E
xpan
sion
Und
erin
sure
dU
nins
ured
Retiree Benefits
Circa 2012: Medicaid
Exp.,Health Exch.
Adam Sheingate, Professor, John Hopkins University Political Science Department, August 2012
Good News for the Uninsured
Cover up to 35 million more people– Individual Mandate (SCOTUS considers the fine a “tax”)– Employer Mandate– Insurance Regulation
• Kids covered on parents policy to age 26• No exclusion for pre-existing conditions
– Health Insurance Exchanges and subsidies– Changes to Medicaid
Good News for Seniors
• Fill in donut hole in Medicare Rx• Reduce Hospital readmissions• Reduce Medicare premiums• Increase Medicare preventive
services• Increase access and
quality for dual eligibles
Carrots and Sticks for Providers
• Primary Care team focuses on wellness and coordination of care
• Goal: Keep people healthy and out of the hospital
• Responsible for quality and costs; can earn shared savings
Medicare Electronic Health Records (EHR) Incentive Program
$44,000 bonus for ‘meaningful use’ of HIT– The use of a certified EHR in a meaningful manner, re: e-prescribing.– Electronic exchange of health information to improve quality of health
care– Submit clinical quality and other measures
-.5 to 5% penalty for no EHR after 2015
Bonus for Primary Care Providers10% bonus to primary care physicians and surgeons working in Health Profession Shortage Areas (HPSAs)Incentive payments for PC services if patient stays out of the hospital “Independence at Home”
Medicare Value Based Payment Modifier
• Value-based ‘purchasing’ based on physician performance and quality
• New physicians could be ‘dinged’ as their cost profiles are higher
Increase Reimbursement to Medicare Advantage
Medicare Prospective Payment System for FQHCs
Mostly ‘Sticks’ for Hospitals
• No payment for preventable readmissions• Reduce payment updates for hospitals, home
health and SNFs• Bundled payment for an episode of care• Eliminate DSH payments
Control Medicare Spending
• Independent Payment Advisory Board – to reduce rate of growth – depoliticize process
Get Involved
• Invite speakers on key issues– AOA Dept Gov. Relations– AACOM Dept Gov. Relations– Former HPF and TIPS Fellows
• Educate yourself– Monitor, analyze and advocate for issues
• Educate elected officials about key issues• Attend DO Day on the Hill – or Visit State Capitol• AACOM Health Policy Internship • Training in Policies Studies Program OGME II and III
Generate Discussion
Stay Informed