ACA: Evidence-Based Update

Seth Trueger, MD, MPH

Assistant ProfessorEmergency MedicineUniversity of Chicago@MDaware

DISCLOSURES

Emergency Physicians MonthlyMedical Society of Virginia Foundation

Heart Course: EmergencyDaiichi Sankyo

Medical College of Wisconsin

(bias?)

PlanEnrollment & Penalties

Subsidies/CSR

Plans (premiums, OOPs, networks)

Expansion (states, DSH)

Provider impact

Payment reform (ACOs, HRRP, HVBP)

ENROLLMENTstolen mostly from Charles Gaba

2015 Enrollment

Marketplaces

Medicaid

2015 Enrollment

Marketplaces

2015 Enrollment

11 million paid QHP

2015 Enrollment

11 million paid QHP

9 million off-Exchange QHP

2015 Enrollment

Medicaid

2015 Enrollment

11 million paid QHP

9 million off-Exchange QHP

9.08 million Medicaid expansion

2015 Enrollment

11 million paid QHP

9 million off-Exchange QHP

9.08 million Medicaid expansion

3.4 million Medicaid woodworkers

2015 Enrollment

11 million paid QHP

9 million off-Exchange QHP

9.08 million Medicaid expansion

3.4 million Medicaid woodworkers

950,000 bulk transfers

2015 Enrollment

11 million paid QHP

9 million off-Exchange QHP

9.08 million Medicaid expansion

3.4 million Medicaid woodworkers

950,000 bulk transfers

~50 million traditional Medicaid

RAND study

net increase of 16.9 million

RAND study

net increase of 16.9 million

22.8 million newly insured

RAND study

net increase of 16.9 million

22.8 million newly insured

5.9 million lost coverage

RAND study

net increase of 16.9 million

22.8 million newly insured

5.9 million lost coverage

uninsured: 42.7 million to 25.8 million

insurance gains

9.6 million increase in employer plans

1.5 million other

(Medicare, military insurance, state

plans)

individual mandate?

individual mandate?

improving economy/employment?

5.9 million lost coverage

5.9 million lost coverage

24.6 million moved from one source of

insurance to another

5.9 million lost coverage

24.6 million moved from one source of

insurance to another

doi: 10.1377/hlthaff.22.6.244

doi: 10.1377/hlthaff.2010.1000

28 million

Medicaid

Exchanges

28 million

Medicaid

Exchanges

income fluctuations around 100-133% FPL

38% churn 4x or more

3 months of coverage=

no penalty

who is paying penalties?

who owes at tax time?

individual mandate?

CBO: 87% of uninsured exempt

individual mandate?

CBO: 87% of uninsured exemptmostly hardship exemptions

individual mandate?

CBO: 87% of uninsured exemptmostly hardship exemptions

Treasury: 3-6 million penalties

April 2015 tax time

IRS reconciliation

IRS reconciliation50-65% owe

$729 (4.5-7.5 million)

IRS reconciliation50-65% owe

$729 (4.5-7.5 million)

25-45%refund$425

ObamaCare

INSURANCE

ObamaCare

INSURANCE

“Despite concerns about plan cancellations, only

600,000 people starting out with nongroup

coverage became uninsured.

Of the 155.8 million people with insurance in

September 2013, 80 percent experienced no

changes in the source of their insurance during

the study period.

Among those who were uninsured at baseline, 47

percent remained uninsured at follow-up.”

“Despite concerns about plan cancellations, only

600,000 people starting out with nongroup

coverage became uninsured.

Of the 155.8 million people with insurance in

September 2013, 80 percent experienced no

changes in the source of their insurance during

the study period.

Among those who were uninsured at baseline, 47

percent remained uninsured at follow-up.”

“Despite concerns about plan cancellations, only

600,000 people starting out with nongroup

coverage became uninsured.

Of the 155.8 million people with insurance in

September 2013, 80 percent experienced no

changes in the source of their insurance during

the study period.

Among those who were uninsured at baseline, 47

percent remained uninsured at follow-up.”

EMPLOYER SPONSORED INSURANCE

UNINSURED

MEDICAID

MARKETPLACES & OFF EXCHANGE

SUBSIDIESwe are the forty seven percent

Premium Subsidies

85%per CMS

$272 /mo

Premium Subsidies

$272 /mo

$3,264 /yr

Premium Subsidies

$272 /mo

$3,264 /yr

$33 billion

Premium Subsidies

$272 /mo

$3,264 /yr

$33 billion$3 trillion /yr

Premium Subsidies

Household 100% FPL 400% FPL

1 $11,490 $45,960

2 $15,510 $62,040

3 $19,530 $78,120

4 $23,550 $94,200

5 $27,570 $110,280

<400% FPL

64%

<400% FPL

64%

>200 million

<400% FPL

64%

>200 million

such Exchanges

or

or

or

or

?

CSRs

Cost Sharing Reductions

“the other subsidies”

(pork/chicken of the sea)

CSRs

earlier: premium subsidies

CSRs

earlier: premium subsidiesmonthly bill

CSRs

earlier: premium subsidiesmonthly bill400% FPL

CSRs

earlier: premium subsidiesmonthly bill400% FPL

CSR: deductibles, copays, coinsurance

CSRs

earlier: premium subsidiesmonthly bill400% FPL

CSR: deductibles, copays, coinsurance

out of pocket, based on use

CSRs

earlier: premium subsidiesmonthly bill400% FPL

CSR: deductibles, copays, coinsurance

out of pocket, based on use250% FPL

CSRs

earlier: premium subsidiesmonthly bill400% FPL

CSR: deductibles, copays, coinsurance

out of pocket, based on use250% FPLonly Silver+ (not cheaper

Bronze)

CSRs

FFM SBM Total

CSR 4,500,205 1,300,731 5,800,936

total 7,524,234 2,662,964 10,187,198

% 60% 49% 57%

http://xpostfactoid.blogspot.com/2015/06/new-data-on-cost-sharing-reduction-in.htmlhttp://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-02.html

CSR uptake

CSR uptake

WHAT PLANS?aka skin in the game

premiums vs pre-ACA

MLR

EHB

OOP limits

no annual limits

no preexisting conditions

Home Depot

premiums vs pre-ACA

MLR

EHB

OOP limits

no annual limits

no preexisting conditions

Home Depot

premiums vs pre-ACA

my take2014 rates were low

my take2014 rates were low

“subsidy equilibrium”

my take2014 rates were low

“subsidy equilibrium”

rate increase requests ≠ rate increases

my take2014 rates were low

“subsidy equilibrium”

rate increase requests ≠ rate increases

deductibles??

deductibles = evil?

deductibles = evil?skin in the game?

3 issues

not w/o value (e.g. preventative

services)

3 issues

not w/o value (e.g. preventative

services)

100% insured after

3 issues

not w/o value (e.g. preventative

services)

100% insured after

compare employer sponsored

insurance

$15-17k

EXPANSIONsome maps & DSH

SOURCE: State Health Insurance Marketplace Types, 2015, KFF State Health Facts:http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.

MARKETPLACES

AK

WA

OR

WY

UT

TX

SD*

OK

ND

NM

NV NE*

MT*

LA

KS*

ID

CO CA

ARAZ

WI

WV VA*

TN SC

OH*

NC

MS

MN

MI

KY

IA

IN IL

GA

FL

AL

VT

PA

NY

NJ

NHMA

ME*

CT

DE

RI

MD

DC

Federally-supported State-based Marketplace (3 states)State-based Marketplace (13 states and DC)Partnership Marketplace (7 states)Federally-facilitated Marketplace (27 states)

MO

SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated May 26, 2015.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

MEDICAID EXPANSION

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT**

MO

MS

MN

MI*

MA

MD

ME

LA

KY KS

IA*

IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Expanded (30 States including DC)under discussion (3 States)

nope (18 States)

State Decisions on Health Insurance Marketplaces and the Medicaid Expansion, KFF State Health Facts, updated May 26, 2015. http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/.

EXCHANGES & MEDICAID

WY

WI

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA

OR*

OK

OH

ND

NC

NY

NM*

NH

NV* NE

MT**

MO

MS

MN

MIMA

MD

ME

LA

KY KS

IA

IN IL

ID

GA

FL

CT

CO CA

ARAZ

AK AL

SBM – MCD (Idaho) FFM - MCD(20 States)

FFM + MCD (14 States)SBM + MCD (16 States including DC)

DSH

DSH

DisproportionateShareHospitals

DSHFederal $ states hospitals

DSHFederal $ states hospitalsMedicaid + uninsured

DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)

DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)

ACA:

DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)

ACA:fewer uninsured decrease DSH

DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)

ACA:fewer uninsured decrease DSHpay for ACA

billion $

2018 2

2019 3

2020 4

2021 5

2022 6

2023 7

2024 8

2025 8

DSH

93% of $ large urban hospitals

65% of $ teaching hospitals

6300 hospitals

6300 hospitals

3100 DSH

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

529 DSH reliant

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

529 DSH reliant 551 weak

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

529 DSH reliant 551 weak

225 DSH reliant

+weak

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

529 DSH reliant 551 weak

225 DSH reliant

+weak

307 bad mix

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

551 weak307 bad

mix 225 DSH reliant

+weak

529 DSH reliant

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

551 weak307 bad

mix

132 bad mix

+DSH reliant

+weak

225 DSH reliant

+weak

529 DSH reliant

6300 hospitals

3100 DSH

2100 DSH Eligible in High DSH State

551 weak307 bad

mix

132 bad mix

+DSH reliant

+weak

44 bad payer mix

+DSH reliant

+weak

+ no Medicaid expansion

225 DSH reliant

+weak

529 DSH reliant

most vulnerable

big urban hospitals

bad payer mixes

non-expansion states

PROVIDER IMPACThospitals and physicians

2014 - 2022

$2.757 trillion in overhead

ACA: $273.6 billionnew private insurance$172.2 billion

“Most of this soaring private insurance

overhead is attributable to rising

enrollment in private plans which carry

high costs for administration and

profits.”

overhead

MLR

Medicare Advantage

Managed Medicaid

22% Private

14% MA

9% Medicaid

2% Medicare

no Medicaid expansion?

24 states w/o Medicaid expansion

6.7 million

2013 to 2022:

$423.6 billion in federal Medicaid $

Hospitals: lose $167.8 billion

no Medicaid expansion?

24 states w/o Medicaid expansion

6.7 million

2013 to 2022:

$423.6 billion in federal Medicaid $

Hospitals: lose $167.8 billion

PAYING FOR QUALITYACO APM P4P PQRS HRRP HVBP MSSP & MORE

early experiences

data lacking

mixed messages

Peter Viccellio

Peter Viccellio@MDaware tweet #6, 1 June 2011, SAEM (67K)

ACOs

Accountable

Care

Organizations

FFS vs bundle

FFS

ECG

FFS

ECG CXR

FFS

ECG CXR lab

FFS

ECG CXR lab admit

FFS vs bundle

ECG CXR lab admit

ACOs

FFS vs bundle

ECG CXR lab admit

ACO:

retain FFS

some CQM

shared savings

ACOs

mixed

some good

Pioneers

32 systems

13 quit

Pioneer ACOs

23 in second year

11 bonuses = $68 million

3 penalties = $7 million

$380 million

$36 pmpm vs $11 pmpm

Pioneer ACOs

23 in second year

11 bonuses = $68 million

3 penalties = $7 million

$380 million total savings

$36 pmpm vs $11 pmpm

Readmissions

Readmissions

outpatient networkincentives

Readmissions

outpatient networkincentives

nearly 20%

Readmissions

outpatient networkincentives

nearly 20%

down 1.1%

penalties?

2015: 80%

all 3: 57% (!)

https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

penalties?

2015: 80%

all 3: 57% (!)

https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

penalties?

average $100-300k

2013: teaching & safety-net hospitals

2015: more broadly distributed (still gap)

improving teaching & safety net?

surgical?https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

penalties?

average $100-300k

2013: teaching & safety-net hospitals

2015: more broadly distributed (still gap)

improving teaching & safety net hospitals?

penalties?

average $100-300k

2013: teaching & safety-net hospitals

2015: more broadly distributed (still gap)

improving teaching & safety net hospitals?

surgical?

HVBP differences

safety nets get penalized more

HVBP differences

safety nets get penalized more

…$12k/hospital

Hello, MIPS

ntrueger@gmail.com@MDaware