ACA: Evidence-Based Update - 2015 Policy Prescriptions® Symposium
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Transcript of ACA: Evidence-Based Update - 2015 Policy Prescriptions® Symposium
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ACA: Evidence-Based Update
Seth Trueger, MD, MPH
Assistant ProfessorEmergency MedicineUniversity of Chicago@MDaware
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DISCLOSURES
Emergency Physicians MonthlyMedical Society of Virginia Foundation
Heart Course: EmergencyDaiichi Sankyo
Medical College of Wisconsin
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(bias?)
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PlanEnrollment & Penalties
Subsidies/CSR
Plans (premiums, OOPs, networks)
Expansion (states, DSH)
Provider impact
Payment reform (ACOs, HRRP, HVBP)
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ENROLLMENTstolen mostly from Charles Gaba
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2015 Enrollment
Marketplaces
Medicaid
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2015 Enrollment
Marketplaces
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2015 Enrollment
11 million paid QHP
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2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
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2015 Enrollment
Medicaid
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2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
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2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
3.4 million Medicaid woodworkers
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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
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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
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RAND study
net increase of 16.9 million
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RAND study
net increase of 16.9 million
22.8 million newly insured
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RAND study
net increase of 16.9 million
22.8 million newly insured
5.9 million lost coverage
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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
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insurance gains
9.6 million increase in employer plans
1.5 million other
(Medicare, military insurance, state
plans)
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individual mandate?
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individual mandate?
improving economy/employment?
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5.9 million lost coverage
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5.9 million lost coverage
24.6 million moved from one source of
insurance to another
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5.9 million lost coverage
24.6 million moved from one source of
insurance to another
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doi: 10.1377/hlthaff.22.6.244
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doi: 10.1377/hlthaff.2010.1000
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28 million
Medicaid
Exchanges
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28 million
Medicaid
Exchanges
income fluctuations around 100-133% FPL
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38% churn 4x or more
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3 months of coverage=
no penalty
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who is paying penalties?
who owes at tax time?
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individual mandate?
CBO: 87% of uninsured exempt
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individual mandate?
CBO: 87% of uninsured exemptmostly hardship exemptions
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individual mandate?
CBO: 87% of uninsured exemptmostly hardship exemptions
Treasury: 3-6 million penalties
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April 2015 tax time
IRS reconciliation
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IRS reconciliation50-65% owe
$729 (4.5-7.5 million)
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IRS reconciliation50-65% owe
$729 (4.5-7.5 million)
25-45%refund$425
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ObamaCare
INSURANCE
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ObamaCare
INSURANCE
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“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.”
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“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.”
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“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.”
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EMPLOYER SPONSORED INSURANCE
UNINSURED
MEDICAID
MARKETPLACES & OFF EXCHANGE
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SUBSIDIESwe are the forty seven percent
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Premium Subsidies
85%per CMS
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$272 /mo
Premium Subsidies
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$272 /mo
$3,264 /yr
Premium Subsidies
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$272 /mo
$3,264 /yr
$33 billion
Premium Subsidies
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$272 /mo
$3,264 /yr
$33 billion$3 trillion /yr
Premium Subsidies
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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
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<400% FPL
64%
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<400% FPL
64%
>200 million
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<400% FPL
64%
>200 million
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such Exchanges
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or
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or
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or
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or
?
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CSRs
Cost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)
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CSRs
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earlier: premium subsidies
CSRs
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earlier: premium subsidiesmonthly bill
CSRs
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earlier: premium subsidiesmonthly bill400% FPL
CSRs
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earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
CSRs
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earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use
CSRs
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earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPL
CSRs
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earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPLonly Silver+ (not cheaper
Bronze)
CSRs
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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
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CSR uptake
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CSR uptake
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WHAT PLANS?aka skin in the game
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premiums vs pre-ACA
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MLR
EHB
OOP limits
no annual limits
no preexisting conditions
Home Depot
premiums vs pre-ACA
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MLR
EHB
OOP limits
no annual limits
no preexisting conditions
Home Depot
premiums vs pre-ACA
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my take2014 rates were low
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my take2014 rates were low
“subsidy equilibrium”
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my take2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
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my take2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
deductibles??
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deductibles = evil?
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deductibles = evil?skin in the game?
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3 issues
not w/o value (e.g. preventative
services)
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3 issues
not w/o value (e.g. preventative
services)
100% insured after
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3 issues
not w/o value (e.g. preventative
services)
100% insured after
compare employer sponsored
insurance
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$15-17k
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EXPANSIONsome maps & DSH
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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
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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)
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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)
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DSH
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DSH
DisproportionateShareHospitals
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DSHFederal $ states hospitals
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DSHFederal $ states hospitalsMedicaid + uninsured
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DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
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DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:
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DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:fewer uninsured decrease DSH
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DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:fewer uninsured decrease DSHpay for ACA
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billion $
2018 2
2019 3
2020 4
2021 5
2022 6
2023 7
2024 8
2025 8
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DSH
93% of $ large urban hospitals
65% of $ teaching hospitals
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6300 hospitals
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6300 hospitals
3100 DSH
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
225 DSH reliant
+weak
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
225 DSH reliant
+weak
307 bad mix
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6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
551 weak307 bad
mix 225 DSH reliant
+weak
529 DSH reliant
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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
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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
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most vulnerable
big urban hospitals
bad payer mixes
non-expansion states
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PROVIDER IMPACThospitals and physicians
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2014 - 2022
$2.757 trillion in overhead
ACA: $273.6 billionnew private insurance$172.2 billion
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“Most of this soaring private insurance
overhead is attributable to rising
enrollment in private plans which carry
high costs for administration and
profits.”
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overhead
MLR
Medicare Advantage
Managed Medicaid
22% Private
14% MA
9% Medicaid
2% Medicare
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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
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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
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PAYING FOR QUALITYACO APM P4P PQRS HRRP HVBP MSSP & MORE
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early experiences
data lacking
mixed messages
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Peter Viccellio
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Peter Viccellio@MDaware tweet #6, 1 June 2011, SAEM (67K)
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ACOs
Accountable
Care
Organizations
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FFS vs bundle
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FFS
ECG
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FFS
ECG CXR
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FFS
ECG CXR lab
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FFS
ECG CXR lab admit
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FFS vs bundle
ECG CXR lab admit
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ACOs
FFS vs bundle
ECG CXR lab admit
ACO:
retain FFS
some CQM
shared savings
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ACOs
mixed
some good
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Pioneers
32 systems
13 quit
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Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million
$380 million
$36 pmpm vs $11 pmpm
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Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million
$380 million total savings
$36 pmpm vs $11 pmpm
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Readmissions
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Readmissions
outpatient networkincentives
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Readmissions
outpatient networkincentives
nearly 20%
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Readmissions
outpatient networkincentives
nearly 20%
down 1.1%
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penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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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/
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penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?
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penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?
surgical?
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HVBP differences
safety nets get penalized more
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HVBP differences
safety nets get penalized more
…$12k/hospital
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Hello, MIPS
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[email protected]@MDaware