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What to Expect with the Affordable Care

ActBrief overview of what Florida physicians should changes they can

expect with the Affordable Care Act

Warning: If you suffer from depression, please leave the room or take your medication.

Presented by: Andrew Eriksen, CMPE

IntroductionTo be clear, this presentation is intended to be an overview, not a comprehensive analysis. The goal of this presentation is to equip you for changes that are likely to impact your practice in the coming months.Please don’t misinterpret this as a political presentation. I am addressing facts and will let the pundits bloviate over the hypothetical.

What Changed?

Too much to discuss in this presentation but here are few things worth mentioning: Eliminated the preexisting condition clause,

mandated certain preventative services such as mammograms, requires that all health plans use at least 80% of premium dollars on actual care and eliminates the lifetime/yearly benefit ceiling.

Subsidies provided to individuals based on household income through the new insurance marketplace(once it works)

Expanded Medicaid by raising the poverty line 133% Requires health plans to cover participation in

clinical trials Instituted a penalty (or tax..) if you fail to obtain

coverage

Insurance Marketplace Created to promote competition and theoretically drive down costs

Health plans are not required to participate and individuals are not required to buy insurance through the exchange.

Aetna, Avmed, BCBS, Coventry/First Health (now part of Aetna), Molina, Humana & Sunshine State are participating in the exchange. 82 plans currently offered in Florida. Plans split into 4 categories: Catastrophic, Bronze, Silver & Gold. Within these categories you have HMOs, EPOs, PPOs and HSAs. HMOs are provide the greatest value to members which is where most patients will likely end up. Only 6 of the 82 plans offered on the exchange are PPOs.

The proliferation of HMOs means lower reimbursements and an increased burden on the physicians. Fee schedules for most exchange products are an average of 10%. The EPO plans offered by BCBS rely on their HMO network but do not require a referral in most cases. They do however use the HMO fee schedule which is about 10-15% lower than the PPO fee schedule.

With the proliferation of HDHPs, it would be wise to develop ways within the office to collect more of what a patient owes prior to claim adjudication. This is commonly referred to as Real Time Claim Adjudication. This may be unpopular with some of your patients, but it could save your office from a lot of bad debt.

How has it helped?

Florida’s Exchange

Meet your New Patient- Medicaid Reform

Approximately 1 million new lives in Florida due to the poverty level being raised by 133%

Medicaid expansion eliminates straight Medicaid and turns over all current members to the managed care plans. Florida is divided into 11 regions with each region having approximately 3-6 managed care plans.

Opportunities for internal medicine trained physicians to attest and receive Medicare rates. PCPs receive Medicare funds for participating but do not have specialists to refer to. This creates obvious access issues which will likely result in better payments for specialists in the near future.

Currently, Medicaid pays approximately 60% of Medicare to specialists. There is a spreadsheet in Box folder with an analysis comparing Medicare and Medicaid for our most common codes.

Sunshine State, Wellcare and UHC are and will continue to have the most Medicaid members in Central Florida.

Regions in Florida

Medicaid Plans in Central Florida

Medicare & Where your Patients Went

P4P, Shared Savings and Captitated contracts are, and will continue to be, a focus for Medicare and commercial payers. Captitation is utilized heavily within the Medicare advantage market through shared risk agreements between IPAs and MSOs. They receive a PMPM fee for each member and based on their performance, share in the profit or loss.

PCPs are required to be part of an IPA now for many Medicare advantage plans. Some of the plans in Central Florida are Wellcare, Freedom/Optimum and PUP or Physicians United Plan.

Utilize ACOs to incentivize physicians to start thinking of ways to save money. While it’s a noble concept and certainly nothing new, it carries with it the potential for severe access and quality issues. ACOs have to save a minimum of 4% in order to share in the savings which means we can expect them to be very aggressive if they want to see a return on their investment. ER diversion is a primarily how they save but another easy way is to limit referrals to specialists. Hospitals have combatted this issue by joining ACOs or creating their own ACO with a group of their “preferred” physicians.

Access to specialists and ancillary services is being restricted through a Gate Keeper mentality and financial incentives tied to saving Medicare dollars

http://www.americanthinker.com/2013/12/the_future_of_medical_specialists_under_the_affordable_care_act.html

ClosingThe financial burdens of medicine have never been greater, but that is not a reason to change the way you practice. Patient centered, outcome based medicine, will always create value for the payers and loyalty among patients and referring physicians.