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Transcript of mHealth Israel_President Trump and the Future of US Healthcare Regulation and Reimbursement_Harry...
President Trump and the Future of U.S. Healthcare Regulation and
ReimbursementPresented by: Harry Nelson
I. Understanding Obamacare as a Prelude to What Comes Next
II. Anticipated Signature Trump Healthcare Initiatives
III. Implications for Healthcare and Life Science Providers
I. ACA Overview
Medicaid Expansion: Coverage For Low-Income Individuals
To 138% FPL
Employer-Sponsored Coverage (mandated 50+ FTEs)
Exchange Marketplaces: Subsidies for Moderate
Income Individuals 138-400% FPL w/o
access to employer-sponsored insurance
IndividualMandate
Health Insurance Market Reforms
Patient Protection and Affordable Care Act Goal: Universal
Coverage
ACA-RelatedCost Reduction-Quality Improvement Initiatives• Readmission Penalties
• ACOs• Bundled Payment Initiatives • MACRA – Shift to Value-Based
Reimbursement
2010-2015:ACA Political Drama
• Over 60 Repeal Attempts by Republicans in Congress
• 3 Supreme Court Challenges (ACA upheld but recognizing religious rights of objection)
Coming Soon:Repeal/Roll Back of the ACA
• Unpopular elements to be unraveled:• State exchanges• Individual and employer mandates• Medicaid expansion• Minimum essential benefit requirements
• Popular components to be retained/replaced:• guaranteed issue irrespective of preexisting
conditions• Keeping kids on parents’ policies until age 26
6
Scaling back of Medicaid
• Cap on federal contributions to the states to fund Medicaid coverage for low-income Americans via a “block grant” model• Program design flexibility at state level• Jockeying at state level for grant funding
• Substantial losses of coverage for 20m+ able-bodied adults in “Expansion” States (No change in “Hold-Out” States”)
• Big question: Which states will fill the void? California/Colorado? Illinois? New York? 7
Signature Trump Initiative #1: Global Medicare Capitation • Paul Ryan alternative to Obamacare: • Medicare“premium support” model • Raised eligibility age to 67
• Cap on federal contribution. Pressure on states to determine whether to expand benefits. • Big questions ahead for end-of-life care and
expensive chronic conditions that exceed personal limit: Who will cover costs? 8
Signature Trump Initiative #2:Expansion of Health Savings Accounts
• Incentivize employees to control healthcare costs by allowing them to keep unspent funds. • 2016: HSA holders can save up to $3,350
individual/$6,750 family (+$1,000 if over 55) - 100% tax deductible/tax free distribution for qualified expenses. • (Note: More extreme GOP alternative - overhaul
of IRS Code to eliminate deductions and special credits generally)
9
GOP Vision: HSAs and HDHPs • Strategy- control costs by incentivizing more
consumer-driven employee behavior - value-oriented shoppers for cost-effective health care --onus on individual
• Shift to high-deductible health plans (HDHPs)
• Elephant in the room: Even with employer funding of HSAs, numbers don’t come close to cost for catastrophic events or chronic conditions
Signature Trump Initiative #3
• National insurance underwriting in place of current state-by-state regulation.
• Big questions: • Legally permissible? (Federal/State
Question)•Will it make a meaningful difference? 11
Questions Ahead: Value-Based Care Initiatives?•Will President Trump continue (or
accelerate) Medicare risk shifting to providers via value-based care initiatives? • Bundled Payment for Care Initiative
(BPCI)• Comprehensive Care for Joint
Replacement (CJR) program •MACRA
12
• Policies were medically underwritten
• Many policies excluded benefits such as prescription drugs and maternity care
• Policies typically had high cost sharing (deductibles)/Premiums were unsubsidized leaving them unaffordable for many
• Insurers prohibited from discriminating based on health status
• Policies must cover “minimum” essential benefits: hospitalization, outpatient medical, emergency care, rx drugs, maternity, mental health, rehab, lab tests, preventive services, pediatric dental, vision
• Consumer out-of-pocket spending reduced but not eliminated
Questions Ahead: Status of coverage rules?
Pre-ACA Post-ACA
Winners and Losers?Worst Impact Most Promising
Acute Care Hospitals Home Care
Post-acute/Skilled Nursing Facilities
Assisted Living Facilities
Home Health Agencies Outpatient ___________
Pharmacies Telehealth/Telemonitoring
Workplace Wellness14
Questions Ahead re: FDA• Historically greater GOP deference to markets in setting
drug prices. Possible populist exception: enabling Medicare to negotiate prices for high-cost, low-competition drugs?
• Anticipated FDA changes – subject to leadership choice• Reduction of FDA biologic exclusivity period (currently
12 years)• Prioritized, expedited review of FDA to biosimilar
applications with limited competition in the marketplace,• Accelerated approval process for generics and other drug
applications• Mobile health applications?
15
Questions Ahead re Marijuana
• Summer 2016: DEA rescheduling of marijuana to Schedule II Controlled Substance did not happen.• Will Congress loosen banking laws for more
investment, finance, tax revenue collection in decriminalized states?• Will delegation to states continue (with growing
decriminalization) or will a more hardline AG Sessions roll back liberalization on cultivation and dispensaries? • Status of Marijuana research 16
Ahead next political cycle: Single-Payor?
• Democratic campaign: Hillary Clinton lambasted Bernie Sanders for advocating the costly expansion of Medicare into a universal, single-payer healthcare program
• For Democrats, Obamacare was always a compromise postition
• Democratic opposition platform likely to shift to single-payer “public option” in 2020 and 2024 17
Prediction: Continued stalemate in DC
• 3-Headed GOP Monster:• President Trump• Speaker Ryan• Senate Leader McConnell
• After the initial roar to repeal the ACA, stalemate in DC is a reasonable bet…
18
Inside Healthcare Transformation
• Consolidation• Coordinated
Care• Competitive
Landscape• Precision
Health
• Bundled Payment Value-Based Care
• Shared Risk• Pay for Performance• Preauthorization
• Digital Health• Alternative
Care Settings• Physician
Extenders
• Consumer-Driven• Underinsured• Aging
Evolving Patient
Demand
New Care
Delivery Models
Re-Alignmt
New Financial Models
Questions? Comments? Airing of grievances?Harry NelsonNelson Hardiman, [email protected]