WHA Update

Health Care

Reform – Where Are We Today?

Key Themes in the ACA - 20111. Access to Affordable Coverage– Health Insurance

Exchanges, Medicaid expansion, individual insurance purchase mandate

2. Health Insurance Reform - Guaranteed issue, Medical Loss Ratio, etc.

3. New care delivery and financing methods – Accountable Care Organizations, Paying for “Value”/Quality

4. Adequate Access to Care – Workforce issues

Key Themes in the ACA – Today’s Discussion1. Access to Coverage–

• Exchange and Medicaid Coverage By the Numbers• King vs. Burwell

2. Health Insurance Reform – • Insurance Market Changes• Network Adequacy • Transparency

3. New care delivery and financing methods • Wisconsin specific initiatives around payment reform

4. Adequate Access to Care – Primary Care

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Recap-Wisconsin• Chose Federal Health Exchange

• Chose not to accept federal Medicaid $

$, But, instead… Moved individuals (parents/caretakers) with

income between 100-200% FPL off of Medicaid and into Federal Exchange

Expanded Medicaid (without taking Federal $$) to cover childless adults with income up to 100% of FPL ($11,670 for a single person)

Coverage/Enrollment As of March 2015

• Net 146,000 newly enrolled in Medicaid (childless adults with income <100% FPL)

• 67,500 no longer receiving Medicaid compared to March 2014 (mostly parents/caretakers, some children)

oOf those disenrolled, 54% moved into Exchange or other private insurance; Leaves 27,000 without insurance (based on DHS data from June 2014).

• 207,349 selected a health plan on Federal Exchange (89% receiving premium assistance) during open enrollment in 2015

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The Hospital RoleWHA Enrollment Survey - 29 responses/50 hospitals

48% said efforts higher in 2015 Significant dollars spent on enrollment assistance 138 CACs, plus 47 other assisters 18 respondents tracked cases – assisted nearly 17,000

people in 2014 71% actively participated in RENs Other activities: community enrollment fairs; mailings and

phone calls; phone banks; info on web; toll free hotline, media campaign; local discussion groups; posters

Participated in both Medicaid and Exchange enrollment activities

Exchange Enrollment - 2015Wisconsin National*

Total Enrollees 207,349 8.84 million

Bronze n/a 21%

Silver n/a 69%

Gold n/a 6%

Platinum n/a 3%

< age 18 6% 11%

18-34 26% 28%

35-44 15% 17%

45-64 53% 47%

New enrollees 44% 53%

Re-enrollments 56% 47%

Official HHS data, March 10, 2015, ASPE Report, *States Using the FFM Platform

Exchange Enrollment - 2015Total Enrollees 207,349

Percent with premium tax credit 89%

Average monthly premium before premium tax credit

$440

Average monthly premium tax credit $315

Average monthly premium after tax credit $125

Average percent reduction in premium after tax credit

72%

Official HHS data, March 10, 2015, ASPE Report, *States Using the FFM Platform

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The Courts Continue toTackle ACA Challenges

On March 4, 2015, the U.S. Supreme Court heard arguments in the case, KING, DAVID, ET AL. V. BURWELL, SEC. OF H&HS, ET AL.

Issue: Are federal tax subsidies available for purchase in a federally-facilitated exchange?

Timing: decision in late June/early July

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King v. Burwell“Millions at risk of losing coverage in Supreme Court case”Washington Post 2/17/15

• Key component of WI approach to expansion/rejection of Fed $• 207,000 enrolled via exchange in WI (89%=184,800 receiving

subsidy)• Timing of ruling impact – 90 day grace period??• State legislators concerned, work group created• WHA convening credible stakeholders to craft a state solution• Ron Johnson legislation – extend subsidies to 2017; repeal

individual and employer mandates, essential health benefits

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Exchange Planning for 2016Expected Date (2015) Activity

April 15 – May 15 Insurers submit QHP (Qualified Health Plan*) applications Filing 2 sets of rates (pending outcome of KvB)

May 18 – June 26 CMS reviews QHP applications.

June 29-June30 CMS sends first correction notice to insurer

July 10 Deadline for revised data to be submitted to CMS

July 13 - August 12 CMS reviews corrected applications

August 25 Final insurer data submission; Final deadline for state approval

August 26 – September 16 CMS completes re-review

September 21 – September 25 Insurers sign agreements with CMS; QHP data finalized

October 8 – October 9 Countersigned Agreements sent to Issuers

November 1, 2015 – January 31, 2016

Open enrollment

Key Themes in the ACA – Today’s Discussion1. Access to Coverage–

• Exchange and Medicaid Coverage By the Numbers• King vs. Burwell

2. Health Insurance Reform – • Insurance Market Changes• Network Adequacy • Transparency

2014 - What Changed?1. Anthem (CompCare) was in 72

counties, now 312. Dean – expanded to Vernon,

Kewaunee 3. GHC SC – expanded to Lafayette,

Rock, Green; previously not a large individual market presence

4. Molina – new to commercial market; previously Medicaid only

5. United, Humana chose not to participate in the Exchange

6. Common Ground – new to Wisconsin; Coop plan established under ACA

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2015 Insurers Participating

Exchange individual market:

• All Savers Insurance Company• Arise (WPS Health Plan, Inc.)• Common Ground Cooperative• Compcare Health Services• Dean Health Plan, Inc.• Group Health Cooperative of SC WI • Gundersen Health Plan, Inc.• Health Tradition Health Plan

• Managed Health Services • Medica Health Plans of Wisconsin• MercyCare HMO, Inc.• Molina Healthcare of Wisconsin, Inc• Physicians Plus• Security Health Plan of Wi.• Unity Health Plans

Network Adequacy• National Association of Insurance Commissioners

working on model act.

• NAIC re-started its discussions February 23, with weekly, and now twice weekly, phone calls. Illinois Hospital Association and AHA also participate.

• 115 page document summarizes comments from payers, providers, consumers.

2015 ONGOING ISSUES – WHA NA COUNCIL• Out of network providers/practitioners working in the

in-network hospital (NAIC also to discuss balance billing)

• Health plans not offering contracts to any hospital within the county

• Health plan offers contract at low rates – good faith?

• Network listings/consumer information about providers is not displayed consistently across all providers in network

• Overall, lack of consumer understanding

• Tiering issues

Network Adequacy

After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

He billed the Adamis $4,878 for eight stitches that were coded as “open wound, jaw, complicated.” “When I looked at the bill, I laughed and I told the surgeon’s office, ‘Process this claim with my insurer. I’m not paying out of pocket,’ ” Mr. Adami said. “The hospital has control over who they bring in. But I do not.”

ACA - Transparency

Modern HealthcareThe leader in healthcare business news, research & data  

IRS issues final billing, collections guide for not-for-profit hospitalsBy Beth Kutscher  | December 31, 2014

The Internal Revenue Service has issued final guidance to not-for-profit hospitals on the thorny issue of billing and collections, codifying consumer protections that providers must follow to keep their tax-exempt status.

Additionally, the ACA requires hospitals to report annually and make public a list of hospital charges for items and services

New IRS Section 501(r) Overview• New requirements for non-profit hospitals :

– Community Health Needs Assessment (CHNA)– Financial Assistance Policy (FAP)– Limitation on Charges (Amounts Generally Billed)– Billing and Collection Requirements

• Potential sanctions for noncompliance include financial penalties, tax on hospital activities, and even loss of Code Section 501(c)(3) status

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• Full compliance mandatory by start of first tax year beginning after December 29, 2015

Key Themes in the ACA – Today’s Discussion1. Access to Coverage–

• Exchange and Medicaid Coverage By the Numbers• King vs. Burwell

2. Health Insurance Reform – • Insurance Market Changes• Network Adequacy • Transparency

3. New care delivery and financing methods • Wisconsin specific initiatives around payment reform

Reform

Reform

Medicare Value Based PurchasingAdjusts hospitals’ payments based on performance on four domains • Clinical Process of Care (20% weight)• Patient Experience of Care (30% weight)• Outcome (30% weight)• Efficiency (20%)

1.5% Payment reduction in 2015.Penalty/bonus depending upon improvement or achievement

Separate Hospital Readmission Reduction Program

WHA Partners for Patients• 108 hospitals – 2012 through 2014• Project will restart mid-2015

Partners for Patients - Aggregate Impact

Year Patients with Improved Care

Estimated Cost Savings

2012 2060 $17,497,000

2013 4530 $44,558,000

2014 (Estimated) 2714 $25,039,000

Total 9304 $87,094,320

ACA – Payment Reform• Value Based Payment Reform - Physicians• Medicare announcement –30% of all Medicare

provider payments in alternative payment models tied to quality and value by 2016; 50% by 2018.• Medical home• Accountable Care organization• Bundled payments

• Sim/SHIP Grant in WI

• WI Medicaid has its own P4P

What are the questions for the revenue cycle?

Key Themes in the ACA – Today’s Discussion1. Access to Coverage–

• Exchange and Medicaid Coverage By the Numbers• King vs. Burwell

2. Health Insurance Reform – • Insurance Market Changes• Network Adequacy • Transparency

3. New care delivery and financing methods • Wisconsin specific initiatives around payment reform

4. Adequate Access to Care – Primary Care

ACA Payment Increase for Primary Care

Which Primary Care Providers?

Family Medicine, Internal Medicine, Pediatric Medicine and specialists or subspecialists in these areas recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Physician Specialties.

60% of Medicaid claims were for the E&M codes specified in the regulation (99201-99499 and vaccines)

Higher payment also made for primary care services rendered by practictioners working under the personal supervision of a qualifying physician

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ACA Payment Increase for Primary Care

Considerations

1. DHS estimated this provision resulted in additional $229 million in federal payments over 2 years.

2. The federal government discontinued the rate increase beyond December 2014.

3. WHA Advocacy: Absent federal reimbursement, a targeted reimbursement could be considered at a level lower than the federal reimbursement or for targeted codes.

4. Rationale: Increased ED utilization as a result of 2014 changes

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So where are we today?1. Access to Coverage

• More coverage in Exchange and Medicaid • Waiting for King v Burwell• Impacts of Premiums/Cost Sharing (overall UC impacts)

2. Health Insurance Reform –• Open Enrollment Period 3 coming up• Network Adequacy and Transparency = Hot Topics

3. New care delivery and financing methods • Quality remains critical – continuously refining quality measures• Continued focus on reducing costs, reviewing processes for efficiencies

4. Adequate Access to Care • Adequate workforce – including primary care critical• Will ED usage start to decrease?

• Wisconsin hospitals and health systems are providing high value care that shows Wisconsin continues to perform high in the area of Quality:

• AHRQ Ranking• HCAHP Scores

AHRQ Quality Report

So Where are We Today?