The ACA Five- Years Later

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The ACA Five- Years Later

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The ACA Five- Years Later An Update on Health Care Reform Al Heuer, PhD, MBA, RRT, RPFT Professor & Program Director Rutgers School of Health Related Professions – PowerPoint PPT presentation

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Title: The ACA Five- Years Later

1
The ACA Five- Years LaterAn Update on Health
Care Reform

Al Heuer, PhD, MBA, RRT, RPFT
Professor Program Director
Rutgers School of Health Related Professions

2
Learning Objectives

Summarize Key Facts about Our Health Care System
Review the History Legislative Process of
Health Care Reform
Summarize the Some Major Features of the Law.
Describe the Reality of Its Impact on
Us as Clinicians and Consumers
Health Care Organizations
Review Future Implications
Furnish Additional Resources

3
US Health Care SystemThe Best the Worst

Strengths
Strong Investment in Technology Research
Safety Net for Elderly, Disabled Disadvantaged.
Weaknesses
Cost
In 2010. 47 mil. (16) of Americans were
Uninsured
Unequal access to care
Uneven clinical outcomes
Health catastrophes are leading cause of U.S.
bankruptcies.
Inefficient use of services
ER as primary care
Futile CareWe dont know how to say no mas!

4
Health Care Systems of Other Countries

US Health Care cost twice that of other developed
countries approximates 6th largest national GDP.
Universal Health Care - Canada-national public
policy provides disincentives for using private
health insurance.
National Health Care-England-National Health
Service founded in 1948. Co-lateral private
health insurance is allowed.
Germany spends approx. 10 of its GDP on
Health Care 5-6 for many European countries

5
Initial Attempts at Reform

FDR wanted national health care to be included in
the 1935 Social Security Act.
President Truman attempted to initiate a national
health care insurance program.
Was on Jimmy Carters agenda.
1993 Hillary Clinton Ultimately unsuccessful,
largely due to insurance industry opposition.

6
Contentious Political Process for This Law

President Obamas 2010 budget set aside 600
Billion for Health Care reform.
July 15, 2009 - Senate Health Committee passes
its bill.
August/Sept. - White House loses control of the
debate.
November 2009 - Dems introduce new Senate bill,
including an increased payroll tax on the
wealthy.
December 2009 - 25 day debate in the Senate.
February 2010 - Bi-Partisan summit with Obama.
March 2010 - To avoid a Senate Republican
filibuster, House passes the Senate version with
sidecar of fixes.
Final Votes House 228-207 Senate 56-43.
Signed into Law March 23, 2010. (974 pages long)

7
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8
Features of the Bill Impact Many Stakeholders
9
Initial Features of the Bill - Individuals

Mandates that all Americans have Health
Insurance.
Creates Health Insurance Exchanges for
Uninsured
Self-employed
Subsidies for low-income individuals/families
(133 to 400 of the poverty level).
Expands Medicaid coverage.
Prescription Donut Hole Rebate, Fills some of
the limits for prescriptions under Medicare.

10
Initial Features of the Bill - Individuals (cont.)

Must cover preventative care, including checks
ups with no deductible.
Asthma management
Smoking cessation
Coverage for adults with pre-existing conditions.
Young adults can continue on parents plan until
age 26.
Mandated Coverage Penalty of 695/Indiv. in
2016.

11
Features of the Bill - Small Businesses

Creates similar exchanges for small-medium sized
businesses.
Small Business tax Credits 50 of health ins.
premiums applied as credits for businesses with
less than 50 employees.
Companies with 50 or more employees must cover
95 of full-time employees by 2016.

12
Initial Features of the Bill - Insurance Companies

End of Rescissions-Insurance Cos cant cut
someone when he/she gets sick.
Insurance Company Transparency-Must reveal amount
spent on overhead.
Higher loss-ratio requirements (now 85) for
insurance companies to take advantage of tax
benefits.
Customer Appeals-Any new plan must implement an
appeal process for coverage determinations and
claims.
40 tax on insurance companies offering Cadillac
H.I. Plans.

13
Initial Features of the Bill Hospitals
Doctors Practices

Decreases Medicare coverage but Temporarily
increased reimbursements for general practice
physicians/surgeons.
Medicare payt protections extended to rural
hospitals.

14
Value over VolumePay-For-Performance (P4P)

ACA Re-Emphasizes Emerging Themes

15
What Does Value over Volume Mean to an RT?

Old Philosophy If a patient stays on a
ventilator longer or has a stay, thats is good
for our Job Security!
New Philosophy - Fewer Vent Days, shorter LOS
and Happier patients are Rewarded!
How does this work?

16
The Answer The ACAs Value-Based Purchasing
Provision

Value Based Purchasing Program (VBP)
Begin to pay hospitals for their actual
performance
Requires a portion of Medicare reimbursement to
be withheld and returned in proportion to how the
Hospital performs, Initially in 3, Now in 4
Categories.

17
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18
Soooo, VBP Can Reward Clinicians for Contributing
to Better Outcomes!

Patient weans off ventilator sooner.
Shorter LOS.
Better clinical outcome and happier patient means
higher VBP performance.
Better VBP performance means more reimbursement
to the hospital.
More reimbursement means more for resources,
including staff, equipment

19
ACA created the HRRP, which will reduce
Medicare payment rates for hospitals with higher
than expected readmission rates for specific
conditions.

Another Form of Pay-for Performance The
Hospital Readmission Reduction Program (HRRP)

20
Conditions Covered Under HRRP

Initial 2013 Conditions
Acute Myocardial
Infarction (AMI)
Heart Failure
Pneumonia

2015 Expansion
COPD
Coronary Bypass Surgery-
Coronary Angioplasty
Other Vascular Conditions

21
Shhh! Dont Say Frequent Flyer!, HRRP Rewards
Less Frequent Flying and Heres How!

Patient is admitted but gets enrolled in a
Re-admission Reduction Protocol
Patient gets educated about their condition and
the importance of adhering to their Tx. plan.
Potential barrier to successful discharge are
addressed and post discharge follow-up done.
Patient stays out of the hospital.
Better HRRP performance means more
reimbursement to the hospital.
More reimbursement means more for resources,
including staff, equipment, etc.

22
Changing ReimbursementPay-For-Performance
Payment Reform for Hospitals
Fiscal Year Value Based Purchasing Hospital Readmission Reduction Program Hospital Acquired Conditions Total
2013 1.00 1.00 0 2.00
2014 1.25 2.00 0 3.25
2015 1.50 3.00 1.00 5.50
2016 1.75 3.00 1.00 5.75
2017 2.00 3.00 1.00 6.00
.
Alexander, K.,LHA Legislative regulatory
Update. LA Assn for Healthcare Quality Annual
Education Conference, April 2012
23
2013 (Interim) Reimbursement PenaltiesThe Facts

2,211 American hospitals received reimbursement
penalties for high readmission rates
Together they will forfeit about 280 million in
Medicare funds over next year
According to Medicare, 2 out of 3 hospitals
evaluated failed to meet its new standards for
preventing 30 day readmissions.
Hence, more hospitals lost than gained.

24
Five years Later-- Public Remains Divided on ACA

Late June 2015
Favorable 43
Unfavorable 40

25
Other Realities -- ACA--Five Years Later Health
Ins. Coverage

15 million Fewer uninsured individuals since 2010
But, 35 million Individuals still without
insurance
Most gains are from expanded Medicaid expansion
12 million More people enrolled in Medicaid since
2010.

26
Health Ins. Coverage - Reality

5.8 million people gained coverage in the
individual market.
4.9 million individuals lost employer coverage
during the same period.
In other words, for that period in which raw
data are available, almost 90 of coverage gains
were in the Medicaid program.

Fewer Adults Without Health
Insurance

28
Why do we Care About Medicaid Expansion???

Positive
More Americans are Covered!!!
All adults up to 133 of the FPL will gain
Medicaid coverage.
Should promote healthier life styles--Example
Starting in 2014, Medicaid programs that provide
prescription drugs must cover tobacco cessation
medications.
Those who are low-income and uninsured are more
likely to use tobacco.
These enrollees will now have access to six
cessation counseling sessions a year.
Negative
Possible Influx of Insureds with poor health.
Incentives to Primary Care Physicians to
Accept Medicaid are running out.
Cost of expanded Medicaid passed onto tax
payers?

29
ACAPositives Five Years Later - Individuals

2.3 million young adults gained coverage from
2010 through Sept. 2013 by staying on their
parents' plan.
11 million Individuals have insurance through a
state or federal exchanges.
7.7 million Individuals receiving tax subsidies
for coverage through an exchange.

30
ACANegatives Five Years Later - Individuals

900,000 Americans individual or
employer-sponsored health policies were cancelled
for 2015 because they did not comply with the
ACA.
Individual Premiums have increased dramatically.
1 in 2 Number of American households eligible for
a premium subsidy in 2014, paid some money back
to the government in 2015 because of income
changes
794 Estimated average payment these households
will owe the government in 2015.

31
ACA--Five Years Later Large Corporations

Group Health Insurance Premiums have Skyrocketed.
Corporations with 50 Employees must provide
Health Insurance to 95 of emplyees
Both of the Above have caused Corporations to
Be cautious in hiring
If they do hire, keeping hours below 30/wk.
Sent more job overseas
Future uncertainties have curbed other forms of
corporate spending

32
Accountable Care Organizations (ACOs)

In section 2706 3022 of the ACA
An ACO is a network of physicians, hospitals, and
other health providers that collaborate to
improve care and reduce costs for Medicare
participants.
The ACA, created a shared savings program,
providing incentive payments for improving
quality and reducing cost.
A Pioneer ACO--one which has experience in
coordinating care across settings.

33
Accountable Care Organizations (ACOs)- The 2014
Results

97 ACOs qualified to share in savings by meeting
quality and cost benchmarks earned a total
shared savings of more than 422 mil.
The results indicate ACOs improve over time 37
percent of the ACOs that launched in 2012
generated shared savings
compared to 27 in 2013
and 19 in 2014.
ACOs also improved on quality compared to 2013.
ACOs that reported in both preceding years showed
improvement in 27 out of the 33 quality measures
Clinician-patient communication
Patient ratings of physicians
Tobacco Blood Pressure Screening
EHR use
4. The program is still receiving strong
interest and CMS plans to announce new and
renewing ACOs.

34
ACOs-Why Should you Care?

May explain increased emphasis on
interprofessional collaboration between and among
disciplines/care settings.
Better coordination better outcomes.
If your organization is receiving shared savings,
theres more for staffing, supplies, equip.
education.
Can counteract reductions elsewhere, from VBP,
Short-term Re-admit penalties, and reimburse.
reductions.

35
Meaningful Use the ACA

Health Care Organizations receive incentives and
beginning in 2015 penalties for demonstrating
that they are meaningfully using Electronic
Health Records (EHRs).
Meaningful Use was Actually Created by the Health
Information Technology for Economic Clinical
Health (HITECH) Act (2009), not the ACA.
Grants and other incentives are in the ACA to
promote health information technology
enhancements.

36
EHRs Meaningful Use

Stage 1 -- 2011-2012
Electronic capturing of health info.
Initial reporting of clinical quality measures.
Using information to Track Clinical Conditions.
Stage 2 2014
Increased requirements for e-prescribing and
incorporating lab results.
Electronic transmission of patient care summaries
across multiple settings
Stage 3 2016
Improving quality, safety, and efficiency,
leading to improved health.
Patient access to self-management tools.

37
Meaningful Use Financial Incentives

Through 2014, 44K-66K per physician in
financial incentives meeting the criteria.
Approx. 50-60 of health care facilities fail to
show that they are using the system in a
meaningful way
Penalties for Failing to Demonstrate Meaningful
Use
2015 2016 -- 1-2 reimb. penalty
2017-- 3 reimb. penalty
2018 -- 4
2019 -- 5

1-2 reimb. penalty
38
Meaningful Use Why Should Clinicians Care?

Explains changes to Elec. Health Records (EHR)
and Computer Physician Order Entry (CPOE) at your
institution.
If you organization is receiving Incentives (or
avoiding penalties), they will have more for
staffing, equip
May have a positive Impact of other Measures
Patient Satisfaction
Can counteract reductions elsewhere (e.g., VBP,
S/T Re-admit penalties, etc.

39
Meaningful Use Why Else Should Clinicians Care?

Meaningful Use (Stage 3) promotes Telemedicine
and Digital Resource Development and other
similar
Stage 3 Criteria Outcomes for Improving
quality, safety, and efficiency, leading to
improved health outcomes.
Applications in Respiratory Care
Virtual Pulmonary Rehabilitation Progs.
Digital Disease ManagementCOPD, Asthma
Computerized Educational Resources
Care Plan Compliance Monitoring
Smoking Cessation Aids

40
Original ProjectionsPaying for the Plan

Increased Medicare Tax for Singles earning gt
200K and Couples gt 250K. (Beginning 2013)
From 1.45 to 2.35 on earned income
New 3.8 tax on interest, capital gains.
W-2 reporting of employer H.I. Premium value.
Will this lead to future taxing of those
benefits?
Reductions for Medical Expense Itemization.
From expenses over 7.5 earned income to over
10 earned income.
Medicare Reductions.

41
Original Claims -- The ACA Would be A Deficit
Reducer

Actually President and congress claims it will!
OMB estimates savings of 138 Billion over 1st 10
years 1.2 Trillion over next 10 years.
Reality is Appearing Different.

42
Reality--Paying for the Bill

Reality
Consumers have experienced sharp, double-digit
premium increases, combined with breathtaking
increases in their deductibles.
The law locks in massive entitlement spending,
last estimated at 1.7 trillion over the next 10
years.
Exchanges are 21.5 less competitive (offer few
choices)

Claim
Health reform would reduce the typical family's
healthcare costs by 2,500 a year
The law is a deficit reducer.
Health Exchanges will increase competition and
lower premiums

43
Other Looming Concerns

Many provisions didnt activate until 2013-15.
Little to no mention of Tort Reform, governing
Med-Mal Lawsuits.
Some only apply to new insurance companies.
Originally was to tax cosmetic surgery, but due
to apparent lobbying efforts, will tax tanning
shops instead.

44
The Future of the ACA?