Post on 10-Aug-2015
ACA: Evidence-Based Update
Seth Trueger, MD, MPH
Assistant ProfessorEmergency MedicineUniversity of Chicago@MDaware
DISCLOSURES
Emergency Physicians MonthlyMedical Society of Virginia Foundation
Heart Course: EmergencyDaiichi Sankyo
Medical College of Wisconsin
(bias?)
PlanEnrollment & Penalties
Subsidies/CSR
Plans (premiums, OOPs, networks)
Expansion (states, DSH)
Provider impact
Payment reform (ACOs, HRRP, HVBP)
ENROLLMENTstolen mostly from Charles Gaba
2015 Enrollment
Marketplaces
Medicaid
2015 Enrollment
Marketplaces
2015 Enrollment
11 million paid QHP
2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
2015 Enrollment
Medicaid
2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
3.4 million Medicaid woodworkers
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
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
RAND study
net increase of 16.9 million
RAND study
net increase of 16.9 million
22.8 million newly insured
RAND study
net increase of 16.9 million
22.8 million newly insured
5.9 million lost coverage
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
insurance gains
9.6 million increase in employer plans
1.5 million other
(Medicare, military insurance, state
plans)
individual mandate?
individual mandate?
improving economy/employment?
5.9 million lost coverage
5.9 million lost coverage
24.6 million moved from one source of
insurance to another
5.9 million lost coverage
24.6 million moved from one source of
insurance to another
doi: 10.1377/hlthaff.22.6.244
doi: 10.1377/hlthaff.2010.1000
28 million
Medicaid
Exchanges
28 million
Medicaid
Exchanges
income fluctuations around 100-133% FPL
38% churn 4x or more
3 months of coverage=
no penalty
who is paying penalties?
who owes at tax time?
individual mandate?
CBO: 87% of uninsured exempt
individual mandate?
CBO: 87% of uninsured exemptmostly hardship exemptions
individual mandate?
CBO: 87% of uninsured exemptmostly hardship exemptions
Treasury: 3-6 million penalties
April 2015 tax time
IRS reconciliation
IRS reconciliation50-65% owe
$729 (4.5-7.5 million)
IRS reconciliation50-65% owe
$729 (4.5-7.5 million)
25-45%refund$425
ObamaCare
INSURANCE
ObamaCare
INSURANCE
“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.”
“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.”
“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.”
EMPLOYER SPONSORED INSURANCE
UNINSURED
MEDICAID
MARKETPLACES & OFF EXCHANGE
SUBSIDIESwe are the forty seven percent
Premium Subsidies
85%per CMS
$272 /mo
Premium Subsidies
$272 /mo
$3,264 /yr
Premium Subsidies
$272 /mo
$3,264 /yr
$33 billion
Premium Subsidies
$272 /mo
$3,264 /yr
$33 billion$3 trillion /yr
Premium Subsidies
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
<400% FPL
64%
<400% FPL
64%
>200 million
<400% FPL
64%
>200 million
such Exchanges
or
or
or
or
?
CSRs
Cost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)
CSRs
earlier: premium subsidies
CSRs
earlier: premium subsidiesmonthly bill
CSRs
earlier: premium subsidiesmonthly bill400% FPL
CSRs
earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
CSRs
earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use
CSRs
earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPL
CSRs
earlier: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPLonly Silver+ (not cheaper
Bronze)
CSRs
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
CSR uptake
CSR uptake
WHAT PLANS?aka skin in the game
premiums vs pre-ACA
MLR
EHB
OOP limits
no annual limits
no preexisting conditions
Home Depot
premiums vs pre-ACA
MLR
EHB
OOP limits
no annual limits
no preexisting conditions
Home Depot
premiums vs pre-ACA
my take2014 rates were low
my take2014 rates were low
“subsidy equilibrium”
my take2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
my take2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
deductibles??
deductibles = evil?
deductibles = evil?skin in the game?
3 issues
not w/o value (e.g. preventative
services)
3 issues
not w/o value (e.g. preventative
services)
100% insured after
3 issues
not w/o value (e.g. preventative
services)
100% insured after
compare employer sponsored
insurance
$15-17k
EXPANSIONsome maps & DSH
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
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)
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)
DSH
DSH
DisproportionateShareHospitals
DSHFederal $ states hospitals
DSHFederal $ states hospitalsMedicaid + uninsured
DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:
DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:fewer uninsured decrease DSH
DSHFederal $ states hospitalsMedicaid + uninsured$17.4 billion (2011)
ACA:fewer uninsured decrease DSHpay for ACA
billion $
2018 2
2019 3
2020 4
2021 5
2022 6
2023 7
2024 8
2025 8
DSH
93% of $ large urban hospitals
65% of $ teaching hospitals
6300 hospitals
6300 hospitals
3100 DSH
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
225 DSH reliant
+weak
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
529 DSH reliant 551 weak
225 DSH reliant
+weak
307 bad mix
6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH State
551 weak307 bad
mix 225 DSH reliant
+weak
529 DSH reliant
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
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
most vulnerable
big urban hospitals
bad payer mixes
non-expansion states
PROVIDER IMPACThospitals and physicians
2014 - 2022
$2.757 trillion in overhead
ACA: $273.6 billionnew private insurance$172.2 billion
“Most of this soaring private insurance
overhead is attributable to rising
enrollment in private plans which carry
high costs for administration and
profits.”
overhead
MLR
Medicare Advantage
Managed Medicaid
22% Private
14% MA
9% Medicaid
2% Medicare
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
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
PAYING FOR QUALITYACO APM P4P PQRS HRRP HVBP MSSP & MORE
early experiences
data lacking
mixed messages
Peter Viccellio
Peter Viccellio@MDaware tweet #6, 1 June 2011, SAEM (67K)
ACOs
Accountable
Care
Organizations
FFS vs bundle
FFS
ECG
FFS
ECG CXR
FFS
ECG CXR lab
FFS
ECG CXR lab admit
FFS vs bundle
ECG CXR lab admit
ACOs
FFS vs bundle
ECG CXR lab admit
ACO:
retain FFS
some CQM
shared savings
ACOs
mixed
some good
Pioneers
32 systems
13 quit
Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million
$380 million
$36 pmpm vs $11 pmpm
Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million
$380 million total savings
$36 pmpm vs $11 pmpm
Readmissions
Readmissions
outpatient networkincentives
Readmissions
outpatient networkincentives
nearly 20%
Readmissions
outpatient networkincentives
nearly 20%
down 1.1%
penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/
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/
penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?
penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?
surgical?
HVBP differences
safety nets get penalized more
HVBP differences
safety nets get penalized more
…$12k/hospital
Hello, MIPS
ntrueger@gmail.com@MDaware