Today’s Presentation

1. The Affordable Care Act in West Virginia: An UpdateMay 15, 2014HFMA ConferenceStonewall Resorts

2. Today’s Presentation • Review the four major provisions of the Affordable Care Act (ACA) • Where does reform go from here? • Q&A

3. ACA Has Four Main Goals • Strong regulations of the insurance industry • Renewed emphasis on prevention • Expands health insurance • System improvements

4. Regulations of the insurance industry • Young adults can stay on their parents’ policy until age 26 • End to annual and lifetime cap on benefits • End to gender rating • End to pre-existing conditions

5. Prevention • US Preventive Services Task Force recommended A and B services required to be covered without cost sharing in: • Medicare • Most private insurance plans • Grandfathered plans are exempt

6. Preventive measures forwomen

7. Additional Preventive Measures for Women • All new plans must provide women with preventive measures with no cost sharing: • All FDA approved contraceptives • Well-woman visit for women under 65 • Domestic violence screening and counseling • Breastfeeding support and supplies

8. Health Insurance Coverage Is Expanded In Two Ways • Medicaid is expanded to cover everyone under 138% of the federal poverty level who is under age 65. • New Health Insurance Marketplaces are created for subsidized, private insurance products.

9. New Coverage Options

10. Medicaid Expansion: Income Eligibility for a Family of Three

11. 2014 Income Eligibilityfor Medicaid

12. Medicaid Expansion: A Huge Success Story • An estimated 133,500 low-income West Virginians became eligible for coverageJanuary 1st • 117,658 enrolled as of May 3th, or 88% of those eligible enrolled in 7 months. West Virginia is the national leader in enrollment

13. Health Insurance Marketplace • A marketplace offers private health insurance policies • Policies offered through a web site, 1-800 number, by mail or with personal assistance

14. Health Insurance Marketplace • The marketplace is open to individuals who do not have health insurance (generally) • Significant tax credits for individuals between 100% and 400% of the FPL.

15. Subsidy for family of 4 earning $40,000(170% of FPL) Policy Cost = $753 Family Pays = $168 Govt. Subsidy = $585 (78%) $750 & $1,500 deductible And $1,500 & $3,000 out of pocket maximum 15

16. Marketplace Enrollment • Although nationally 8 million Americans selected a qualified health plan, only about 25,000 West Virginians did -- about 25% of those eligible • Those who did enroll in West Virginia were older than the national average

17. Reasons for the low enrollment • Costs of the plans, particularly for those earning more than 200% of the federal poverty level ($23,340 for an individual and $39,580 for a family of three) • Lack of a media campaign

18. Where Does Reform Go from Here • Enrollment continues for Medicaid • Special Enrollment continue • Next open enrollment is November 15th through February 15th • Focus on system improvements

19. System Improvement: Why Its Needed • 20% of US total health care cost is waste, including: • $102 billion in failure of the delivery of care (e.g., lack of widespread adoption of best care practices) and • $158 billion in overtreatment (e.g., overuse of antibiotics) Source: Berwick & Hackbarth, JAMA, 2012;307(14):1515-1516

20. System Improvement: Why It’s Needed “The current (payment) system, based on volume and intensity, does not disincentivize, but rather pays more for overuse and fragmentation.” Mark McClellan

21. ACA: Improving Quality to Containment Costs • Moving away from fee for service. Examples include: • Reduce payment for high incident of hospital acquired conditions • High incident of hospital readmission

22. System Improvements • Accountable Care Organizations • Center for Medicare and Medicaid Innovation • Emphasis on primary care • Doubling appropriations for FQHCs • Doubling appropriations for National Health Services Corp

23. Patient-Centered Medical Homes • PCMH are a team approach to providing primary care to people with chronic illnesses • The team could be led by a physician or nurse practitioner and includes pharmacist, social workers and other professional

24. Patient-Centered Medical Homes • PCMH need coordination among payers: • Focus on the same chronic illnesses • Identical reporting requirements • Similar reimbursement methods

25. System Improvement Needs • Gubernatorial leadership • Legislative leadership • Administrative leadership • Payer leadership • Provider leadership • Consumer involvement

26. Choosing Wisely: A Physician Led Reform • Choosing Wisely was started by the National Alliance of Physicians when three physician organization each submit 5 procedures in their area of expertise that have questionable value

27. Choosing Wisely • Choosing Wisely is now operated by the American Board of Internal Medicine Foundation and has identified 270 low-value procedures from more than 50 physician organizations

28. Choosing Wisely • Examples include: • Using antibiotics for a viral infection is ineffective and potentially harmful • Don’t order imaging for uncomplicated low-back pain • Use Pap test appropriately • Imaging for headaches is ineffective

29. Choosing Wisely • Consumer Reports has written 31 two-page summaries for consumers on these low-value procedures plus other helpful discussion guides for consumers

30. Consumer Reports Five Questions to Ask Your Physician • Do I really need this procedure? • What are the risks? • Are there simpler, safer options? • What happens if I don’t do anything? • How much does it cost?

31. Choosing Wisely in West Virginia • Coalition of providers, consumers, payers and state agencies working to engage providers and consumers on avoiding low-value procedures

32. Choosing Wisely in West Virginia • Provider organizations likely to be early adopters, include: • WV Primary Care Association • WV Association of Free Clinics • WV Academy of Pediatrics • Perinatal Partnership

33. Choosing Wisely in West Virginia • WVAHC has become a partner with Consumer Reports for the Choosing Wisely initiative • WVAHC’s goal is to distribute 50,000 two-page summaries to physician offices across the state

34. Challenges • Evaluation: currently only process evaluations have been identified. Real goals is to reduce the number of inappropriate low-value procedures. Appropriateness of procedures makes claims data inadequate.

35. Challenges • Changing physician behavior is difficult, particularly for dispersed, independently practicing physicians.

36. Challenges • Reaching the subset of 1.8 million West Virginians who may use low-value procedures is difficult. • Messaging that more health care is not necessarily better health care is counter-intuitive.

37. Contact Information Perry Bryant perrybryant@sudddenlink.net 304-344-1673 (Office) www.wvahc.org