May 2012 FLI Expanding Access and Choice for Your Patients: A Description of How the Affordable Care Act is Important to the Naturopathic Physician Hon. Deborah Senn May 5, 2012
3 Minute UniversityThe Affordable Care ActMinute #1 Reforming the current insurance market • Pre-existing conditions 2014 (exc. kids) • Portability 2014 • Guaranteed renewability 2014 • No lifetime policy limits 2010 • Annual limits--restricted 2010 • Dependent Coverage (under 26) 2010 • No Rescission 2010 • High Risk Pools 2010
Minute #2Insurance Reforms cont. • Medical Loss Ratio and rate review 2011 • Independent appeal process 2010 • Coverage of Preventive services 2010 • Close Medicare donut hole 2010 • Essential Benefits Package* 2011 • Sec. 2706 Anti-discrimination*2014 • Sec. 3205 Medical Homes*2014 • Workforce Definition*
Minute #3Expanding coverage--expanding the pool • Exchanges—established by states 2014 • Exchanges provide tiers of basic health services: bronze, silver, gold, platinum, • Individual mandate 2014 (penalty if not covered) linked to: subsidies in the exchange • Tax provisions--many
New Law effective January 2014Section 2706 • A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.
New Law con’t. • This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”
Washington state law: 1993 • (1) Every health plan delivered, issued for delivery, or renewed by a health carrier on and after January 1, 1996, shall: (a) Permit every category of health care provider to provide health services or care for conditions included in the basic health plan services to the extent that: (i) The provision of such health services or care is within the health care providers' permitted scope of practice; and
Implementation Misconceptions • Too expensive (statement of Blue Shield counsel) • How to credential • Challenging law in court • Excluding entire groups of licensed providers • Limiting on number of visits or scope of practice • Capping dollar amount of coverage • Inadequate network of providers • PCP Referral requirements for CAM only
CAM Provider Impact • Problem provider Contracts • Using subcontractors (sometimes illegally) • Failure to comply with state contract req. • Failure to notify providers of duties and responsibilities under the contract • Failure to disclose termination or audit procedures or have an adequate grievance procedure • Illegal termination practices • No provider manual • Untimely payments--burdensome documentation
Good News-Regence studyCompetition and Cost advantage • There is significant potential to control costs with alternative healthcare. There is mounting evidence that practitioners of alternative therapies can be highly cost-effective relative to conventional providers at treating several increasingly pervasive chronic and stress related conditions
Regence Study cont. • (savings of 30% and more have been found in recent European outcome studies) such as heart disease chronic pain, respiratory illness, diabetes…which are major cost drivers in the health care system and for which conventional medicine has less cost-effective treatments.
More Recent Studies • CAM users averaged $1,420 less in annual health care expenditures than nonusers in patients with the heaviest disease burden • Corporate health management programs associated with prevention and wellness showed a 26% reduction in health care costs and a $5.81-$6 returned for every $1 invested4
More Recent Studies cont. • Median per-visit expenditures were $39.00 for CAM care and $74.40 for conventional outpatient care in Washington. The total expenditures per enrollee were $2,589, of which only $75 (2.9%) was spent on CAM. • A systematic review of cost benefit analyses of CAM compared to conventional care revealed 42% of the published studies showed cost savings
The Way Forward • Where is the process? • Rules • HHS • Labor • Treasury • Essential benefits package • Exchanges