Date post: | 27-Jan-2017 |
Category: |
Health & Medicine |
Upload: | cedric-dark |
View: | 269 times |
Download: | 0 times |
Seth Trueger MD MPHUniversity of Chicago @MDaware
ACA: Evidence-Based Update
DISCLOSURES
Emergency Physicians Monthly
(bias?)
PlanENROLLMENT stats, uninsured
PLANS premiums, deductiblesnarrow networks, balance
billing
SCOTUS Zubik, House v Burwell
PAY/QUALITY readmits v obs, MACRA
ENROLLMENTstolen mostly from Charles Gaba
Kaiser Family Foundation. Health Insurance Coverage in the US, 2011.Kaiser Slides. 19 October 2012.
Medicaid, 13%
VA/Other, 5%
Medicare, 13%
Private, Non-group, 5%
Employer-Sponsored Insurance,
49%
Uninsured, 16%2011
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Medicaid, 19%
VA/other, 6%
Medicare, 17%
Private, Non-group, 6%
Employer-Sponsored Insurance,
43%
Uninsured, 9%2016
Medicaid, 13%
Medicare, 13%
Private, Non-group, 5%
Employer-Sponsored Insurance,
49%
Uninsured, 16%Medicaid, 1319% VA/other, 6%
Medicare, 1317%
Private, Non-group, 56%
Employer-Spon-sored Insurance,
4843%
Uninsured, 169%
20112016
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Medicaid, 19%
VA/other, 6%
Medicare, 17%
Private, Non-group, 6%
Employer-Sponsored Insurance,
43%
Uninsured, 9%2016
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
http://ccf.georgetown.edu/ccf-resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Household 138% FPL 400% FPL1 $16,242 $47,080 2 $21,983 $63,720 3 $27,724 $80,360 4 $33,465 $97,000 5 $39,205 $113,640
2016 Enrollment
MarketplacesMedicaid
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
2015 Enrollment11 million paid QHP9 million off-Exchange QHP
2015 Enrollment11 million paid QHP9 million off-Exchange QHP
2016 Enrollment11 million Exchange QHP6 million off-Exchange QHP2 million off-Exchange grandfathered
2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers
2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers
2016 Medicaid11 million Medicaid expansion3.8 million Medicaid woodworkers0.5 million Basic Health Plan
“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
UNINSURED
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
MEDICAID EXPANSION
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
Adopted (32 States including DC)
Not Adopting At This Time (19 States)
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf
Exchange enrollment by income
20140%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12%
38%
70%83%
56%
http://kff.org/slideshow/employer-sponsored-insurance-offer-and-coverage-rates/
<100FPL
100-250%
250-400%
>400%
<65yo
ESI by income
PMID 27076474
vs no ACA?18.1 million reduction in uninsured46% reduction (nonelderly)
PLANSpremiums deductibles narrow networks oh my
my take2014 rates were low
“subsidy equilibrium”rate increase requests ≠ rate increases
deductibles??
lower premiums?
“Under the law, no one can be denied coverage because of a pre-existing medical condition.”
BAD THING OTHER BAD THING
NOT BECAUSE OF OBAMACARE
BECAUSEOBAMACARE
MAG
NITU
DE
TIME
OBAMACAREBEGAN
narrow networks
balance billing
balance billingout of network ED
balance billingout of network EDinsurance has to pay
balance billingout of network EDinsurance has to payhow much?
balance billingout of network EDinsurance has to payhow much?ED bill balance
$?
$?
$?$
$?$
$
$?$
$
EMTALA
$?$
$
EMTALA
SCOTUSZubik v Burwell & House v Burwell
Zubik v Burwell
Zubik v BurwellLittle Sisters
Zubik v BurwellLittle SistersOCPs
Zubik v BurwellLittle SistersOCPs2 page form
Zubik v BurwellLittle SistersOCPs2 page formduck
House v Burwell
CSRsCost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)
above: premium subsidiesmonthly bill400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use250% FPLonly Silver+ (not cheaper
Bronze)
CSRs
CSR uptake
CSR uptake
X
X
X
X
X
¯\_(ツ )_/¯
PAYING FOR QUALITYthe card says MIPS
Readmissions
Readmissions
outpatient networkincentives
Readmissions
outpatient networkincentives
20%!
PMID: 26910198
Readmissions
outpatient networkincentives
21.5% 17.8%15.3% 13.1%
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 $100-300k2013: 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/
Readmission penalties?risk adjustment
socioeconomic status
¯\_(ツ )_/¯
Readmission penalties?hiding in observation?
¯\_(ツ )_/¯
PMID: 26910198
MIPS APMFFS + P4P
ACO, CMMIbundles
2019 ±4% 5% bonus2020 ±5% 5% bonus2021 ±7% 5% bonus2022 ±9% 5% bonus2023 ±9% 5% bonus2024 ±9% 5% bonus2025 ±9% 5% bonus2026+ 0.25%+ baseline
annually0.75%+ baseline
annually
¯\_(ツ )_/¯
[email protected]@MDaware