"Market Disruption: Can the ACAsInsurance Reforms Support Primary Care?"
Disruption• AAFP policy: Healthcare for All …. Everyone in the United States will have health care coverage - here’s our opportunity!• Harvard Business School professor’s theory; disruptive innovation helps create a new market, and eventually goes on to disrupt an existing one, displacing an earlier version.
Setting the Bar for Innovation“Health insurance exchanges must require thatparticipating plans provide access to team-based, coordinated primary health care if theyare to successfully improve outcomes, addresshealth care disparities and bend the costcurve.” – Lori Heim, MD, 2009 President American Academy of Family Physicians
AAFP weighs in on developing exchanges1. Fair Representation of Stakeholders2. Payment for PCMH & Enhanced Access3. Standardized Contracting4. Set Primary Care Targets5. Require Robust Primary Care-BasedEssential Benefits6. Presume Eligibility7. Reward Quality8. Protect Consumers & Physicians
How will Family Medicine make a difference?• On Oct. 6th, IOM’s report “Essential Health Benefits: Balancing Coverage and Cost emphasized finding the right balance between making a breadth of coverage available for individuals at a cost they could afford• As HHS defines this package of essential health benefits, let’s remind them: primary care physicians = lower cost and higher quality
National Academy for State Health Policy“No wrong door” - ACA’s simplified enrollmentvision: integrated and seamless eligibilitysystems, electronic data sharing and minimumdocumentation burdens.Some call it radical simplification*Paving an Enrollment Superhighway: Bridging State Gaps Between2014 and Today – March 2011
How will exchanges work with Medicaid?• coordinate with state Medicaid and CHIP agencies to develop specific transition procedures, particularly for enrollee populations with significant health care needs• develop procedures for coordinating plan payments in the event that changes in individual or family income result in a change in eligibility for Medicaid during an enrollment period
Other Factors in Seamless Coverage• Continuity of care will depend on what is designated as a qualified health plan (QHP)• Providers will have to be accepting of all the QHPs AND Medicaid• Challenge will be to elevate the stature of Medicaid in order to coordinate better with health plans
Who’s impacted in Illinois?• Currently, 700,000 individuals without health insurance will have coverage by 2014• By 2020, a projected 1.4 million Illinoisans will get coverage through the insurance exchange• The percentage of Illinois residents without health insurance will decrease from 12% currently to a projected 7% in 2020 (the remaining uninsured will be primarily those who do not seek coverage or are undocumented)
What does IL AFP want?We want the exchange to have themandate and the power to ensure thatconsumers get the best possible rates forgood insurance. Period.Here’s how we’re involved to make ithappen …..
Engaged in the DialogueIL AFP shared its views with:• The health advocates coalition• IL Dept. of Insurance• IL Attorney General• IL General Assembly members• A Legislative Study Task Force appointed by the IL Commission on Government Forecasting and Accountability (COGFA)
What did we say?• Shared a customized version of AAFP’s Principles with all stakeholders• Submitted written testimony and provided written comments to the Study Committee’s report• Stated that Illinois should have the power to expand the requirements for plans participating in the Exchange beyond the minimum federal requirements
NO assessment on providers• Budget-strapped states, such as Illinois, should:• optimize the flow of federal funds coming into the state.• leverage its Medicaid program to finance the Exchange administration– so by including Medicaid plans and providers, the state would be bringing in more federal dollars to support the Health Benefits Exchange.• levying an assessment on providers where Medicaid provider rates are low is NOT an option.
Will exchanges make life better or worse ?• As small business owners: – many family physicians will shop the exchange for their practice – potential to increase a practice’s bottom line• As clinicians: – those purchasing coverage are likely to be relatively older, less educated, and more racially diverse and report to have poorer health, but have fewer diagnosed conditions than those who currently have private insurance
Aligning GoalsFamily Medicine HHS’ Triple Aim• Improving quality of • Improving care care• Requiring primary care- • Promoting health based essential benefits• Primary care = lower • Reducing overall system costs costs
How to engage and prepare• This “market disruption” will create an array of new insurance products.• Consumers will have “navigators” helping them, but who’ll be the docs’ navigator?• Here are some important considerations and questions …..
First ask, What’s YOUR chapter’s role in YOUR state’s insurance exchange?• How do family physicians view exchanges as small business owners?• How will continuity of care look and work?• Will the plans in the exchange have to participate in Medicaid?• Ethically, will the providers in the exchange have to accept Medicaid?
Questions for me? Gordana Krkic, CAE Deputy Executive Vice President of External AffairsIllinois Academy of Family Physicians firstname.lastname@example.org THANK YOU!