As the cost of healthcare continues to climb, the payers have asked enrollees/consumers to pay a higher portion of what services cost
This chart givesdetail on who pays the U.S. health care expenditures. As you can see the majority of expenditures are paid by the federal government (mostly Medicare and Medicaid) and by private insurance.
Typically in a plan yearPlans may have both per individual and family deductibles.Some plans may have separate deductibles for specific services. For example, a plan may have a hospitalization deductible per admission.Coinsurance: Once any deductible amount and coinsurance are paid, the insurer is responsible for the rest of the reimbursement for covered benefits Example: You might cover 20% of total costs while Medicare handles the rest.Not all procedures and care require costs sharing – this is determined by the payerThese are not the only ways the Insurer shares costs with the patients (co-pays at time of care and or on Rx, premiums - upfront payment as a requirement of coverage, etc.)
An enrollee with cancer costs the payer ix and a half times as much for healthcare costs aloneIn contrast, Maternity costs tend to range about 5% (500M x 10% $50M year)
Transcript of "Cecily Hall Call-on Congress 2012 Presentation"
THE IMPACT OF THEAFFORDABLE CARE ACT ON COLORECTAL CANCER SCREENING Cecily Hall Consultant and Former Director of Employee Benefits, Microsoft Corporation
Topics for Review• Healthcare Coverage – basic concepts• The Affordable Care Act – coverage for cancer screenings• The Challenge• Your Opportunity to Make a Difference
Healthcare Coverage - A Few Basic Concepts• The Payers• Enrollees• Cost Sharing
Healthcare Coverage: The PayersThe Government, Insurers and Employers Play Big Roles Source: Centers for Medicare & Medicaid Services, Office of the Actuary
Healthcare Coverage: The Enrollee • Enrollee – The patient who is eligible for coverage under the employer’s, the government’s or the insurer’s plan – May also be referred to as the Member or Plan Participant
Healthcare Coverage: Cost-Sharing • Why do cost sharing strategies exist? • Two common approaches to cost sharing* – Deductible: A fixed dollar amount that the patient pays before their insurance makes payments for covered medical services – Coinsurance: Requires the patient to pay a percentage of medical expenses after the deductible amount is paid *Both examples are triggered when care is delivered
The Affordable Care Act:Coverage for Colorectal Screening The Intent • Remove cost barriers for Medicare participants that are candidates for colorectal screenings – No out-of-pocket expenses for the patient for colorectal screenings
The Problem• The Affordable Care Act requires Medicare patients pay for a portion of their colorectal screening/colonoscopy if a polyp is found and removed• If a polyp isn’t found/removed during screening, the patient isn’t required to pay any out of pocket expenses for that screening• You said What...?
The Problem• This problem is due to an oversight that occurred when writing the legislation• The oversight impedes screenings that would reduce the US healthcare spend• …AND save lives
The ProblemClearly this outcome was an unintended consequence …And it needs to be fixed.
Your Mission• Educate Congressional Representatives about this oversight• Help them understand the unintended consequences• Arm them with relevant information so they can educate others and quickly correct this
Helpful, Important Facts• Cancer is the leading cause of death for people ages 20-65 (prime workforce ages)• A 2006 Milliman Study revealed: • Enrollees with cancer tend to make up 1.6% of the employer/insurer population but generate ~10% of the medical costs • The average monthly cost to a payer for an enrollee without cancer: $360 • The average monthly cost to a payer for an enrollee with cancer: $2,390** Does not include disability costs, lost productivity and life insurance payment
Important Facts• Medical literature demonstrates that screening leads to earlier detection, lowering disease severity and resulting in fewer deaths• People with more advanced cancer cost more than people with less advanced cancers• People who die from cancer cost more than cancer survivors (considers both medical and non-medical insurance costs (disability and life))Therefore, screening for cancer reduces costs- and saves lives.Source: 2005 Milliman report commissioned by C-Change and the American Cancer Society
Your MissionHelp correct the oversight and these these unintended consequences currently part of the Affordable Care Act Medicare Policy Thank you!