Hello everyone. My name is Dr Sandra Koch, I’m on obgyn and I’ve been delivering babies in Northern Nevada for over 20 years. Tonight though I’m here to deliver my views on the ACA I want to Thank Dr Pintar and the Sierra Nevada Forum for inviting me to talk tonight about the affordable care act. It’s quite a task trying to summarize 2700 pages in 15 minutes – I know DrPintar thinks I talk fast- but this is really going to be a challenge.
America has the most expensive healthcare in the world and yet we rank only 37th in the quality of the healthcare we provide, right behind Slovenia! Too many Americans aren’t covered by health insurance, there are too many medical errors, too much inefficiency and it costs too much.
The red line shows the growth in the percent of GDP that represents our expenditures on health care. The cost is Bankrupting our nation. It’s also bankrupting many of us.
Health care costs are the number 1 reason for bankruptcy in our community.
The map on the left side represents the percent of uninsured women in the United States ages 19-64. The dark blue represents states where 1 in 4 women are with out insurance, the light blue 1 in 5 and the purple 1 in 8. the map on the right side shows the changes we’ll see when the ACA is fully implemented. Being without insurance is dangerous for your health.
If youre unlucky enough to get really sick, not having health insurance reduces your chance of survival. So how many uninsured do we have?
By 2019 we would have had @ 57 million uninsured.
With the ACA there will be 34 million less uninsured by 2019
I like this quote from the flight of the buffalo. Many folks are scared about the changes coming, afraid they will lose coverage or be refused treatment based on age. A show of hands please from anyone who has received an email like this one.
This particular email has been the subject of debunking and fact checking by multiple sites .Virtually every statement is exaggerated, misleading, inaccurate or just plain wrong. I would ask all of you to identify a fact checking website and use it whenever you receive information that just doesn’t seem quite right. Here are two that I recommend.
So lets look at some of the beneficial changes.
No preexisting condition I”ve seen many cases where woman had a single abnormal pap test leading to exclusion of the entire reproductive system for life. That won’t happen any moreWomen have been paying up to twice as much for individual health care plans. Under the ACA that won’t happen any moreI’ve seem many women over the years that sign up for insurance that have a 9 month exclusion and if they got pregnant during that 9 months – no coverage. That won’t happen any more.Many folks with serious health condition, for example transplant patients, run through their lifetime limits on insurance expenditures and get dropped. That won’t happen anymore.Young people when they finish their educations have had very high rates of being uninsured. IF they get sick or more likely injured their health care and sometimes their futures are compromised. Requiring insurance companies to allow parents to insure their children until age 26 has dropped the number of uninsured in this age group. Another area of major change is in preventative health care coverage. In an effort to encourage folks to take advantage of life saving services the ACA has mandated coverage of many services.
Formedicare patients there will be No more Part B deductibles or copayments if your doctor acceptsassignmen for these services.The four most important things you can do to improve or prolong your health are control your BP, don’t smoke, control your weight and get get vaccinated. These are all covered under the preventative services listed above
A busy slide listing services for those too young for medicare- please notice all the vaccines covered with no co-pay.
For women the biggest changes are first dollar coverage for pregnancy and for contraception. Everyone understands the importance of prenatal care. I want to emphasize the importance of the contraception coverage. Nevada has one of the highest rates of unplanned pregnancy in the US. About one in three unplanned pregnancies is also an unwanted pregnancy. It’s clear that Unintended and unwanted pregnancies are bad for babies, mothers and our society. The ACA by mandating this coverage is going to significantly impact these pregnancies. IN addition. For every dollar we spend as a nation on contraception we SAVE three dollars the first year and thirty dollars over the next ten years.
The last list of preventative service sis for the children- as you can see- many services are covered. The next topic I want to review is medicare coverage of medications.
Has anyone heard of the donut hole? Until the ACA anyone who’s medication costs exceeded $2900 ended up in the donut hole. This meant- no assistance in paying for an individual’s medications until they’re personal outlay for medications had exceeded almost $5000. The ACA addressed this immediately.
Theamount of money you will have to pay for prescription medications within the donut hole will be reduced each year until 2020 when Medicare will pay for ¾ of your medication expenses. .
Many folks are wondering who’s going to see the 34 million newly insured Americans. AS some of you know from first hand experience- Already it is hard to find a physician willing to accept you as a new patient if you have medicaid or medicare in our community. This is not going to get better right away. We need many more providers- both physicians and midlevel providers. Ideally everyone will eventually have a medical “HOME” but until that time ERs will continue to see many of these folks. Urgent cares will also be heavily utilized. Carson Tahoe has free standing urgent care centers in Dayton and Carson city as well as one in all three Walmarts. Carson Medical Group has an urgent care for established patients also.
Standardization to reduce error -improve efficiencyIncrease transparency so that patients and their families are better aware of their treatment options including effectiveness of therapies and costs. Improve communication between health care providers to increase care coordination and decrease overlapActively promote best practices for prevention and treatment of the leading causes of death through mandates and dat analysisInvolve communities by promoting best practices for healthy living.
To get this accomplished we need computers. Healthcare at 18% of the GDP until recently has largely been run as a cottage industry. To move that volume to a computerized system is an enormous undertaking. First step is to move computers into the health care arena. To help this along CMS introduced a program called
The goal is to institute quality measure reporting using the Electronic Health Record for “Meaningful Use”Participation is mandatory for all health care providersPhysicians who participated got 1% bonus payments in 2011. to help with the costsPQRI bonuses fall to 0.5% in 2012 to 2014. Physicians will receive penalties in 2015 if they don’t participate.
Have you noticed that you’ve been filling out a lot more paper work at your doctors office? These are some of the first measures CMS has asked to have reported.
Carson Tahoe hospital has a computer system and it slowly working its’ way to fully utilizing it. On labor and delivery all our orders are computerized and all the nurses charting is. Here’s a problem though- one that’s even worse in the ORs and ICUs WE have lots of machines that do things for us but they don’t communicate. Therefore nurses and doctors are spending an inordinate amount of time transcribing data. Example BP and fetal monitoring on OB
Cost containment For patients- making cost more transparent- the idea that Computer generated data should steer healthcare. For providersIN theory best practices will be identified and implemented using EMR. The most effective and cost efficient treatment approaches will be sought. Using computers Health care centers will be linked to avoid duplication.Additionally finding ways to stop paying for procedures and instead pay for health outcomes. No one fully understands the implications of the ACA. The regulations for many parts of the ACA have yet to be written. Will it increase costs for private health insurance- yes because it mandates what must be covered. Is it perfect- NO will it change – yes. It was a first step in moving our country to a system that will cover most of our uninsured and may help us control our health costs through increasing standardization while mprovingthe quality of our health care.
For those of you who can’t read this it saysMay I be excused? My brain is full. I’m sure many of you feel this way – it’s a lot to take in.
I’ll leave you with one final comment- you might as well Embrace the Change – because There’s no going back!Thank you
Percent of Women Ages 19 to 64 Uninsured by State, 2009–2010 and Under the Affordable Care Act When Fully Implemented Affordable Care Act fully implemented (estimated) 2009–2010 WA VT NH NH ME WA VT ME MT ND MT ND MN OR NY MN SD WI MA OR NY ID ID WI MA WY MI RI SD PA MI RI IA NJ CT WY PA NJ CT NE OH IA NV IN DE NE OH IL WV MD IN DE UT VA NV IL CO DC UT WV MD KS MO KY CO VA CA DC NC CA KS MO KY TN NC OK SC TN AZ AR OK NM AZ AR SC MS AL GA NM AL GA MS TX LA TX LA FL FL <7% AK AK HI 7%–<11% HI 11%–<16% 20% of women 16%–<21% 8% of women ages 19–64 uninsured ages 19–64 uninsured 21%–30%Sources: Analysis of the March 2011 and 2010 Current Population Surveys by N. Tilipman and B. Sampat of Columbia Universityfor The Commonwealth Fund; uninsured rates are two-year averages. Estimates for the Affordable Care Act when fully implementedby Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund.
People are more likely to die from cancer More likely to die from car accidents Less likely to be vaccinated and therefore more likely to develop life threatening infections More likely to die from virtaly all chronic illnesses .
Private Insurance Govt Insurance MedicareLarge Group Mkt 60M 218M Medicaid and Small Uninsured SCHIP Group 57M 63M Mkt 26M Other Individual Fed Mkt 15M 26M
Private Insurance Govt InsuranceLarge Group Mkt Medicare 218M 60M Small 2M Medicaid and Group Mkt SCHIP 83M Individual Mkt Uninsured 23M Other Fed Health 15M Insurance Exchanges
―Change is hard because people overestimate the value of what they have—and underestimate the value of what they may gain by giving that up.― — James Belasco and Ralph Stayer Flight of the Buffalo (1994
HB 3200 Page 50/section 152: The bill will Page 317 and 321: The government provide insurance to all non-U.S. residents, even if they are here illegally. will impose a prohibition on hospital expansion; however, communities may petition for an exception. ** ** Page 425, line 4-12: The government JUDGE KITHIL IS Page 58 and 59: The government will have real-time access to an individuals bank account and will have the authority to make electronic fund transfers mandates advance-care planning consultations. Those on Social Security will be required to attend an "end-of-life planning" seminar from those every five years. (Death THE 2ND accounts. ** Page 65/section 164: The plan will be subsidized (by the government) for all union members, union retirees and for counseling..) ** Page 429, line 13-25: The government will specify which doctors can write an end-of-life community organizations (such as order. OFFICIAL WHO the Association of Community Organizations for Reform Now - ACORN). ** HAS OUTLINED Page 203/line 14-15: The tax imposed under this section will not be treated as a tax. (How could anybody in their right mind come up with that?) THESE PARTS ** OF THE Page 241 and 253: Doctors will all be paid the same regardless of specialty, and the government will set all doctors fees. ** CARE BILL. Page 272. section 1145: Cancer hospital will ration care according to the patients age. **
• No preexisting condition exclusions• No gender rating differences• No 9 month waiting periods• No annual lifetime limits• Parents can cover their adult children until age 26 through their health insurance plan
Abdominal aortic aneurysm screening HIV screeningsAlcohol misuse screenings and Mammograms (screening) counseling Nutrition therapy servicesAnnual Wellness exams* Obesity screenings andBone mass measurements (bone counseling* density)* One-time ―Welcome to Medicare‖Cardiovascular disease screenings preventive visitCardiovascular disease (behavioral Pap tests and pelvic exams therapy) (screening)Colorectal cancer screenings* Prostate cancer screeningsDepression screenings Sexually transmitted infections screening and counselingDiabetes screenings* Tobacco use cessation counseling*Diabetes self-management trainingGlaucoma tests* Flu shots Hepatitis B shots Pneumococcal shots
Abdominal Aortic Aneurysm one-time screening for men of specified ages who Immunization vaccines for adults-- have ever smoked doses, recommended ages, and Alcohol Misuse screening and recommended populations vary: counseling ◦ Hepatitis A Aspirin use for men and women of certain ages ◦ Hepatitis B Blood Pressure screening for all adults ◦ Herpes Zoster Cholesterol screening for adults of ◦ Human Papillomavirus certain ages or at higher risk ◦ Influenza (Flu Shot) Colorectal Cancer screening for adults over 50 ◦ Measles, Mumps, Rubella Depression screening for adults ◦ Meningococcal Type 2 Diabetes screening for adults ◦ Pneumococcal with high blood pressure ◦ Tetanus, Diphtheria, Pertussis Diet counseling for adults at higher risk for chronic disease ◦ Varicella HIV screening for all adults at higher risk
Anemia screening Gestational diabetes screening for BRCA counseling about genetic testing women at high risk of developing Breast Cancer Mammography gestational diabetes* screenings Hepatitis B screening for pregnant women at their first prenatal visit Breastfeeding comprehensive support and counseling* Human Immunodeficiency Virus (HIV) screening and counseling for Cervical Cancer screening for sexually sexually active women* active women Chlamydia Infection screening for Human Papillomavirus (HPV) DNA younger women and other women at Test: high risk HPV DNA testing every higher risk three years who are 30 or older* Osteoporosis screening for women Contraception: Food and Drug over age 60 depending on risk factors Administration-approved contraceptive methods, sterilization procedures, and Prenatal Care patient education and counseling, not Tobacco Use screening and including abortifacient drugs* interventions for all women, and Domestic and interpersonal violence expanded counseling for pregnant screening and counseling for all women* tobacco users Folic Acid supplements for women who Sexually Transmitted Infections (STI) may become pregnant counseling for sexually active women* Well-woman visits to obtain recommended preventive services*
Alcohol and Drug Use assessments for adolescents Autism screening for children at 18 and 24 months Vision screening for all children Behavioral assessments for children of all ages Immunization vaccines for children from birth to age 18 —doses, Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 recommended ages, and recommended populations vary: to 17 years. ◦ Diphtheria, Tetanus, Pertussis Blood Pressure screening for children ◦ Haemophilus influenzae type b Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 ◦ Hepatitis A to 17 years. ◦ Hepatitis B Cervical Dysplasia screening for sexually active females ◦ Human Papillomavirus Congenital Hypothyroidism screening for newborns ◦ Inactivated Poliovirus Depression screening for adolescents ◦ Influenza (Flu Shot) Developmental screening for children under age 3, and surveillance throughout childhood ◦ Measles, Mumps, Rubella Dyslipidemia screening for children at higher risk of lipid disorders ◦ Meningococcal Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. ◦ Pneumococcal Fluoride Chemoprevention supplements for children without ◦ Rotavirus fluoride in their water source ◦ Varicella Gonorrhea preventive medication for the eyes of all newborns Iron supplements for children ages 6 to 12 months at risk for Hearing screening for all newborns anemia Height, Weight and Body Mass Index measurements for children Lead screening for children at risk of exposure Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years. Medical History for all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 Hematocrit or Hemoglobin screening for children to 17 years. Hemoglobinopathies or sickle cell screening for newborns Obesity screening and counseling HIV screening for adolescents at higher risk Oral Health risk assessment for young children Tuberculin testing for children at higher risk of tuberculosis Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years. Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 Phenylketonuria (PKU) screening for this genetic disorder in to 17 years. newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
Begins when total costs for your medications ( your cost and the amount Medicare has paid) exceed @ $2900 Ends when YOUR total costs exceed $4750 ( equivalent to drug costs $14,250)
Your drug costs within the ―HOLE‖2008: 100% brand-name 100% generics2012: 50% brand-name 86% generics2020: 25% brand-names 25%generics
Who will see these patients? ◦ It will take a long time to get these patients into a primary care system. ◦ We will need more mid level providers. ◦ The ER will still continue to see many Medicaid patients ◦ Urgent care clinics will be heavily utilized – Carson Tahoe urgent/emergent care clinics CMG plus Wal-Mart
― Meaningful Use‖Participation is mandatoryDiminishing Bonus payments first 3 yearsPenalties begin in 2015
E-prescribingRecord Demographic Implement one clinicalSmoking status decision supportMedications Laboratory value(s)Allergies Vital signs – height, weight,Drug drug interaction alerts blood pressure, BMIProblem list Care plan field(s), includingProtect health information goals and instructions Capability to exchange key clinical information electronically
Charts are legible Charts are accessible from multiple locations and are never lost although they may ―crash‖ Patients now have access online to there charts, test results, vaccine records. Fewer medication errors Improved use of preventative healthcare
In our region alone millions of dollars have been spent already trying to achieve this communication They are not interconnected. Protection of patient privacy/patient records may be more difficult at high levels. Physicians brains aren’t structured to work like computers- Data is difficult to enter.
Patients Providers Make costs more Identify and Drive best transparent practices Find ways to move away Move towards Consumer from paying for health Driven Health Care care procedures and decision making instead pay for health care outcomes