The Affordable Care Act: Impact on Hospitals in Kansas


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  • What does the ACA do to address the issue? That’s what we’re here to talk about today, but from a very broad perspective, the law makes sweeping changes to our nation’s healthcare system with a vision to provide health coverage to all Americans and promote more efficient care delivery through health insurance reforms, coverage expansion and quality enhancements—all of which we’re going to talk about today.
  • Advanced Patient Advocacy, Virginia-based company, specializes in helping hospitals and medical clinics determine whether their underinsured and uninsured patients are eligible for Medicaid and helping enroll them in the program. In KS, it has workers stationed in three HCA Healthcare hospitals: Overland Park Regional Medical Center and Menorah Medical Center, both in Overland Park, and Labette County Medical Center in Parsons.“Right now, most of our work is with patients who are already in the hospital or they’re seeing a physician who’s affiliated with the hospital,” said Wendy Bennett, president of Advanced Patient Advocacy.“We will continue to do that,” Bennett said. “But with this grant, we’ll be hiring some additional staff and developing some technologies that will allow us expand our services beyond the ‘four walls’ of a hospital or a physician’s office and into the community at-large.”Ascension Health, includes in KS the Via Christi Health hospitals in Wichita and Pittsburg, Mercy Regional Health Center in Manhattan and Wamego Health Center in Wamego.According to Keisha Humphries, oncology service line administrator at the Via Christi Cancer Center in Wichita, Ascension Health’s grant will be used to hire and train two workers who will help cancer patients and survivors obtain health insurance.“This is a very vulnerable population,” Humphries said. “A lot of them have had insurance, lost it, and now they can’t afford it.”Initially, the workers’ outreach efforts, she said, will be limited to Sedgwick, Butler, Cowley, and Sumner counties.“We’re talking about thousands of uninsured patients, literally, in a four-county area,” Humphries said.The initiative, she said, should be up and running next month.Source: Kansas Health Institute, Kansas Groups Receive Grants to Help with Obamacare Outreach, August 15, 2013,
  • Navigators in NY (additional background)Amount of Funding$27.2 million per year for a period of 5 yearsYear 1 includes an additional $4.5 million in start up fundsAwards amount will be determined by service areaDeadline to RespondLetter of Intent: February 27, 2013Application: April 8, 2013Anticipated Start DateAugust 1, 2013The IPA Program will commence within 30 days of the date that contracts awarded under this procurement are approved by the state The Navigator Program will commence on a date to be determined and no later than January 1, 2014. Service AreaApplicants must identify a service area by countyDutiesIPAs and navigators will provide the baseline services as well as: Facilitate enrollment into Medicaid/CHIP. Provide enrollment assistance to potential enrollees with the renewal of health plans. The DOH anticipates that the Facilitated Enrollment Program will be replaced by the IPA/Navigator Program.
  • Medicaid/CHIP providersState or tribal child support enforcementElementary or secondary schoolsTANF, Medicaid, CHIP agencies/entitiesHead Start, WIC, subsidized child care, federally funded housingEmergency food and shelter programsOthers the state deems appropriate
  • --Toolkit provides details about how to take advantage of this opportunity and how to make it work in your hospital
  • Stress importance of connecting the patients to ongoing coverage
  • The Affordable Care Act: Impact on Hospitals in Kansas

    2. 2. Agenda and Introductions Discussion Topic Presenter Ascension Health’s Role in this Work Overview of ACA Coverage Options Mary Ella Payne Senior Vice President Policy & Legislative Leadership Ascension Health Health Insurance Marketplaces, Insurance Reforms and More Beth C. Fuchs, Ph.D. Principal Health Policy Alternatives, Inc.
    3. 3. Our Mission Rooted in the loving ministry of Jesus as healer, we commit ourselves to serving all persons with special attention to those who are poor and vulnerable. Our Catholic health ministry is dedicated to spiritually centered, holistic care which sustains and improves the health of individuals and communities. We are advocates for a compassionate and just society through our actions and our words.
    4. 4. Health Ministry Ascension Participating Entities appoint members of Ascension Health Ministries “Ascension Health Ministries” (PJP composed of up to 12 individuals) Founding Participating Entities Participating Entities Sponsor System Parent Health Ministries Approved by Rome June 30, 2011 Oak Hill Capital Partners Ascension Health Ventures Ascension Health Care Network Management Agreement Leadership Academy Ascension Health Solutions Ascension Health Services Ascension Health (Delivery) Health Ministry Health Ministry Affiliate Organizations Appoint Participating Entities Infrastructure Support Congregation of St. Joseph Sisters of St. Joseph of Carondelet Daughters of Charity Province of St. Louise Alexian Brothers Sisters of the Sorrowful Mother
    5. 5. Ascension Health, part of Ascension, is the largest Catholic and nonprofit health system, and the third largest system (based on revenues) in the United States, operating in 23 states and the District of Columbia. Our Delivery System Daughters of Charity Health System is an affiliate of Ascension Health
    6. 6. Ascension Health’s Major Healthcare Delivery Platforms Ambulatory Care and Diagnostics Ambulatory Surgery Centers 70 Employer/Occ Health 44 Free-standing Imaging 83 Retail Lab Collection Sites 256 Primary Care Clinics 491 Specialty Clinics 260 Retail Pharmacies 35 Sleep Centers 28 Telemedicine Programs 59 Inpatient Facilities General Acute Care 100 Long-term Acute Care 3 Rehabilitation 3 Psychiatric 7 Total 113 Prevention & Wellness Programs Alternative Care 13 Community/Social Services 120 Wellness/Fitness 20 Post Acute Service Sites Behavioral Health – Acute units 31 Behavioral Health – Outpatient 76 Cancer Centers 20 Durable Medical Equipment 23 Home Health Agencies 26 Hospice/Palliative Programs 35 Infusion Therapy Programs 23 Private Duty Services 4 Rehabilitation – Outpatient 226 Rehabilitation – Inpatient units 35 Updated May 2013 Long-term Care & Senior Living Sites – 38 communities comprised of the following: Adult Day Care 11 Assisted Living (AL) 7 Independent Living (IL) 3 Skilled Nursing (SNF) 21 CCRC (combined SNF/AL/IL) 9 PACE 3
    7. 7. FY12 Systemwide Statistics* Discharges 693,544 Available beds 18,450 Number of births 72,121 Total surgical visits 529,341 Home health visits 534,232 Clinic visits 1,877,970 Emergency visits 2,454,455 Physician office visits 6,974,451 Total outpatient visits 20,155,034 Associates 122,000 * FY12 Statistics do not include Ministry Health Care, St. John Health System, or Via Christi Health
    8. 8. Strategic Direction: ‘Architecture’ for Realizing our Vision Vital Presence Healthcare That Leaves No One Behind Inspired People Trusted Partnerships Empowering Knowledge Healthcare That Is Safe Healthcare That Works Our outward promise to those we serve Enabled by focused inner strengths
    9. 9. Provider-Centered: transactional model Person-Centered: relationship model Focus  Providers’ delivery of medical services to patients to address a healthcare episode  Trust-based relationship that promotes a spiritually centered, holistic approach to supporting a person’s health and well-being Locus of Control  Primarily providers  Primarily the person and family supported by a trusted ecology of resources Nature of Choices  Healthcare choices are mostly reactive  Health choices are well-understood and frequently proactive Primary Locations  Hospitals and clinics  More care and support in the community, in the home and by virtual means Health Information  Provider-based, episodic, transactional  Coordinated, transparent data managed by well- informed individuals Duration  Episode of care  Lifetime relationships Transformational Path to Realizing our Vision Person- Centered Approach Fostering Continuous, Dynamic Relationships With Those We Serve Moving from Provider-Centered to Person-Centered
    10. 10. Our Guiding Features of a Reformed Healthcare Policy Ensure 100% Access to Healthcare Services Achieve Destination of 100% Coverage Reform Insurance Rules; Shared Obligation and Responsibility for Coverage Make Health Insurance Affordable and Equitable Eliminate Coverage and Service Gaps, Particularly for the Vulnerable Ensure Economic Viability Through Shared Financial Responsibility Improved Health for Our Community We are committed to redesigning the healthcare delivery system and partnering with policymakers to achieve 100% access and 100% coverage.
    11. 11. An Overview of the Coverage Continuum in the Affordable Care Act
    12. 12. Healthcare Reform: What Is It? Healthcare Reform Quality & Delivery System Reforms Insurance Coverage Expansion Health Insurance Reforms Patient Protection and Affordable Care Act (ACA) signed on March 23, 2010 Constitutionality Affirmed by Supreme Court on June 28, 2012. The healthcare reform law makes sweeping changes to our nation’s healthcare system with a vision to provide health coverage to all Americans and promote more efficient care delivery. 12
    13. 13. 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Coverage: Medicaid expansion, major insurance reforms (e.g., guaranteed issue, rating rules, no pre-ex for adults) insurance exchanges, premium / cost sharing subsidies, individual / employer responsibility requirements Medicare Savings: MA payment reductions, productivity offset to FFS updates Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal Coverage: Small business premium tax credit Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review Delivery System Reform: Center for Medicare and Medicaid Innovation Delivery System Reform: ACOs, hospital value-based purchasing Delivery System Reform: Hospital readmissions, payment bundling Delivery System Reform: Physician quality reporting penalties New Revenue: Tax on prescription drug manufacturers New Revenue: Excise tax on medical device makers, Medicare tax on high earners New Revenue: Tax on health insurers New Revenue: Tax on high-cost health plans Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates Timeline of Key Health Reform Provisions Passed March 23, 2010
    14. 14. 14 Current Sources of Coverage for Non-Elderly in U.S. and Kansas (2011-2012) Kansas U.S. Employer-Sponsored 60% 56% Individual Insurance 6% 6% Medicaid 14% 18% Other public 4% 3% Uninsured 15% 18% Total 100% 100% Close to 365,000 Kansans are currently uninsured Sources: Kaiser Family Foundation,; Kansas Health Institute, Insurance Exchange Will Provide Many Kansas Consumer With New Options, January 2013,
    15. 15. 15 Health Coverage Options for Individuals in 2014 Source: CCIIO, Insuring America, Presentation, NIHCM Webinar, May 7, 2013 133% FPL for family of 3 -- $25,975 400% FPL for family of 3 -- $78,120 Sliding Scale
    16. 16. Supreme Court Decision and Medicaid Expansion Coverage Expansion Becomes Voluntary for States  States can choose not to expand Medicaid to cover all state residents under 133% FPL, without risking federal funding for their entire Medicaid program.  HOWEVER, the balance of Medicaid provisions still stand, including cuts in funding that support hospitals that provide higher levels of care to uninsured individuals and uncompensated care. June 2012 U.S. Supreme Court Decision
    17. 17. 17 Kaiser Family Foundation, Status of State Action on the Medicaid Expansion Decision, as of September 3, 2013, Medicaid Expansion Decision as of September 3, 2013
    18. 18. Source: Kaiser State Health Facts, January 2013 Kansas Medicaid Eligibility and Eligibility for Tax Subsidies for Private Insurance Currently Eligible for Medicaid in KS Eligible for Subsides in the Insurance Marketplaces (100% – 400% FPL) 31% 25% No coverage options for 88,000. 100% FPL 400% FPL Children Pregnant Women Working Parents Jobless Parents Childless Adults 150% 133% FPL 100% 150% FPLBy age 0-1 150% 1-5 133% 6-9 100%
    19. 19. Income Level Upper Income Limit for Family of Three Premium as Percent of Income Cost/Month at High End Up to 133% FPL $25,975 2% $43 133-150% FPL $29,295 3-4% $98 150-200% FPL $39,060 4-6.3% $158 200-250% FPL $48,825 6.3-8.05% $327 250-300% FPL $55,590 8.05-9.5% $440 300-400% FPL $78,120 9.5% $618 Premium Tax Credits Individual Premium Tax Credits/ Cost Sharing Reductions Source: Kaiser Family Foundation, July 2012 Cost-sharing reductions also are available for individuals <250% FPL.
    20. 20. Insurance Reforms and Health Insurance Marketplaces
    21. 21. 21 ACA Insurance Reforms Now in Place  No lifetime limits; limits on use of annual dollar limits on benefits  Insurance companies cannot renege on promised coverage  No pre-existing conditions exclusions for children under 19  Children up to age 26 can be covered a parent’s plan  Patient cost sharing eliminated for recommended preventive services
    22. 22. 22 More ACA Insurance Reforms Now In Place • Medical Loss Ratio o 80% of insurance premiums must be spent on healthcare delivery 85% for large insured group plans) o Insurers must rebate excess premiums • Enhanced rate (premium) review by state regulators • Uniform explanation of coverage documents; standardized definitions
    23. 23. Regulatory Environment for Exchanges in 2014 23 Fair Health Insurance Premiums Health status and gender not used to set premiums; limit on age rating Single Risk Pool Issuers cannot use separate risk pools to charge certain customers higher rates Guaranteed Availability Coverage must be offered to all comers, with limited exceptions, during enrollment or special enrollment periods Guaranteed Renewability Coverage must be renewed for all policyholders, with limited exceptions Adapted from CMS, Health Insurance Market Rules, Rate Review, 2012 These rules apply to insurance sold in and outside of Exchange
    24. 24. Under Current Rules, Small Group Rating Rules: Premiums Vary Significantly 24Source: National Association of Insurance Commissioners and the Center for Insurance Policy and Research
    25. 25. 25 Insurance Reforms as of 2014 • Insurers have to charge small firms in same area for identical coverage more similar premiums regardless of health status of their employees. • Within area premiums can only vary for family size, age, tobacco use • No one can be turned down or cancelled because of health status, pre-existing condition or use of healthcare. • No pre-existing condition exclusions • Apply at annual and special enrollment periods
    26. 26. Insurance Reforms in Kansas as of 2014 For Kansas small businesses-- • Age adjusted community rating (3:1 limits on age variation) • No 90-day, pre-existing condition waiting periods for timely enrollment • Insurers must offer Essential Health Benefits Comparable to largest small business policy in the state May be more comprehensive than current policy 26
    27. 27. 27 Essential Health Benefits (EHB) • States selected among certain existing option(s) for their EHB benchmark plan. Default is largest small group policy in the state • Kansas: BCBS Comprehensive Major Medical-Blue Choice Blue Shield of Kansas Comprehensive Plan • EHBs must cover 10 categories of required services: Ambulatory care, emergency services, hospitalization, maternity/newborn care, mental health and substance use disorder services, including behavioral health treatment, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management
    28. 28. 28 Actuarial Value (AV) and Cost Sharing • Plans offering EHBs have to meet certain cost-sharing standards: Limits on maximum out-of-pocket (MOOP) costs for EHBs: $6,350 for an individual, $12,700 for a family for 2014 • Plans have to meet certain AV levels (the so- called “metals” levels) – Bronze: 60% AV – Silver: 70% AV – Gold: 80% AV – Platinum: 90% AV • The cost-sharing is reduced on sliding scale basis under affordability programs
    29. 29. Marketplaces will: Provide one-stop-shopping for individuals and small businesses seeking healthcare insurance coverage in transparent, competitive marketplaces. Provide consumer friendly online tools comparing premium rates and benefit packages for health insurance coverage options that meet minimum standards. Allow individuals to apply for insurance subsidies online, in person, by mail or by telephone. Bottom line, make it easier to shop for and enroll in health insurance Administered by states, the federal government, or a partnership between the two. What is a Health Insurance Marketplace?
    30. 30. 30 Why Marketplaces (Exchanges)? • Premiums are reduced by pooling small-business buying power, structure of competition, and economies of scale • More choice of insurance options for small employers and their employees • Comparing and making choices among insurance options is easier • Ultimate goal: drive innovation and improvements in affordability, quality and customer service
    31. 31. 31 Status of the States’ Exchange Decisions for 2014 State-based Exchange: 16 states + DC have declared Partnership Exchange: Seven states are planning for a Partnership Exchange Federally-Facilitated Exchange: 26 states currently default to the Federally-Facilitated Exchange Kaiser Family Foundation,;
    32. 32. Which Insurers in Kansas will be Selling through the Individual Exchange? As of late August • Blue Cross and Blue Shield of Kansas • Blue Cross of Kansas City Also Multistate Plan Program option in same 103 counties • Coventry Life and Health, and Coventry Health Care of Kansas PPO and an HMO Source: Wichita Eagle, How will the Affordable Care Act Work? August 28, 2013, 32
    33. 33. Revamped text
    34. 34. Federally Facilitated SHOP– 34
    35. 35. 35 Sponsored by Kansas Department of Insurance
    36. 36. 36 • Many key design decisions left to states; therefore what exchanges do and how well they do it will vary by state • Exchanges must compete with insurance offered in the outside market, so will need to offer plans that are cost competitive and high quality • Exchanges need to maximize participation to gain scale, avoid adverse selection Will Exchanges Succeed?
    37. 37. Exchanges Projected to Start at Seven Million and Reach About 25 Million Exchange enrollment estimated to be about seven million in 2014, increasing to about 22 million by 2016 and 25 million in 2018. More than 80 percent of enrollees estimated to be eligible for sliding-scale tax-credits. About three million estimated to be in small business (SHOP) Exchange. 37 Source: Congressional Budget Office. May 2013 Baseline
    38. 38. Exchanges: Overall Timeline 38 2013 October 1 Open-enrollment begins December 15 Deadline for QHP selection in order to qualify for January 1, 2014 coverage effective date 2014 January 1 Coverage begins January 15, February 15, March 15 Deadlines for plan selection for enrollment in following month March 31 Open-enrollment ends
    39. 39. Exchanges: Reinforcing the New Provider/Purchaser Environment Incentive for low premium plans in Exchanges, especially to attract those with tax credits (~ 85% of likely enrollees) • Premium tax credit tied to second lowest price silver (70% AV) plans • ACA takes away selected underwriting, pricing, cost control and design tools that plans have used in small group and individual market • Result: Plans in Exchanges turning to other cost control devices: networks, provider pricing, utilization controls Reinforces comparable pressures on providers from larger employers, Medicare and Medicaid • Standardized FFS approaches and payments will be increasingly unattractive • Incentives for new arrangements among providers and with payers to lower total cost growth 39
    40. 40. Charity Care and Bad-Debt Exposure Continues • While number with coverage are likely to increase by about 25 million, providers face financial constraints About 30 million remaining uninsured Medicaid an increasing source of coverage with limited payment rates • Cost-sharing in Exchanges and in employer policies remains Cost-sharing continues to increase under traditional employer policies Cost-sharing can be substantial even with “minimum essential coverage” (e.g. larger employer plans) While maximum out-of-pocket cost limits in place, cost-sharing remains in the plans in the Exchange • State law loopholes in insurance regulation For example, possibility of limited duration plans 40
    41. 41. Implications for Hospitals • Patients covered under Exchange plans may result in better coverage with lower out of pocket maximums • There will be more insured patients, but many uninsured likely to be unaware of the Exchanges and subsidies in 2014; effects of ACA may be limited at first • Plans have to meet network adequacy requirements, but Exchange plans may have narrower networks than non-Exchange plans • To keep premiums competitive, insurers may try to negotiate deeper discounts from hospitals 41
    42. 42. Eligibility, Outreach and Enrollment • Navigators • Certified Application Counselors (CACs) • Presumptive Eligibility
    43. 43. Eligibility and Enrollment Pathways and Consumer Assistance Navigators Agents / Brokers / Producers In-Person Assisters Certified Application Counselors Assistance Entities State Agency (e.g., Depts. Of Health / Social Services) Online PhoneIn-person Enrollment Complete Mail
    44. 44. Outreach Efforts for 2014 for Kansas Marketplace • Navigators Kansas Association for the Medically Underserved, $524,846 • (Consortium of Kansas Hospital Association, the Kansas Association of Local Health Departments, the Association of Community Mental Health Centers of Kansas, the Kansas Area Agencies on Aging Association, and the Kansas Insurance Department). Aim to assist about 48,000 people Advanced Patient Advocacy, $195,556 Via Christi Health, Ascension Health, $165,683 • Certified application counselors (e.g., community health centers, hospitals, social service agencies) • Agents and brokers • HHS Call Center; 44
    45. 45. Navigator Duties 45 Marketplaces must establish a Navigator program to provide in-person education, and eligibility/enrollment assistance. Navigators must: • Maintain expertise in eligibility, enrollment and program specifications, and conduct public education activities to raise awareness about the Marketplace. • Provide information and services in a fair, accurate and impartial manner, and help enrollees with grievances and complaints. • Help enrollees select a Qualified Health Plan. • Provide information in a manner that is culturally and linguistically appropriate, including individuals with limited English proficiency.
    46. 46. What does a CAC organization do? As a CAC organization, staff will help people understand, apply and enroll for health coverage through the Marketplace. Hospitals must agree to make sure that designated individuals complete required training, and that they comply with privacy and security laws, and other program standards. Your organization must: • Have processes in place to screen your staff to make sure that they protect consumer information • Engage in services that position you to help those you serve with health coverage issues • Have experience providing social services to the community September 18, 201346 Certified Application Counselors (CACs)
    47. 47. What Is Presumptive Eligibility (PE)? • Ability for “qualified entities” to make immediate, temporary Medicaid/CHIP determinations • Providers are paid for all services provided during temporary eligibility period • Individual must complete full Medicaid/CHIP application by end of the month after the PE determination was made in order to retain ongoing coverage • Previously, states could opt to use PE only for children and/or pregnant women in Medicaid/CHIP 47
    48. 48. Two New Ways to Use PE Two new PE options, available starting January 1, 2014: 1. States can use PE to connect adults to Medicaid (not just children and pregnant women) 2. Hospitals can use PE for any income-based population regardless of whether the state uses PE 48
    49. 49. Why Is PE An Important Enrollment Tool? 49 Allows people to connect to coverage in trusted settings when already naturally thinking about healthcare Immediate access to needed services, and providers get paid Bridge to coverage when real-time eligibility determination not possible (verification issues, system issues, natural disasters, etc.) Follow-up, referrals essential to ensure individuals are fully enrolled
    50. 50. Overview of PE Toolkit 50
    51. 51. What Happens Next? • Individual must complete full Medicaid application by the end of the month after the PE determination was made to keep Medicaid coverage. • Hospitals are paid for all services provided during PE period, regardless of a patient’s ultimate Medicaid eligibility determination. 51
    52. 52. Discussion and Q&A