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INTRO TO US HEALTH POLICY
- 1. INTRO TO HEALTH POLICY Rachel Solnick, MD MSc EMRA Board of Directors, Director of Health Policy Yale Emergency Medicine @RachelSolnickMD Laura Medford-Davis ACEP YPS Legislative Advisor Baylor College of Medicine @MedfordDavis
- 2. ■ Overview of US healthcare ■ Advocacy issues ■ Legislative landmarks ■ Current trends ■ Active legislative issues Contents
- 4. US healthcare “system:” Not designed, a patchwork of fixes
- 5. 20% Households Private business 28% Other private revenues 7% 17% Federal government 28% State & local government Rule #1: Government pays biggest portion of healthcare (45%) SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group, 2016 National Health Expenditure Accounts HEATLHCARE: 17.9% OF GDP Original source of all healthcare funds % of total payments
- 6. Medicare: massive part of government budget, and rising Managed by: • Government • Private insurance SOURCE: Kaiser Family Foundation interpretation of Congressional Budget Office, Budget and Economic Outlook, 2017 to 2027 (January 2017) Breakdown of total Federal outlays of $3.9T, %
- 7. Medicaid: joint federal and state funding SOURCE: Kaiser Family Foundation interpretation of Federal register, January 21, 2014 (Vol 79, No 13), pp 3385-3588 Proportion of Medicaid funded by the federal government in each state
- 8. Medicaid: covers kids, spends on disabled SOURCE: Center on Budget and Policy Priorities, Spending and enrollment estimates for FY2015 from the CBO’s March 2016 Medicaid baseline
- 9. Medicaid expansion SOURCE: Status of State Action on the Medicaid Expansion Decision. Kaiser Family Foundation State Health Facts, updated April 5, 2018 Expanded Not expanded
- 10. HHS policies impact 1 out of every 2 Americans Department of Health and Human Services (HHS) CDC FDA NIH CMS Government administration: HHS, et al.
- 11. Contents ■ Overview of US healthcare ■ Advocacy issues ■ Legislative landmarks ■ Current trends ■ Active legislative issues
- 12. Rule #2: Policy happens at all levels, through multiple avenues Clinical Setting Local State Federal Legislative • Tort reform • Balance billing • ACA Regulatory • Sugary beverage tax • FSEDs • Quality measures Judicial • Reproductive health limitations • Medicaid expansion • Measles outbreaks • Violent animal reporting Other • State medical board • Executive orders • ACEP • NEMPAC • City or county medical societies • Sepsis alerts • Hospital by- laws
- 13. Rule #2: Policy happens at all levels, through multiple avenues Clinical Setting Local State Federal Legislative • Tort reform • Balance billing • Marijuana • ACA Regulatory • Sugary beverage tax • FSEDs • Quality measures Judicial • Reproductive health limitations • Medicaid expansion • Measles outbreaks • Violent animal reporting Other • State medical board • Executive orders • ACEP • NEMPAC • City or county medical societies • Sepsis alerts • Hospital by- laws
- 14. Rule #2: Policy happens at all levels, through multiple avenues Clinical Setting Local State Federal Legislative • Tort reform • Balance billing • Marijuana • ACA Regulatory • Sugary beverage tax • FSEDs • Quality measures Judicial • Reproductive health limitations • Medicaid expansion • Measles outbreaks Other • State medical board • Executive orders • ACEP • NEMPAC • City or county medical societies • Sepsis alerts • Hospital by- laws
- 15. Rule #2: Policy happens at all levels, through multiple avenues Clinical Setting Local State Federal Legislative • Tort reform • Balance billing • ACA Regulatory • Sugary beverage tax • FSEDs • Quality measures Judicial • Reproductive health limitations • Medicaid expansion • Measles outbreaks Other • State medical board • Executive orders • ACEP • NEMPAC • City or county medical societies • Sepsis alerts • Hospital by- laws
- 16. Rule #2: Policy happens at all levels, through multiple avenues Clinical Setting Local State Federal Legislative • Tort reform • Balance billing • ACA Regulatory • Sugary beverage tax • FSEDs • Quality measures Judicial • Reproductive health limitations • Medicaid expansion • Measles outbreaks Other • State medical board • Executive orders • ACEP • NEMPAC • City or county medical societies • Sepsis alerts • Hospital by- laws
- 17. Contents ■ Overview of US healthcare ■ Advocacy issues ■ Legislative landmarks ■ Current trends ■ Active legislative issues
- 18. • 1986: Emergency Medical Treatment and Labor Act (EMTALA) • 1994-1999: Prudent Layperson Standard • 2010: Affordable Care Act (ACA) • 2015: Medicare Access and CHIP Reauthorization Act (MACRA) Rule #3: Patient protections shaped our legislative past A B C D
- 19. A 1986 – EMTALA Emergency Medical Treatment and Labor Act • “People have access to healthcare in America. After all, you just go to an emergency room.” --George W. Bush • Anyone presenting to an ED must be stabilized regardless of their ability to pay • Unfunded mandate
- 20. B 1994-2010 – Prudent Layperson Standard • Emergency = immediate threat to health, body function, body organ or part, pregnancy, regardless of final diagnosis • 1994 – Defined in EMTALA update • 1997 – Balanced Budget Act defined it for Medicaid • 2010 – Defined federally by the ACA
- 21. C 2010 – Affordable Care Act (ACA) Aims • Increase coverage • Protect patients ‒ Essential health benefits including ED ‒ No exclusions for pre-existing conditions ‒ No lifetime limit Status • Uninsured rate dropped ~17% to 10% • ED visits continue to rise ~5% • Decreased uncompensated care by $7.4 B
- 22. ED Visits continue to rise
- 23. D 2015 – MACRA Medicare Access and CHIP Reauthorization Act • 2 tracks: MIPS or APMs • Started last year • Up to 9% reduction in reimbursement by 2020 • Reimbursement impact lags by 2 years, and can follow you to your next job • EM-specific quality measures • ACEP CEDR • Example: CT use for head trauma Doesn’t apply to EM *yet* • Must attest • Example: use state PDMP opioid website Doesn’t apply to EM
- 24. AHCA BCRA Skinny repeal Cassidy Graham Most ACA repeal efforts would have increased uninsured rates, decrease Medicaid rates
- 25. AHCA BCRA Skinny repeal Cassidy Graham Most ACA repeal efforts would have increased uninsured rates, decrease Medicaid rates
- 26. AHCA BCRA Skinny repeal Cassidy Graham Most ACA repeal efforts would have increased uninsured rates, decrease Medicaid rates
- 27. AHCA BCRA Skinny repeal Cassidy Graham Most ACA repeal efforts would have increased uninsured rates, decrease Medicaid rates
- 28. AHCA BCRA Skinny repeal Cassidy Graham Most ACA repeal efforts would have increased uninsured rates, decrease Medicaid rates
- 29. Contents ■ Overview of US healthcare ■ Advocacy issues ■ Legislative landmarks ■ Current trends ■ Active legislative issues
- 30. Rule #4: Consumers are paying more out of pocket SOURCE: Kaiser Family Foundation analysis of Truven Health Analytics Marketplace Commercial Claims - as seen in The Wall Street Journal Change in out-of-pocket health costs, 2004-2014, % Deductibles Coinsurance Worker’s wages Copayments 300 250 200 150 100 50 0 -50
- 31. Percent of Covered Workers in a Plan That Includes a Deductible, 2006-2016
- 32. Average deductibles >$1,200 for Employer- Sponsored insurance and >$2,900 for Obamacare
- 33. Narrow networks, balance billing, confused patients SOURCE: Kaiser Family Foundation/New York Times Medical Bills Survey (conducted August 28-September 28, 2015) of insured households with difficulty paying their medical bills in past 12 months 69% 28% Yes No Don’t know 4% Patient awareness that a provider was OON prior to receiving OON bill, %
- 34. Cost burden causes insured patients to struggle with affordability of healthcare 26 32 75 Received care from an out-of-network provider, and insurance would not cover or would only cover a portion Submitted a claim to insurance but the claim was denied Copays, deductibles, or coinsurance were more than they could afford SOURCE: Kaiser Family Foundation/New York Times Medical Bills Survey (conducted August 28-September 28, 2015) of insured households with difficulty paying their medical bills in past 12 months Reasons insured patients had difficulty paying medical bills, %
- 35. Shift to value-based care, across the entire acute care continuum • “Value” = Low Cost + High Quality • Bundle payments across acuity spectrum • Will ED be asked to prevent admissions, readmissions?
- 37. Accountable care organizations Shared savings/ risk Data sharing Coordination Quality ACO
- 38. Regulatory reform : ACEP’s Alternative Payment Model- Acute Unscheduled Care Model
- 39. Mergers, consolidation 2005-2015 SOURCE: Economist interpretation of Irving Levin Associates, through June 23, 2015 Potential impacts on: • Patient prices • Provider rates
- 40. All EDs are Geriatric EDs
- 41. Take homes 1. Government pays for a huge portion of healthcare, plays big role 2. Many avenues for health policy / advocacy 3. Laws protect patients (e.g., EMTALA, prudent layperson) 4. As health costs rise, payers are passing more costs onto the patient (deductibles) and the provider (value based payments).
- 42. Contents ■ Overview of US healthcare ■ Advocacy issues ■ Legislative landmarks ■ Current trends ■ Active legislative issues
- 43. Active issues • Health Care Safety Net Enhancement Act Extend Federal Tort Claims Act liability protections for on- call/ ED docs • Alternatives to Opioids (ALTO) in the Emergency Department Act ( HR 5197)- $30M to test ALTO protocols • Preventing Overdoses While in Emergency Rooms (POWER) Act ( HR5176)- $50M establish policies/ procedures for initiating MAT in ED, warm hand offs to community providers • Pandemic All-Hazards Preparedness Act (PAHPA) • Prudent layperson standard issues with payers • Drug shortages- request to FDA to convene task force to investigate issue
- 44. Find your avenue, stay involved! •Sign up • ACEP 911 Network • State chapter • EMRA Health Policy Committee/ ACEP committee •Donate to NEMPAC •Give-a-shift resident $ 120 •Learn • Policy research, Write opinion articles • Podcasts: Pulse Check by Politico , What the Health KHN|website: KFF| blogs: PolicyRx.org
- 45. Thank you! Questions? Rachel Solnick, MD MSc EMRA Director of Health Policy Rachel.solnick@gmail.com @RachelSolnickMD Laura Medford-Davis ACEP YPS Legislative Advisor Baylor College of Medicine @MedfordDavis
Editor's Notes
- Health does not exisit in a bubble, probably moreso than in any other field do we see the effects of other problems in society. Getting involved in policy is our chance to help make upstream solutions to the problems we encounter everyday in the ER, and our opportunity to help prevent some of the societal ills we so often see the downstream effects of.
- We have the best healthcare ( tech/ meds/ doctors) and also some of the worse healthcare (infant mortality lower than it should be/ most expensive by far/ only one w.o universal healthcare) Why no universal healthcare? Perhaps employer sponsored insurance- as part of WWII, govt inventivized employer sponsored insurance as tax free, since then unable to break from employer sponsored Gov attempted fill in gaps for non employed ppl w gov sponsored coverage for old, poor, kids, uninsured Despite that, more leaks springing! Ie supreme court essentially stopped Medicaid expansion to some states, CHIP went unfunded Healthcare advocacy Constant challenged to fill gaps bc harder to rebuild foundation Before we move on quiz on how much govt pays for healthcare
- Govt pays 45% of all healthcare Why does this matter? Bc who whas the purse has the power! Optionally present: State/local/ fed gov pays into: private insurance (via premiums to Medicare advantage and managed care organizations for Medicaid), Medicare, Medicaid Private business pays into: health insurance, taxes through employer sponsored tax benefits Households pays into: out of pocket, health insurance ( premiums/ copay/deductible/coinsurance) Before next slide- what cost govt more, national defense of medicare?
- National defense spending is similar percent of fed budget as medicare! Medicare, founded in 1965 as amendment to Social security act, is govt insurance for old ppl ( > 65) At time created, half >65 yo didn’t have insurance! Since then grown more complicated, added on drug coverage by George W Bush, now 1/3 administered by private insurance through Medicare Advantage Funded from a combination of general revenue, pay roll tax,and much smaller part is premiums
- Medicaid is govt insurance for poor people and kids Also started in 1965 at same time Medicare started Medicaid co-funded by varying degrees by state/ feds Medicaid is largest source of federal revenue for states! poorer states receiving larger amounts ( 50%- 73.5%) Federal law specifies core requirements, such as mandatory benefits and mandatory groups that must be covered as a condition of receiving federal Medicaid funding. However, beyond the core requirements, states have broad flexibility regarding optional eligibility groups, optional benefits, provider payment, delivery systems, and other aspects of their programs. Side Notes: The amount of Federal payments to a State for medical services depends on two factors. The first is the actual amount spent that qualifies as matchable under Medicaid and the FMAP. The Federal Medical Assistance Percentage (FMAP) is computed from a formula that takes into account the average per capita income for each State relative to the national average. By law, the FMAP cannot be less than 50%.. Early evidence from states that have adopted the Medicaid expansion indicates there are state budget savings both within Medicaid budgets and outside of Medicaid. Early evidence from some expansion states also indicates budget savings from either the reduced need for or the replacement of state spending on programs for behavioral health, corrections, public health and uncompensated care because of the federal funds for increased coverage in the expansion
- In 1997 Medicaid was expended to cover children Most recipients of Medicaid are Children, most money is spent on adults/ disabled Of note Medicaid covers 40% of all long term care in the US, so when you think of who pays for nursing homes, think Medicaid .this is bc nursing homes cost 90K per year, most ppl cant afford that for very long so they spend their personal savings down until they quality for Medicaid bc they have nothing left.
- In part bc of this state control (beyond fed minimums), large variation in what benefits/ who is covered by their Medicaid coverage With supreme court ruling, expanding Medicaid made optional Map shows that many states in south/ Midwest haven’t expanded Coverage gap-2.6 mil in states that didn’t expand make too little for individual marketplace subsidies, and don’t qualify for Medicaid bc states didn’t increase minimum threshold
- Health and Human Services (HHS) is the federal agency that oversees the administration of health service related centers and programs in the United States. Administration matters bc it writes the regulations that detail how the laws will be further developed/ enforced. CMS is the agency responsible for administering Medicare, working with state legislators to administer Medicaid and the State Children’s Health Insurance Program (SCHIP). Medicare dollars have been largely responsible for funding residency training, or Graduate Medical Education (GME), though the funding has been flat from Medicare in creating new slots since a Balance budget cap in 1997. Hpspitals have stepped in to fund new resident slots since then. .
- Would add pics here
- As a reaction to pt dumping- where private hospitals would send away unstable pt who had no insurance to county hospitals, pt were injured/ died bc of delays of care Applies to hospitals participating in Medicare- ie all hospitals EMRALA is great bc it means we see everyone regardless of who they are/ insurance status, but this makes us more vulnerable to disproportionate amount of uncompensated care/ undercompensated care compared to other non urgent specialties who can decide to not see certain patients, hence referred to as unfunded government mandate
- Emergency = if a layperson expects the absence of immediate medical attention would jeopardize health, body function, body organ or part, pregnancy, regardless of final diagnosis Example: chest pain is an emergency, even if final diagnosis is GERD Before this, pt have to get approval by pcp/ insurance to go to the ED, obviously delaying care EMTALA said EDs mandated to see pt, PLS in a way says insurers need to provide coverage for the pt that thinks they have an emergency, ie that EDs should to be paid by insurance companies even if final dx wasn’t an emergent condition, the presenting symptom qualifies it as a emergency if the prudent layperson (ie man on the street) thinks so
- Aims Increase coverage Insurance marketplaces with tax credits Medicaid expansion parents’ insurance ->age 26 Patient protections Essential health benefits including ED care No exclusions for pre-ex No lifetime limit Free preventative care Results 20M newly insured; uninsured rate dropped ~17% to 10% ( historic low!) ED visits continue to rise (~5%) Decreased uncompensated care by $7.4 B (The economic impacts of Medicaid expansion, uncompensated carecosts and the Affordable Care Act. ASPE Issue Brief. Washington, DC.2015.) Arijit Guha, student who battled Aetna 2012 His insurance policy had a lifetime cap of $300,000. Between his chemotherapy and operations to remove part of his colon, his gallbladder and his abdominal lining, Guha quickly reached that limit. Aetna CEO Bertolini got involved, covered the expenses ("I am glad we connected today and got this issue solved." Bertolini responded. "I appreciate the dialog no matter how pointed. I've got it and own it!...This chapter is another step in the journey. The system is broken, and I am committed to fixing it.”)
- Information from benchmarking alliance, visits continue to rise
- SGR sustainable growth rate formula was finally overturned and replaced w MACRA First reporting period 2017! payment implemented 2019 MIPS merit based incentive payment or APMs advanced Alternative payment models Most ED involved in MIPS, some APM model proposals pending approval It’s budget neural/ zero sum game ie if someone does well with percent incr in medicare reimbursement then someone else must lose (so if everyone is doing well on a quality metric, then no diff btwn providers, gov might create diff metric) \: 1–2% of payments to a +/- 9% payment by 2022. Medicare ~ 18 % of ER pt Example of some official CMS EM specific quality metrics Possibllity for CEDR reporting ED specific Avoid abx & CT for adult sinusitis CT use in minor head trauma Avoid abx for acute bronchitis in adults Appropriate testing and tx of children w/ pharyngitis Topical rather than systemic abx for otitis externa
- In 2017, GOP was in heated battle to try to repeal and replace ACA All efforts failed but some got far along path to becoming a bill Generally tried to cut costs by cutting Medicaid, this would have left millions uninsured, or with bad insurance plans ACEP action alerts were part united front from doctor orgs, hospital and insurer groups to kill previous reform attempts, through ACEP 911 grassroots network of emails. A First Action Alert An iteration of that legislation known as the American Health Care Act (AHCA), or H.R. 1628, in late March contained language that would potentially strip away mandatory insurance coverage of emergency medical care. Our first Action Alert urged House members to instead maintain the protections that patients currently have in accessing emergency medical care, and made it clear thatACEP could not support legislation unless it did so. Many of you responded, and your voices were heard among tens of thousands of other advocates across the country – House leadership pulled the AHCA from consideration just hours before the House was scheduled to vote on the bill. House Passage The following month the House released a newly revised AHCA, and through another Action Alertwe urged Members of Congress to vote against it. This version of the bill also would have allowed insurance plans to be sold that do not cover emergency medical care as an essential health benefit, would lead to more Americans not having any health coverage at all, and would do little to improve our nation’s health. Yet under enormous pressure from past campaign promises, the House narrowly approved (217 to 213) the American Health Care Act on May 4 despite the opposition of a host of stakeholders including ACEP, the American Hospital Association, AARP, the AMA, and many, many others. On to the Senate In June, we turned our efforts to the U.S. Senate where ACEP leadership and staff continued to meet with key members of the Senate engaged in developing that chamber’s version of ACA repeal and replace. Although we initially believed the Senate’s version of the legislation would be much more in line with our emergency medicine principles, the process and the final product were in fact much worse. ACEP issued a statement in late June that was deeply critical of the draft health care legislation introduced in the Senate, known as the Better Care Reconciliation Act, or BCRA. We continued to hold out hope that given ample opportunity to discuss and amend the gaping holes in this legislation, it would improve. But our concerns, which were shared by virtually every other medical group, went unheard. We put out a new Action Alert to urge Senators to vote ‘no’ on BCRA because it made sweeping changes to the health care system that directly contradicted ACEP’s principles and endangered patient safety and patients’ lives, and cited a recent Morning Consult poll in which Americans overwhelmingly — 95 percent — wanted health insurance companies to be required to cover emergency medical care. A Dramatic Finale After a tumultuous week of scrambling and last-minute changes to the bill by Senate Republican leadership to get enough votes, Sens. Susan Collins (R-ME), Lisa Murkowski (R-AK) and John McCain (R-AZ) joined all Senate Democrats early Friday morning to defeat a significantly pared down “skinny repeal” bill, effectively ending (at least for now) Republican efforts to repeal or even significantly modify the Affordable Care Act (ACA).
- AHCA- American Health Care Act- would have made healthcare much more expensive for esp rural and older americans, passed House then died
- Better Care Reconcilliation Act- would have jeopardized Essential Health Benefits package, which includes EM coverage, died after passing Senate
- Skinny repeal and Cassidy Graham ( block grants for Medicaid) didn’t get much traction
- Skinny repeal and Cassidy Graham ( block grants for Medicaid) didn’t get much traction
- http://blogs.wsj.com/economics/2016/08/25/5-things-to-know-about-health-care-spending-in-the-u-s/ Private insurance plans have gotten slightly less generous, according to an analysis of claims by millions of policyholders undertaken by the nonprofit health-care research group the Kaiser Family Foundation. That’s bad news for the majority of people—about 55% of Americans under 65 in 2014—with health-care coverage through an employer. Most of the cost-shifting is courtesy of rising deductibles, which for single workers grew by 67% between 2010 and 2015, roughly seven times as much as wages grew over the same period, according to the Kaiser Family Foundation’s 2015 Employer Health Benefits Survey. The same survey found premium growth has slowed to an average of 5% per year since 2005, down from 11% average annual growth between 1999 and 2005. This trend is set to continue: The CMS expects more people to gain coverage under high-deductible plans in coming years.
- Narrow networks – incr surprise insurance gaps - Narrow-network plans have grown in popularity, particularly on the Affordable Care Act's insurance exchanges, because their cheaper premiums appeal to price-sensitive consumers. About 70% of plans sold on the exchanges in 2014 featured a limited network, and their premiums were up to 17% cheaper than plans with broader networks, according to a study by consulting firm McKinsey&Co. Regardless of what happens legally or politically with the healthcare reform law, narrow-network plans are likely to continue proliferating because of those price advantages. 34 % fewer doctors accept ACA insurance compared to private With such limited doctors, pt often stuck w OON bill without realizing the doctor was out of network
- Interest in less fragmented care bundling care Acute unscheduled care spectrum ( ”Emergency medicine is a specialty, not just a location”) – future opportunities in observation, translational, post acute Example- ACOs and ED’s Increased pressure to reduce ED visit alternative sites to the ED (eg, urgent care) measures or incentives for PCP to reduce ED visits Increased pressure to reduce admission Medicare 3-day waivers (place SNF w/o 3 day hospitalization) Streamlined home care or SNF access Clinical pathways to reduce admissions Expanded care coordination Little to no financial risk/ gain w ACO participation (as of now) http://www.annemergmed.com/article/S0196-0644(17)30880-6/fulltext#appsec1
- Some quality metrics make a lot of sense 30 Day readmissions/ mortality outcomes for ACS/ CHF/ PNA Other metrics of more questionable validity- patient experience of care survey- HCAPHS. Concerns: Hospitals that serve the highest volume of uninsured and underinsured patients, and patients of low socioeconomic status, have struggled on patient perceptions of satisfaction relative to wealthier health systems, (https://smhs.gwu.edu/urgentmatters/news/edcahps-and-changing-landscape-ed-performance-measurement) have less funds to spend on amenities/ get worse scores and worse medicare reimbursements Uni of Cincinnati is one of the best em programs in the country, but hospital only has 2/ 5 stars on pt experience surveys
- Still waiting for the PTAC (physician technical advisory council) to weigh in on this – essentially taking financial risk (w potential benefit) for elderly pt who presented with syncope over 30 day course after ED Source: https://aspe.hhs.gov/system/files/pdf/255906/LOIACEP.pdf super prelim
- Consolidation pushes up prices, less known about quality outcomes. hospitals merging, physician groups merging, (more docs are employed) insurers and other health care groups
- By 2050, one-fifth of the total U.S. population will be aged 65 or older, up from 12 percentin 2000. The associated increase in individuals requiring assistance for chronic illness and1functional decline will put a strain on the health system’s ability to pay for and care for them.
- EMTALA Liability protection for on-call/ emergency physician: “Health Care Safety Net Enhancement Act.” Extends Federal Tort Claims Act liability protections to on-call and emergency physicians, same as Community Health Centers and health centers. EMS issues: "Protecting Patient Access to Emergency Medications Act," Continue access to pain and anti-seizure medications under EMS care by permitting medical directors to issue standing orders Clarifies who can give verbal orders; Option for single EMS agency registration; Synthetic drugs: Add 300 synthetic substances to Schedule I of the Controlled Substances Act while providing an exemption for legitimate research purposes