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Affordable Care Act & its impact on physicians- Florida is the example state chosen for this presentation


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This presentation is an overview of the Affordable Care Act and how it has and will continue to impact physicians. The presentation is focused on the Florida market but most of the information can be applied to any state.

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Affordable Care Act & its impact on physicians- Florida is the example state chosen for this presentation

  1. 1. What to Expect with the Affordable Care Act Brief overview of what Florida physicians should changes they can expect with the Affordable Care Act Presented by: Andrew Eriksen, CMPE Warning: If you suffer from depression, please leave the room or take your medication. S
  2. 2. Introduction To be clear, this presentation is intended to be an overview, not a comprehensive analysis. The goal of this presentation is to equip you for changes that are likely to impact your practice in the coming months. Please don’t misinterpret this as a political presentation. I am addressing facts and will let the pundits bloviate over the hypothetical.
  3. 3. What Changed? S Too much to discuss in this presentation but here are few things worth mentioning: S Eliminated the preexisting condition clause, mandated S S S S certain preventative services such as mammograms, requires that all health plans use at least 80% of premium dollars on actual care and eliminates the lifetime/yearly benefit ceiling. Subsidies provided to individuals based on household income through the new insurance marketplace(once it works) Expanded Medicaid by raising the poverty line 133% Requires health plans to cover participation in clinical trials Instituted a penalty (or tax..) if you fail to obtain coverage
  4. 4. Insurance Marketplace S Created to promote competition and theoretically drive down costs S Health plans are not required to participate and individuals are not required to buy insurance through the exchange. S Aetna, Avmed, BCBS, Coventry/First Health (now part of Aetna), Molina, Humana & Sunshine State are participating in the exchange. 82 plans currently offered in Florida. Plans split into 4 categories: Catastrophic, Bronze, Silver & Gold. Within these categories you have HMOs, EPOs, PPOs and HSAs. HMOs are provide the greatest value to members which is where most patients will likely end up. Only 6 of the 82 plans offered on the exchange are PPOs. S The proliferation of HMOs means lower reimbursements and an increased burden on the physicians. Fee schedules for most exchange products are an average of 10%. The EPO plans offered by BCBS rely on their HMO network but do not require a referral in most cases. They do however use the HMO fee schedule which is about 10-15% lower than the PPO fee schedule. S With the proliferation of HDHPs, it would be wise to develop ways within the office to collect more of what a patient owes prior to claim adjudication. This is commonly referred to as Real Time Claim Adjudication. This may be unpopular with some of your patients, but it could save your office from a lot of bad debt.
  5. 5. How has it helped?
  6. 6. Florida’s Exchange Individual Monthly Health Insurance Premiums Before and After PPACA Gross Annual Premium Comparison HMO / PPO Offering Plans On the Federal (1) Exchange (Yes/No) Florida File Log Number(s) Marketwide Average Monthly Premium per Person Before (2) PPACA Each Company’s Statewide Average Monthly Premium per Person After PPACA Aetna Life Insurance Company PPO Yes 13-08779 $243 Blue Cross Blue Shield Of Florida Cigna Health And Life Insurance Company PPO Yes 13-09201 PPO Yes Coventry Health Care Of Florida, Inc. HMO Florida Health Care Plan, Inc. Silver Plan Comparison Percent Change Adjusted Standard Risk Rate (3) Premium Each Company’s Statewide Average Silver Plan Premium Percent Change $296 21.7% $293 $422 44.2% $243 $361 48.3% $293 $384 31.2% 13-08574 $243 $377 55.3% $293 $437 49.2% Yes 13-08330 $243 $343 41.2% $293 $366 25.1% HMO Yes 13-10554 $243 $324 33.3% $293 $396 35.2% Health First Insurance Company PPO Yes 13-11036 $243 $360 48.2% $293 $373 27.5% Health Options, Inc. HMO Yes $243 $350 44.1% $293 $400 36.7% Humana Medical Plan, Inc. HMO Yes 13-09200 13-06858, 13-06046, 13-06203 & 13-10233 $243 $278 14.3% $293 $315 7.6% Molina Healthcare Of Florida, Inc HMO Yes 13-08632 $243 $412 40.8% $293 $411 40.6% Preferred Medical Plan HMO Yes 13-12081 $243 $331 36.3% $293 $385 31.4% Sunshine State Health Plan Inc Average Change HMO Yes 13-08611 $243 $362 48.7% 39.3% $293 $464 58.8% 35.2% Company (1) A plan available through the Federally-Facilitated Exchange (FFE) may or may not be available outside of the FFE. (2) The before PPACA rates are determined using the “CY 2012 Accident and Health Gross Annual Premium” report trended at 8.9%. The comparison is done on a marketwide basis.
  7. 7. Meet your New PatientMedicaid Reform S Approximately 1 million new lives in Florida due to the poverty level being raised by 133% S Medicaid expansion eliminates straight Medicaid and turns over all current members to the managed care plans. Florida is divided into 11 regions with each region having approximately 3-6 managed care plans. S Opportunities for internal medicine trained physicians to attest and receive Medicare rates. PCPs receive Medicare funds for participating but do not have specialists to refer to. This creates obvious access issues which will likely result in better payments for specialists in the near future. S Currently, Medicaid pays approximately 60% of Medicare to specialists. There is a spreadsheet in Box folder with an analysis comparing Medicare and Medicaid for our most common codes. S Sunshine State, Wellcare and UHC are and will continue to have the most Medicaid members in Central Florida.
  8. 8. Regions in Florida
  9. 9. Medicaid Plans in Central Florida
  10. 10. Medicare & Where your Patients Went S P4P, Shared Savings and Captitated contracts are, and will continue to be, a focus for Medicare and commercial payers. Captitation is utilized heavily within the Medicare advantage market through shared risk agreements between IPAs and MSOs. They receive a PMPM fee for each member and based on their performance, share in the profit or loss. S PCPs are required to be part of an IPA now for many Medicare advantage plans. Some of the plans in Central Florida are Wellcare, Freedom/Optimum and PUP or Physicians United Plan. S Utilize ACOs to incentivize physicians to start thinking of ways to save money. While it’s a noble concept and certainly nothing new, it carries with it the potential for severe access and quality issues. ACOs have to save a minimum of 4% in order to share in the savings which means we can expect them to be very aggressive if they want to see a return on their investment. ER diversion is a primarily how they save but another easy way is to limit referrals to specialists. Hospitals have combatted this issue by joining ACOs or creating their own ACO with a group of their “preferred” physicians. S Access to specialists and ancillary services is being restricted through a Gate Keeper mentality and financial incentives tied to saving Medicare dollars S able_care_act.html
  11. 11. Closing The financial burdens of medicine have never been greater, but that is not a reason to change the way you practice. Patient centered, outcome based medicine, will always create value for the payers and loyalty among patients and referring physicians.