Florida Blue Health Care Policy Overview: Agent CEU Course

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  • EXHBIT 4A
  • Florida Blue Health Care Policy Overview: Agent CEU Course

    1. 1. Health Care Policy in a NutshellHealth Care Policy in a NutshellHealth Care Policy in a NutshellHealth Care Policy in a Nutshell 1
    2. 2. Welcome!Welcome!Welcome!Welcome! Our one-hour session today will cover Health Care Policy, including:  Background and History of Health Policy  Cost, Access, and Quality  Proposed Solutions 2
    3. 3. Background and History ofBackground and History of Health PolicyHealth Policy Background and History ofBackground and History of Health PolicyHealth Policy 3
    4. 4. History of Health System and PolicyHistory of Health System and PolicyHistory of Health System and PolicyHistory of Health System and Policy  Transformation of hospitals and the role of physicians  The role of government • Presidents Teddy Roosevelt, Truman, Clinton and Obama • Medicare and Medicaid • HMO Act of 1973 - Nixon • 1997-SCHIP • 2010 Health Care Reform 4
    5. 5. History of Health System and PolicyHistory of Health System and PolicyHistory of Health System and PolicyHistory of Health System and Policy Employers  World War II Health Insurers  1847-First comprehensive group policy offered by Massachusetts Health Insurance of Boston.  1929 First Blue Cross Plan  Managed Care – Mid-1990’s 5
    6. 6. Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders?Who are the Stakeholders? 6
    7. 7. Who Pays What?Who Pays What?Who Pays What?Who Pays What? Hospital Payment/Cost Ratios  Private Payers - 110% to 130%  Medicare – 92% - 102%  Medicaid – 80% - 95% Private payers pay higher reimbursement rates to physicians Source: Feldstein 7
    8. 8. Health Care System DynamicsHealth Care System DynamicsHealth Care System DynamicsHealth Care System Dynamics  DRG payment system  Managed Care • Provider Response • Consumer Response  Accountable Care Organizations, Shared Savings and Patient Centered Medical Homes • Provider Response • Payer Response 8
    9. 9. The Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care PolicyThe Iron Triangle of Health Care Policy 9
    10. 10. Health Care CostHealth Care CostHealth Care CostHealth Care Cost 10
    11. 11. 2012 National2012 National Health Care Expenditure DataHealth Care Expenditure Data 2012 National2012 National Health Care Expenditure DataHealth Care Expenditure Data Total Health Care Expenditures  $2.823 Trillion Hospital Care  $873.1 Billion (31%) Physician  $542.9 Billion (19.2%) Prescription Drugs  $290.2 Billion (10.3%) Source: CMS https://www.cms.gov/NationalHealthExpendData/downloads/tables.pdf 11
    12. 12. Total Health Expenditure per Capita,Total Health Expenditure per Capita, U.S. and Selected CountriesU.S. and Selected Countries Total Health Expenditure per Capita,Total Health Expenditure per Capita, U.S. and Selected CountriesU.S. and Selected Countries 12
    13. 13. What are the cost drivers?What are the cost drivers?What are the cost drivers?What are the cost drivers?  Medical Technology  Payment structure (fee for service)  Fraud, waste and abuse  Tax incentives  Tort liability  Lifestyle 13
    14. 14. Health Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and FloridaHealth Care Costs and Florida • $132 billion in state health expenditures in 2009 • $23 billion on Medicaid (including federal share) • Medicaid Reform • Medicaid Expansion 14
    15. 15. Medical Treatment vs. PreventionMedical Treatment vs. PreventionMedical Treatment vs. PreventionMedical Treatment vs. Prevention Intervention Number of Lives Saved per 1,000 Additional Participants Cost per Life Saved NICU’s 2.8 $4,778 Prenatal Care 4.5 $39 15
    16. 16. Health Care AccessHealth Care AccessHealth Care AccessHealth Care Access 16
    17. 17. Two Major FactorsTwo Major FactorsTwo Major FactorsTwo Major Factors  Ability to pay  Labor supply versus demand 17
    18. 18. Ability to PayAbility to PayAbility to PayAbility to Pay  Approximately 16.3% of Americans are uninsured.  Approximately 21% of Floridians are uninsured.  Education, jobs and health insurance 18
    19. 19. Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?Expanding Coverage Through the ACA?  Medicaid and Subsidies  Polarized political climate  State and federal budget concerns  Lingering legal issue regarding federal exchanges 19
    20. 20. Supply of Primary Care PhysiciansSupply of Primary Care PhysiciansSupply of Primary Care PhysiciansSupply of Primary Care Physicians  2007 survey showed that only 7% of medical students planned to go into primary care.  In Florida, 37% of non-federal physicians practice primary care, compared to 39% throughout the United States.  15.1% of Floridians are underserved compared to 11.4% nationwide. Source: Kaiser Family Foundation 20
    21. 21. Outlook for Physician DemandOutlook for Physician DemandOutlook for Physician DemandOutlook for Physician Demand  Population growth  Aging population  Per capita income increasing, so use of physicians are increasing  More technology  Increased use of lab tests and imaging services  Calls for more medical schools 21
    22. 22. Outlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician SupplyOutlook for Physician Supply  Decreased work effort expected  Advanced Non-Physician Practitioners  Aging physicians: 61% are 45 or older 22
    23. 23. QUALITYQUALITYQUALITYQUALITY Health Care QualityHealth Care QualityHealth Care QualityHealth Care Quality 23
    24. 24. Definition of QualityDefinition of QualityDefinition of QualityDefinition of Quality “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Source: IOM 24
    25. 25. Quality:Quality: Who measures it and how?Who measures it and how?Quality:Quality: Who measures it and how?Who measures it and how?  Service quality  Clinical quality • Process • Outcomes 25
    26. 26. OpportunitiesOpportunitiesOpportunitiesOpportunities  Americans receive evidence based care 55% of the time  Medical errors cost the health care system $17.1 billion nationally  Death rates from cancer, heart disease and stroke are higher among ethnic minorities in Florida  Defensive medicine 26
    27. 27. Health Care ProposalsHealth Care ProposalsHealth Care ProposalsHealth Care Proposals 27
    28. 28. ThemesThemesThemesThemes  Cover the uninsured  Improve quality while increasing efficiency within the delivery system  Wellness and prevention 28
    29. 29. High Level ACA IssuesHigh Level ACA IssuesHigh Level ACA IssuesHigh Level ACA Issues  Expansion of coverage through Medicaid and subsidies  Health insurance market reforms and exchanges  Quality demonstration projects  Public health initiatives 29
    30. 30. ProposalsProposalsProposalsProposals  Universal coverage (various varieties)  Aggressive outreach to those that are currently eligible for public programs but are not enrolled  Sustainable public programs  Bolster primary care workforce 30
    31. 31. ProposalsProposalsProposalsProposals  Robust health information network  Comparative effectiveness research  Collaboration among patients, providers and payers 31
    32. 32. ProposalsProposalsProposalsProposals  Allow for creative and iteratively innovative approaches to the coordination and delivery of services that focuses on the patient and increases quality and efficiency  Efforts to address health care disparities and health literacy 32
    33. 33. ProposalsProposalsProposalsProposals  Maintaining healthy competition within the delivery system  Maximize efforts to reduce fraud, waste and abuse in the health care system • Tort reform • Greater investment in law enforcement • Use HIT to eliminate duplication and other waste 33
    34. 34. ProposalsProposalsProposalsProposals  Adequately fund safety net programs to expand coverage to vulnerable populations, that is fiscally sustainable  Encourage worksite wellness programs  Strategically craft public health initiatives that will have the largest impact 34
    35. 35. Grow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic ConstraintsGrow, Pay or Cut? Economic Constraints  Medicare  Gross Domestic Product  Federal Taxes 35
    36. 36. Unauthorized EntitiesUnauthorized EntitiesUnauthorized EntitiesUnauthorized Entities An entity that is required to be licensed or registered with the Florida Office of Insurance Regulation but is operating without the proper authorization is identified as an unauthorized insurer.  All persons have the responsibility of conducting reasonable research to ensure they are not writing policies or placing business with an unauthorized insurer.  Any person who, directly or indirectly, aids or represents an unauthorized insurer can lose their licenses or face other disciplinary sanctions. Please see section 626.901, Florida Statutes, to read the laws.  Lack of careful screening can result in significant financial loss to Florida consumers due to unpaid claims and/or theft of premiums.  Under Florida law, a person can be charged with a third-degree felony and also held liable for any unpaid claims and refund of premiums when representing an unauthorized insurer.  It is the person’s responsibility to give fair and accurate information regarding the companies they represent. 36

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