The symposium is designed for clinicians – physicians, nurses, nurse practitioners, physician assistants, and students – and healthcare executives interested in expanding their scope of knowledge about currently popular health policy topics. This presentation is by Dr. Seth Trueger. Dr. Trueger is an emergency physician in Chicago whose interests include social media for health professions, payment and delivery reform, crowding, airway, and resuscitation. He is the Assistant Social Media Editor for Annals of Emergency Medicine. He worked as a health fellow / legislative aide in the office of Congressman John Dingell (D-MI) from 9/2013-3/2014 (while still seeing patients, of course). And since January 1, 2013, has served as the Social Media (Twitter) Editor for Emergency Physicians Monthly. You can follow him on Twitter @MDAware or online at MDAware[dot]org.

1. ACA: Evidence-Based
Update
Seth Trueger, MD, MPH
Assistant Professor
Emergency Medicine
University of Chicago
@MDaware

2. DISCLOSURES
Emergency Physicians Monthly
Medical Society of Virginia Foundation
Heart Course: Emergency
Daiichi Sankyo
Medical College of Wisconsin

3. (bias?)

8. Plan
Enrollment & Penalties
Subsidies/CSR
Plans (premiums, OOPs, networks)
Expansion (states, DSH)
Provider impact
Payment reform (ACOs, HRRP, HVBP)

9. ENROLLMENT
stolen mostly from Charles Gaba

12. 2015 Enrollment
Marketplaces
Medicaid

13. 2015 Enrollment
Marketplaces

16. 2015 Enrollment
11 million paid QHP

17. 2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP

18. 2015 Enrollment
Medicaid

20. 2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion

21. 2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
3.4 million Medicaid woodworkers

22. 2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
3.4 million Medicaid woodworkers
950,000 bulk transfers

23. 2015 Enrollment
11 million paid QHP
9 million off-Exchange QHP
9.08 million Medicaid expansion
3.4 million Medicaid woodworkers
950,000 bulk transfers
~50 million traditional Medicaid

25. RAND study
net increase of 16.9 million

26. RAND study
net increase of 16.9 million
22.8 million newly insured

27. RAND study
net increase of 16.9 million
22.8 million newly insured
5.9 million lost coverage

28. RAND study
net increase of 16.9 million
22.8 million newly insured
5.9 million lost coverage
uninsured: 42.7 million to 25.8 million

29. insurance gains
9.6 million increase in employer plans
1.5 million other
(Medicare, military insurance, state plans)

30. individual mandate?

31. individual mandate?
improving economy/employment?

32. 5.9 million lost coverage

33. 5.9 million lost coverage
24.6 million moved from one source of
insurance to another

34. 5.9 million lost coverage
24.6 million moved from one source of
insurance to another

35. doi: 10.1377/hlthaff.22.6.244

38. doi: 10.1377/hlthaff.2010.1000

39. 28 million
Medicaid
Exchanges

40. 28 million
Medicaid
Exchanges
income fluctuations around 100-133% FPL

41. 38% churn 4x or more

42. 3 months of coverage
=
no penalty

43. who is paying penalties?
who owes at tax time?

44. individual mandate?
CBO: 87% of uninsured exempt

45. individual mandate?
CBO: 87% of uninsured exempt
mostly hardship exemptions

46. individual mandate?
CBO: 87% of uninsured exempt
mostly hardship exemptions
Treasury: 3-6 million penalties

47. April 2015 tax time
IRS reconciliation

48. IRS reconciliation
50-65% owe
$729 (4.5-7.5
million)

49. IRS reconciliation
50-65% owe
$729 (4.5-7.5
million)
25-45% refund
$425

52. ObamaCar
e
INSURANCE

53. ObamaCar
e
INSURANCE

55. “Despite concerns about plan cancellations, only
600,000 people starting out with nongroup coverage
became uninsured.

56. “Despite concerns about plan cancellations, only
600,000 people starting out with nongroup coverage
became uninsured.
Of the 155.8 million people with insurance in
September 2013, 80 percent experienced no
changes in the source of their insurance during the
study period.

57. “Despite concerns about plan cancellations, only
600,000 people starting out with nongroup coverage
became uninsured.
Of the 155.8 million people with insurance in
September 2013, 80 percent experienced no
changes in the source of their insurance during the
study period.
Among those who were uninsured at baseline, 47
percent remained uninsured at follow-up.”

60. SUBSIDIES
we are the forty seven percent

61. Premium Subsidies
85%
per CMS

62. $272 /mo
Premium Subsidies

63. $272 /mo
$3,264 /yr
Premium Subsidies

64. $272 /mo
$3,264 /yr
$33 billion
Premium Subsidies

65. $272 /mo
$3,264 /yr
$33 billion
$3 trillion /yr
Premium Subsidies

66. Household 100% FPL 400% FPL
1 $11,490 $45,960
2 $15,510 $62,040
3 $19,530 $78,120
4 $23,550 $94,200
5 $27,570 $110,280

67. <400% FPL
64%

68. <400% FPL
64%
>200 million

69. <400% FPL
64%
>200 million

72. such Exchanges

85. or

90. CSRs
Cost Sharing Reductions
“the other subsidies”
(pork/chicken of the sea)

91. CSRs

92. earlier: premium subsidies
CSRs

93. earlier: premium subsidies
monthly bill
CSRs

94. earlier: premium subsidies
monthly bill
400% FPL
CSRs

95. earlier: premium subsidies
monthly bill
400% FPL
CSR: deductibles, copays, coinsurance
CSRs

96. earlier: premium subsidies
monthly bill
400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use
CSRs

97. earlier: premium subsidies
monthly bill
400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use
250% FPL
CSRs

98. earlier: premium subsidies
monthly bill
400% FPL
CSR: deductibles, copays, coinsurance
out of pocket, based on use
250% FPL
only Silver+ (not cheaper Bronze)
CSRs

99. FFM SBM Total
CSR 4,500,205 1,300,731 5,800,936
total 7,524,234 2,662,964 10,187,198
% 60% 49% 57%
http://xpostfactoid.blogspot.com/2015/06/new-data-on-cost-sharing-reduction-in.html
http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-
items/2015-06-02.html

100. CSR uptake

101. CSR uptake

102. WHAT PLANS?
aka skin in the game

103. premiums vs pre-ACA

104. MLR
EHB
OOP limits
no annual limits
no preexisting conditions
premiums vs pre-ACA

105. MLR
EHB
OOP limits
no annual limits
no preexisting conditions
Home Depot
premiums vs pre-ACA

109. my take
2014 rates were low

110. my take
2014 rates were low
“subsidy equilibrium”

111. my take
2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases

112. my take
2014 rates were low
“subsidy equilibrium”
rate increase requests ≠ rate increases
deductibles??

123. deductibles = evil?

124. deductibles = evil?
skin in the game?

127. 3 issues
not w/o value (e.g. preventative services)

128. 3 issues
not w/o value (e.g. preventative services)
100% insured after

129. 3 issues
not w/o value (e.g. preventative services)
100% insured after
compare employer sponsored insurance

133. EXPANSION
some maps & DSH

134. SOURCE: State Health Insurance Marketplace Types, 2015, KFF State Health Facts:
http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/.
MARKETPLACES
AK
WA
OR
WY
UT
TX
SD*
OK
ND
NM
NV
NE*
MT*
LA
KS*
ID
CO
CA
ARAZ
WI
WV VA*
TN
SC
OH*
NC
MS
MN
MI
KY
IA
INIL
GA
FL
AL
VT
PA
NY
NJ
N
HMA
ME*
CT
DE
RI
MD
DC
Federally-supported State-based Marketplace (3 states)
State-based Marketplace (13 states and DC)
Partnership Marketplace (7 states)
Federally-facilitated Marketplace (27 states)
MO

135. SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated May 26, 2015.
http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/
MEDICAID EXPANSION
WY
WI*
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA*
OR
OK
OH
ND
NC
NY
NM
NJ
NH*
NV
NE
MT**
MO
MS
MN
MI*
MA
MD
ME
LA
KYKS
IA*
IN*IL
ID
HI
GA
FL
DC
DE
CT
CO
CA
AR*AZ
AK
AL
Expanded (30 States including DC)
under discussion (3 States)
nope (18 States)

136. State Decisions on Health Insurance Marketplaces and the Medicaid Expansion, KFF State Health Facts, updated May 26, 2015.
http://kff.org/health-reform/state-indicator/state-decisions-for-creating-health-insurance-exchanges-and-expanding-medicaid/.
EXCHANGES & MEDICAID
WY
WI
WV
WA
VA
VT
UT
TX
TN
SD
SC
RI
PA
OR*
OK
OH
ND
NC
NY
NM*
NH
NV*
NE
MT**
MO
MS
MN
MI
MA
MD
ME
LA
KYKS
IA
INIL
ID
GA
FL
CT
CO
CA
ARAZ
AK
AL
SBM – MCD (Idaho) FFM - MCD(20 States)
FFM + MCD (14 States)SBM + MCD (16 States including DC)

137. DSH

139. DSH
Disproportionate
Share
Hospitals

140. DSH
Federal $  states  hospitals

141. DSH
Federal $  states  hospitals
Medicaid + uninsured

142. DSH
Federal $  states  hospitals
Medicaid + uninsured
$17.4 billion (2011)

143. DSH
Federal $  states  hospitals
Medicaid + uninsured
$17.4 billion (2011)
ACA:

144. DSH
Federal $  states  hospitals
Medicaid + uninsured
$17.4 billion (2011)
ACA:
fewer uninsured  decrease DSH

145. DSH
Federal $  states  hospitals
Medicaid + uninsured
$17.4 billion (2011)
ACA:
fewer uninsured  decrease DSH
pay for ACA

146. billion $
2018 2
2019 3
2020 4
2021 5
2022 6
2023 7
2024 8
2025 8

150. DSH
93% of $  large urban hospitals

152. 6300 hospitals

153. 6300 hospitals
3100 DSH

154. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State

155. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
529 DSH reliant

156. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
529 DSH reliant
551 weak

157. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
529 DSH reliant
551 weak
225 DSH
reliant
+
weak

158. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
529 DSH reliant
551 weak
225 DSH
reliant
+
weak
307 bad mix

159. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
551 weak
307 bad mix
225 DSH
reliant
+
weak
529 DSH reliant

160. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
551 weak
307 bad mix
132 bad mix
+
DSH reliant
+
weak 225 DSH
reliant
+
weak
529 DSH reliant

161. 6300 hospitals
3100 DSH
2100 DSH Eligible in High DSH
State
551 weak
307 bad mix
132 bad mix
+
DSH reliant
+
weak 225 DSH
reliant
+
weak
529 DSH reliant

162. most vulnerable
big urban hospitals
bad payer mixes
non-expansion states

163. PROVIDER
IMPACT
hospitals and physicians

166. 2014 - 2022
$2.757 trillion in overhead
ACA: $273.6 billion
new private insurance
$172.2 billion

167. “Most of this soaring private insurance
overhead is attributable to rising enrollment
in private plans which carry high costs for
administration and profits.”

168. overhead
MLR
Medicare Advantage
Managed Medicaid
22% Private
14% MA
9% Medicaid
2% Medicare

176. no Medicaid expansion?
24 states w/o Medicaid expansion
6.7 million

177. no Medicaid expansion?
24 states w/o Medicaid expansion
6.7 million
2013 to 2022:
$423.6 billion in federal Medicaid $
Hospitals: lose $167.8 billion

178. PAYING FOR
QUALITY
ACO APM P4P PQRS HRRP HVBP MSSP & MORE

180. early experiences
data lacking
mixed messages

181. Peter Viccellio

182. Peter Viccellio
@MDaware tweet #6, 1 June 2011, SAEM (67K)

183. ACOs
Accountable
Care
Organizations

185. FFS vs bundle

186. FFS
ECG

187. FFS
ECG CXR

188. FFS
ECG CXR lab

189. FFS
ECG CXR lab admit

190. FFS vs bundle
ECG CXR lab admit

191. ACOs
FFS vs bundle
ECG CXR lab admit
ACO:
retain FFS
some CQM
shared savings

192. ACOs
mixed
some good

193. Pioneers
32 systems
13 quit

194. Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million

195. Pioneer ACOs
23 in second year
11 bonuses = $68 million
3 penalties = $7 million
$380 million total savings
$36 pmpm vs $11 pmpm

196. Readmissions

197. Readmissions
outpatient network
incentives

198. Readmissions
outpatient network
incentives
nearly 20%

199. Readmissions
outpatient network
incentives
nearly 20%
down 1.1%

200. penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-
are-we-doing/

201. penalties?
2015: 80%
all 3: 57% (!)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-
are-we-doing/

202. penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-
are-we-doing/

203. penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?

204. penalties?
average $100-300k
2013: teaching & safety-net hospitals
2015: more broadly distributed (still gap)
improving teaching & safety net hospitals?
surgical?

205. HVBP differences
safety nets get penalized more

206. HVBP differences
safety nets get penalized more
…$12k/hospital

213. ntrueger@gmail.com @MDaware