Theres a lot of noise out there about Obamacare, much of it politically driven. This presentation is my attempt to focus on the facts and boil down the over 2000 page law into a short succinct summary
The document discusses how payers must change their approach to better manage population health and accountable care. Specifically:
- Payers currently only interact regularly with 20% of members through monthly bills, but will need to engage more members to improve outcomes.
- The member experience needs to be omni-channel, interactive, cognitive, and mobile-first to better engage individuals.
- The payer business model will shift from business-to-business to consumer-focused in order to retain and service more individual customers.
- Payers currently do not have the right systems or data to effectively support individual members and need strategies to improve care, wellness, and population health management.
Explore how the Affordable Care Act and creation of state level and national exchanges has impacted member risk profiles and demand for small-group and individual health plans.
The document discusses how the Affordable Care Act's insurance reforms could support primary care. It outlines the AAFP's policy of ensuring all Americans have health coverage and access to team-based primary care. The AAFP recommends that health insurance exchanges require plans to provide this type of primary care. The document also discusses issues around defining essential health benefits, coordinating exchanges with Medicaid, the impact of exchanges in Illinois, and questions for family physicians around exchanges.
Rising healthcare costs are driving large-scale changes in the health insurance market. Insurers are merging with health systems to better manage costs. New market entrants like Oscar, Clover, and Nuna are using data and technology to improve care coordination. Private insurance exchanges allow larger employers to define contributions for workers to purchase plans. The use of high-deductible health plans paired with health savings accounts is increasing as a way for consumers to have more control over healthcare spending. Upcoming bipartisan legislation aims to further reforms to HSAs to accommodate chronic disease prevention and wellness.
Medicaid Expansion: Emerging from the Shadows of Healthcare ReformAltegra Health
This document summarizes a presentation given by the executive director of the National Association of Medicaid Directors on the future of Medicaid. It discusses the role and functions of NAMD, provides an overview of Medicaid including its complexity across states, and identifies challenges and opportunities around implementing the Affordable Care Act including the Medicaid expansion decision. It argues that true reform requires moving away from fee-for-service to coordinated, managed care with new payment models incentivizing quality over quantity and holding all parties responsible for outcomes and costs.
Online Conference Takes “Deep Dive” into Affordable Care ActPYA, P.C.
PYA’s Martie Ross, Principal, joined three other panelists in a full-day, online conference sponsored by the American Institute of Certified Public Accountants to offer an in-depth look at healthcare reform under the Affordable Care Act (ACA).
US Healthcare Reform and Impact On Pharma and Healthcare IT CompaniesDr. Susan Dorfman
US Healthcare Reform and Its Impact on Pharma and Healthcare Companies:
Implications Current and Future
Presented at the Edison Ventures Pharma and Healthcare Business Solutions Executive Meeting Lawrenceville, NJ
April 20, 2010
1) While carrier discounts can seem significant, healthcare costs are still accelerating rapidly because discounts are not the only factor controlling claims costs.
2) Large insurance carriers may not have the most efficient claims processing systems due to the large volume of claims they must handle.
3) It is important to focus on your bottom line costs and not just discounts, as higher billed charges or prescription drug costs from large carriers and PBMs can negate discounts. Watching the total spend is key to reducing healthcare costs.
The document discusses how payers must change their approach to better manage population health and accountable care. Specifically:
- Payers currently only interact regularly with 20% of members through monthly bills, but will need to engage more members to improve outcomes.
- The member experience needs to be omni-channel, interactive, cognitive, and mobile-first to better engage individuals.
- The payer business model will shift from business-to-business to consumer-focused in order to retain and service more individual customers.
- Payers currently do not have the right systems or data to effectively support individual members and need strategies to improve care, wellness, and population health management.
Explore how the Affordable Care Act and creation of state level and national exchanges has impacted member risk profiles and demand for small-group and individual health plans.
The document discusses how the Affordable Care Act's insurance reforms could support primary care. It outlines the AAFP's policy of ensuring all Americans have health coverage and access to team-based primary care. The AAFP recommends that health insurance exchanges require plans to provide this type of primary care. The document also discusses issues around defining essential health benefits, coordinating exchanges with Medicaid, the impact of exchanges in Illinois, and questions for family physicians around exchanges.
Rising healthcare costs are driving large-scale changes in the health insurance market. Insurers are merging with health systems to better manage costs. New market entrants like Oscar, Clover, and Nuna are using data and technology to improve care coordination. Private insurance exchanges allow larger employers to define contributions for workers to purchase plans. The use of high-deductible health plans paired with health savings accounts is increasing as a way for consumers to have more control over healthcare spending. Upcoming bipartisan legislation aims to further reforms to HSAs to accommodate chronic disease prevention and wellness.
Medicaid Expansion: Emerging from the Shadows of Healthcare ReformAltegra Health
This document summarizes a presentation given by the executive director of the National Association of Medicaid Directors on the future of Medicaid. It discusses the role and functions of NAMD, provides an overview of Medicaid including its complexity across states, and identifies challenges and opportunities around implementing the Affordable Care Act including the Medicaid expansion decision. It argues that true reform requires moving away from fee-for-service to coordinated, managed care with new payment models incentivizing quality over quantity and holding all parties responsible for outcomes and costs.
Online Conference Takes “Deep Dive” into Affordable Care ActPYA, P.C.
PYA’s Martie Ross, Principal, joined three other panelists in a full-day, online conference sponsored by the American Institute of Certified Public Accountants to offer an in-depth look at healthcare reform under the Affordable Care Act (ACA).
US Healthcare Reform and Impact On Pharma and Healthcare IT CompaniesDr. Susan Dorfman
US Healthcare Reform and Its Impact on Pharma and Healthcare Companies:
Implications Current and Future
Presented at the Edison Ventures Pharma and Healthcare Business Solutions Executive Meeting Lawrenceville, NJ
April 20, 2010
1) While carrier discounts can seem significant, healthcare costs are still accelerating rapidly because discounts are not the only factor controlling claims costs.
2) Large insurance carriers may not have the most efficient claims processing systems due to the large volume of claims they must handle.
3) It is important to focus on your bottom line costs and not just discounts, as higher billed charges or prescription drug costs from large carriers and PBMs can negate discounts. Watching the total spend is key to reducing healthcare costs.
US healthcare insurance can be public (e.g. Medicare, Medicaid) or private (employer or self-purchased plans). Medicare has parts A, B, C, and D that cover different services like hospitals (Part A) and prescription drugs (Part D). Plans may require premiums, deductibles, co-payments, or co-insurance. They often have limits and do not cover all costs. Private insurers provide additional plans like PPOs, HMOs, or Medicare Advantage plans combining Part A, B, and D benefits. SCHIP provides coverage for children from families that do not qualify for Medicaid.
This document discusses consumer informatics and the role of patients using technology in their healthcare. It defines key terms like health literacy, patient portals, personal health records, telehealth, and social media. It explains how patients can use applications and online tools to access health information, communicate with providers, track health data, and engage with their care. The document also outlines factors that impact health literacy and provides strategies to improve patient understanding of health information.
The document discusses major changes that will occur in 2014 under the Affordable Care Act (ACA) and their predicted effects. It outlines provisions of the ACA including no denial of coverage for pre-existing conditions, Medicaid expansion, health insurance exchanges, and individual mandates. It predicts that 1.8-2.7 million uninsured Californians will gain coverage, but 3.1-4 million will remain uninsured, including undocumented immigrants and those who do not enroll despite being eligible. Safety net clinics will need to educate patients about options and continue serving the uninsured. Outreach efforts will be critical to enrollment and the law's success.
Dr. James Mongan spoke about "Health Reform, Past and Present" at the 10th annual William E. Petersen Symposium on Physician Leadership at the University of St. Thomas.
The document discusses problems with the US healthcare system and proposals for reforming it. It outlines issues like rising costs, lack of cost control, inefficiency of private insurers compared to Medicare, and the shortcomings of both the current system and the Affordable Care Act. It then proposes a single-payer system for Pennsylvania called the Pennsylvania Healthcare Plan that would provide comprehensive coverage for all state residents through a publicly financed but privately delivered system. Analysis found the plan would save the state government billions annually and have economic benefits for businesses from reduced healthcare costs. While opponents argue single-payer discourages cost control, proponents counter that Medicare has lower overhead than private insurers. The document evaluates the various options and advocates the Pennsylvania Healthcare Plan
This document summarizes the current state of healthcare quality in Minnesota and discusses how federal and state healthcare reform efforts may affect quality and patient safety. It provides an overview of various quality reporting initiatives in Minnesota, such as nursing home and hospital quality report cards. It also discusses converging forces in healthcare quality and politics that could create opportunities for meaningful healthcare reform. Key components of federal and Minnesota state healthcare reform bills related to quality include accountable care organizations, medical homes, payment reform to incentivize quality, and reducing disparities.
The document discusses Accountable Care Organizations (ACOs) which were created by the Affordable Care Act to improve quality and lower costs. It provides frequently asked questions about ACOs, including whether they are viable, how providers can save money through ACOs, examples of successful ACO programs like Marshfield Clinic, and the healthcare IT components needed to support ACOs. Providers are encouraged to invest in quality, innovation, and data/analytics to prepare for value-based payment models like ACOs.
- The document discusses the history and basics of Health Savings Accounts (HSAs) in the United States. It traces the development of HSAs from their introduction in 1996 to their rapid growth and adoption throughout the 2000s.
- The key aspects of HSAs are outlined, including that they are individual medical savings accounts with tax benefits. Contributions are tax-deductible, savings grow tax-free and can be withdrawn tax-free for medical expenses.
- Evidence suggests that HSAs may help reduce overall healthcare costs as they encourage consumers to be more cost-conscious in their healthcare decisions due to the higher deductibles of HSA-eligible plans.
This document discusses various factors that impact healthcare costs beyond just insurance discounts. It questions whether larger insurance carriers truly offer the lowest costs given rising expenses and variability in provider charges and quality of claims processing. Independent third party administrators are presented as a potentially better option than large carriers for controlling total spending and improving health, though the document notes not all TPAs are equal in their standards and effectiveness. Overall, the key message is for employers to watch their bottom line costs holistically rather than focus solely on discounts.
The document discusses the business opportunities for Medicaid managed care plans created by the health reform expansion of Medicaid. Key points include:
- An estimated 15 million additional people will gain Medicaid coverage, making it a large part of the insurance market.
- States are looking for Medicaid managed care plans to take on the new members and financial risk.
- This provides health plans with new patients and revenue to invest in initiatives like patient-centered medical homes and accountable care organizations.
The document contains a health care reform quiz with 8 multiple choice questions covering topics such as who will be covered or not covered under the proposed health care reform bill, sources of funding, restrictions on insurance companies, cost containment measures, and implementation dates. Key points covered include illegal immigrants and those who pay a fine will not be covered, funding will come from taxes and reduced Medicare payments, insurance companies will be prohibited from denying coverage for pre-existing conditions or lifetime limits, cost containment includes reducing readmissions and drug prices, and implementation dates range from 2010 to 2013.
This document discusses problems with prior authorization requirements, including delayed patient treatment and excessive administrative burdens on physicians and staff. It summarizes the results of an AMA survey that found high prior authorization burdens for physicians and delays in patient care. The document outlines principles for reforming prior authorization developed by a multi-stakeholder workgroup. It discusses state legislative efforts regarding prior authorization and step therapy reform and provides an overview of the AMA's model prior authorization legislation.
The document discusses various topics related to health care economics and financing in the United States, including the legislative process for health reform, current issues, health care financing models, sources of health insurance coverage, national health expenditures, payment reform efforts, and principles of health economics.
The document discusses health care reform efforts in Minnesota and nationally, noting that while Minnesota has relatively low uninsured rates and health costs, costs are still rising unsustainably. It outlines Minnesota's recent reforms which aim to expand coverage while also improving quality, care coordination, payment reform, and transparency to better align incentives and ensure long-term sustainability. Key reforms include expanding public coverage, promoting medical homes, payment reforms tied to quality, and increasing price and quality transparency.
Minnesota Public Programs in an ACA Worldshenry0105
The document provides an overview of Minnesota's public health insurance programs and recommendations from the Minnesota Task Force on Health Care Financing. It discusses recent events impacting Minnesota's public programs marketplace, including ACA implementation and state program recontracting. It then summarizes the task force's workgroups and recommendations. Finally, it offers recommended next steps for health plans, providers, and the state to improve affordability, access, and care across Minnesota's coverage continuum.
Outreach Services helps community hospitals navigate medical assistance programs to cover costs for uninsured and underinsured patients. They have helped over 25,000 patients get over $560 million in hospital bills covered so far in 2007. Providing outreach and advocacy for these patients benefits both the hospitals and communities. It benefits hospitals by recovering costs that would otherwise go unpaid, improving their fiscal health. It benefits communities by providing coverage for families and other providers, as well as maintaining access to care from hospitals that might otherwise close due to high uncompensated costs. Outreach Services recommends hospitals formally define and track their outreach programs to quantify the positive outcomes and demonstrate the community-wide benefits.
The document provides an overview of the key issues in the U.S. healthcare system and proposals for reform. It discusses problems like rising costs, uninsured populations, and disparities in quality. The reform proposals aim to expand coverage, reduce costs, and improve quality through mechanisms like insurance exchanges, individual and employer mandates, expanded Medicaid, and payment reforms. Stakeholders like insurers, providers, consumers would all be impacted by the reforms through changes to financing, coverage, and care delivery.
"You can download this product from SlideTeam.net"
Healthcare Management Powerpoint Presentation Slides is designed especially for the medical industry professionals. Use this PPT slideshow to showcase all the essentials of healthcare administration with a dash of visual brilliance. Demonstrate the key trends and vital stats of the healthcare industry through our content-driven PowerPoint theme. Communicate details about global healthcare economy, and global spending stats. Illustrate the key demand and supply drivers associated with public health management. Employ our audience-friendly medical administration PPT template deck to elucidate stakeholders in the public health system. Cutting-edge graphics and innovative data visualization designs simplify the explanation. Use diagrams featured in this PowerPoint presentation to describe essential public health services. You will also find infographic-style designs to help elaborating concepts like hospital and corporate tie-ups. Utilize the Venn diagram to emphasize the pharma company operating model. Convey the research and development protocol followed in the pharmaceutical industry. Our comprehensive PPT layout contains oodles of other core aspects of hospital management. This includes cost accounting, financial management, data analysis, strategic planning, marketing, and KPI metrics and dashboards. So, hit the download button and captivate your audience. Our Healthcare Management Powerpoint Presentation Slides are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro. https://bit.ly/3oAoykn
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
The Affordable Care Act (ACA) is comprehensive healthcare reform legislation that was signed into law in 2010. It expanded access to health insurance coverage in three primary ways: by expanding Medicaid eligibility; creating health insurance exchanges; and preventing insurance companies from denying coverage due to pre-existing conditions. The ACA was intended to provide more affordable health insurance options for millions of uninsured Americans and supports innovative healthcare delivery methods. It established different metal-tiered health insurance plan options that vary in out-of-pocket costs and premiums.
US healthcare insurance can be public (e.g. Medicare, Medicaid) or private (employer or self-purchased plans). Medicare has parts A, B, C, and D that cover different services like hospitals (Part A) and prescription drugs (Part D). Plans may require premiums, deductibles, co-payments, or co-insurance. They often have limits and do not cover all costs. Private insurers provide additional plans like PPOs, HMOs, or Medicare Advantage plans combining Part A, B, and D benefits. SCHIP provides coverage for children from families that do not qualify for Medicaid.
This document discusses consumer informatics and the role of patients using technology in their healthcare. It defines key terms like health literacy, patient portals, personal health records, telehealth, and social media. It explains how patients can use applications and online tools to access health information, communicate with providers, track health data, and engage with their care. The document also outlines factors that impact health literacy and provides strategies to improve patient understanding of health information.
The document discusses major changes that will occur in 2014 under the Affordable Care Act (ACA) and their predicted effects. It outlines provisions of the ACA including no denial of coverage for pre-existing conditions, Medicaid expansion, health insurance exchanges, and individual mandates. It predicts that 1.8-2.7 million uninsured Californians will gain coverage, but 3.1-4 million will remain uninsured, including undocumented immigrants and those who do not enroll despite being eligible. Safety net clinics will need to educate patients about options and continue serving the uninsured. Outreach efforts will be critical to enrollment and the law's success.
Dr. James Mongan spoke about "Health Reform, Past and Present" at the 10th annual William E. Petersen Symposium on Physician Leadership at the University of St. Thomas.
The document discusses problems with the US healthcare system and proposals for reforming it. It outlines issues like rising costs, lack of cost control, inefficiency of private insurers compared to Medicare, and the shortcomings of both the current system and the Affordable Care Act. It then proposes a single-payer system for Pennsylvania called the Pennsylvania Healthcare Plan that would provide comprehensive coverage for all state residents through a publicly financed but privately delivered system. Analysis found the plan would save the state government billions annually and have economic benefits for businesses from reduced healthcare costs. While opponents argue single-payer discourages cost control, proponents counter that Medicare has lower overhead than private insurers. The document evaluates the various options and advocates the Pennsylvania Healthcare Plan
This document summarizes the current state of healthcare quality in Minnesota and discusses how federal and state healthcare reform efforts may affect quality and patient safety. It provides an overview of various quality reporting initiatives in Minnesota, such as nursing home and hospital quality report cards. It also discusses converging forces in healthcare quality and politics that could create opportunities for meaningful healthcare reform. Key components of federal and Minnesota state healthcare reform bills related to quality include accountable care organizations, medical homes, payment reform to incentivize quality, and reducing disparities.
The document discusses Accountable Care Organizations (ACOs) which were created by the Affordable Care Act to improve quality and lower costs. It provides frequently asked questions about ACOs, including whether they are viable, how providers can save money through ACOs, examples of successful ACO programs like Marshfield Clinic, and the healthcare IT components needed to support ACOs. Providers are encouraged to invest in quality, innovation, and data/analytics to prepare for value-based payment models like ACOs.
- The document discusses the history and basics of Health Savings Accounts (HSAs) in the United States. It traces the development of HSAs from their introduction in 1996 to their rapid growth and adoption throughout the 2000s.
- The key aspects of HSAs are outlined, including that they are individual medical savings accounts with tax benefits. Contributions are tax-deductible, savings grow tax-free and can be withdrawn tax-free for medical expenses.
- Evidence suggests that HSAs may help reduce overall healthcare costs as they encourage consumers to be more cost-conscious in their healthcare decisions due to the higher deductibles of HSA-eligible plans.
This document discusses various factors that impact healthcare costs beyond just insurance discounts. It questions whether larger insurance carriers truly offer the lowest costs given rising expenses and variability in provider charges and quality of claims processing. Independent third party administrators are presented as a potentially better option than large carriers for controlling total spending and improving health, though the document notes not all TPAs are equal in their standards and effectiveness. Overall, the key message is for employers to watch their bottom line costs holistically rather than focus solely on discounts.
The document discusses the business opportunities for Medicaid managed care plans created by the health reform expansion of Medicaid. Key points include:
- An estimated 15 million additional people will gain Medicaid coverage, making it a large part of the insurance market.
- States are looking for Medicaid managed care plans to take on the new members and financial risk.
- This provides health plans with new patients and revenue to invest in initiatives like patient-centered medical homes and accountable care organizations.
The document contains a health care reform quiz with 8 multiple choice questions covering topics such as who will be covered or not covered under the proposed health care reform bill, sources of funding, restrictions on insurance companies, cost containment measures, and implementation dates. Key points covered include illegal immigrants and those who pay a fine will not be covered, funding will come from taxes and reduced Medicare payments, insurance companies will be prohibited from denying coverage for pre-existing conditions or lifetime limits, cost containment includes reducing readmissions and drug prices, and implementation dates range from 2010 to 2013.
This document discusses problems with prior authorization requirements, including delayed patient treatment and excessive administrative burdens on physicians and staff. It summarizes the results of an AMA survey that found high prior authorization burdens for physicians and delays in patient care. The document outlines principles for reforming prior authorization developed by a multi-stakeholder workgroup. It discusses state legislative efforts regarding prior authorization and step therapy reform and provides an overview of the AMA's model prior authorization legislation.
The document discusses various topics related to health care economics and financing in the United States, including the legislative process for health reform, current issues, health care financing models, sources of health insurance coverage, national health expenditures, payment reform efforts, and principles of health economics.
The document discusses health care reform efforts in Minnesota and nationally, noting that while Minnesota has relatively low uninsured rates and health costs, costs are still rising unsustainably. It outlines Minnesota's recent reforms which aim to expand coverage while also improving quality, care coordination, payment reform, and transparency to better align incentives and ensure long-term sustainability. Key reforms include expanding public coverage, promoting medical homes, payment reforms tied to quality, and increasing price and quality transparency.
Minnesota Public Programs in an ACA Worldshenry0105
The document provides an overview of Minnesota's public health insurance programs and recommendations from the Minnesota Task Force on Health Care Financing. It discusses recent events impacting Minnesota's public programs marketplace, including ACA implementation and state program recontracting. It then summarizes the task force's workgroups and recommendations. Finally, it offers recommended next steps for health plans, providers, and the state to improve affordability, access, and care across Minnesota's coverage continuum.
Outreach Services helps community hospitals navigate medical assistance programs to cover costs for uninsured and underinsured patients. They have helped over 25,000 patients get over $560 million in hospital bills covered so far in 2007. Providing outreach and advocacy for these patients benefits both the hospitals and communities. It benefits hospitals by recovering costs that would otherwise go unpaid, improving their fiscal health. It benefits communities by providing coverage for families and other providers, as well as maintaining access to care from hospitals that might otherwise close due to high uncompensated costs. Outreach Services recommends hospitals formally define and track their outreach programs to quantify the positive outcomes and demonstrate the community-wide benefits.
The document provides an overview of the key issues in the U.S. healthcare system and proposals for reform. It discusses problems like rising costs, uninsured populations, and disparities in quality. The reform proposals aim to expand coverage, reduce costs, and improve quality through mechanisms like insurance exchanges, individual and employer mandates, expanded Medicaid, and payment reforms. Stakeholders like insurers, providers, consumers would all be impacted by the reforms through changes to financing, coverage, and care delivery.
"You can download this product from SlideTeam.net"
Healthcare Management Powerpoint Presentation Slides is designed especially for the medical industry professionals. Use this PPT slideshow to showcase all the essentials of healthcare administration with a dash of visual brilliance. Demonstrate the key trends and vital stats of the healthcare industry through our content-driven PowerPoint theme. Communicate details about global healthcare economy, and global spending stats. Illustrate the key demand and supply drivers associated with public health management. Employ our audience-friendly medical administration PPT template deck to elucidate stakeholders in the public health system. Cutting-edge graphics and innovative data visualization designs simplify the explanation. Use diagrams featured in this PowerPoint presentation to describe essential public health services. You will also find infographic-style designs to help elaborating concepts like hospital and corporate tie-ups. Utilize the Venn diagram to emphasize the pharma company operating model. Convey the research and development protocol followed in the pharmaceutical industry. Our comprehensive PPT layout contains oodles of other core aspects of hospital management. This includes cost accounting, financial management, data analysis, strategic planning, marketing, and KPI metrics and dashboards. So, hit the download button and captivate your audience. Our Healthcare Management Powerpoint Presentation Slides are topically designed to provide an attractive backdrop to any subject. Use them to look like a presentation pro. https://bit.ly/3oAoykn
Presentation from INTEGRATED's Chuck Gooder, senior advisor, and Blake Sternard, the business analyst. The presentation focuses on the ways to identify the major changes of healthcare, with specific attention to the potential challenges posed to enrollees, physicians, hospitals, and healthcare organizations associated with the implementation of Obamacare.
The Affordable Care Act (ACA) is comprehensive healthcare reform legislation that was signed into law in 2010. It expanded access to health insurance coverage in three primary ways: by expanding Medicaid eligibility; creating health insurance exchanges; and preventing insurance companies from denying coverage due to pre-existing conditions. The ACA was intended to provide more affordable health insurance options for millions of uninsured Americans and supports innovative healthcare delivery methods. It established different metal-tiered health insurance plan options that vary in out-of-pocket costs and premiums.
This document discusses the Affordable Care Act and its provisions regarding pre-existing conditions. It notes that the ACA aims to expand insurance coverage, reduce costs, and increase quality and affordability of healthcare. A key part is that it prohibits insurance companies from denying coverage or charging more due to pre-existing conditions. While this improves access, it may also increase insurance costs. The document also examines strengths like expanded choice and protections, but weaknesses like potentially higher overall healthcare costs. It recommends focusing on lowering costs to prevent insurer bankruptcies from high medical bills.
The document summarizes the future of America's health care system based on a presentation given to the Ventura Rotary Meeting. It discusses key aspects of health care reform including reducing the uninsured, expanding Medicaid, establishing health insurance exchanges, individual and employer mandates, and revenue generation strategies. Implementation will occur between 2010-2020 with the goals of increasing access to insurance and reducing costs over time. Concerns were raised about the increased costs and bureaucracy that employers and those with current coverage may face during the transition.
The Affordable Care Act touches the lives of most Americans. In fact, nearly 21 million will be at risk if Obamacare is struck down, and may even lose health insurance completely if the law is ruled unconstitutional. This webinar will discuss what the outcome may be if ACA is repealed.
The Proposed Health Care Reform’S Impact On MarketingStone Ward
The document summarizes key aspects of the proposed US health care reform plan, including:
1) It would require all Americans to have health insurance and businesses to provide it or pay a penalty. Subsidies would help lower-income families purchase insurance.
2) Health insurance exchanges would be created to allow consumers to compare plans starting in 2013.
3) While hospitals, doctors, and private Medicare plans oppose aspects of the plan, supporters argue it will reduce costs and improve care by covering more of the uninsured.
hapter 5What Are the Governmental AlternativesThe United StatJeanmarieColbert3
hapter 5
What Are the Governmental Alternatives?
The United States has tried an alphabet soup of health policy options: HSAs, HMOs, IPAs, PPOs, POS plans, ACOs, and so on. Health care analysts often must look beyond specific organizational and financial alternatives and address issues at a higher level and deal with the threads of economic and political thought behind different proposals while considering the overall criteria of access, cost, and quality of care.
Politicians and businesspeople from outside the health care sector advocate many alternatives. To offset their tendency to ignore professional issues, in this chapter we discuss alternatives affecting professional status and roles and institutional responses to them. Table 5-1 presents an array of federal alternatives organized by their primary criteria—access, quality, or cost—and then by the economic philosophies behind them. The items in this array are not intended to be either mutually exclusive or collectively exhaustive; rather, the table provides a framework for looking at both the broad policy picture and specific health care actions taken at various times and places. Later in the chapter, another table (Table 5-3) summarizes policy alternatives added by state and local governments. Many of these alternatives were included as provisions of the Affordable Care Act (ACA). They are still included here, partly because they may be subject to reconsideration in the future.
Table 5-1 Illustrative Federal Government Health Policy Options
Access to Care
• Administered systems
• Universal coverage
• Expand or reduce eligibility or benefits
• Mandate coverage and services
• Captive providers
• Control insurance industry practices
• Mandate employer-based insurance coverage
• Consumer-driven competition
• Implement insurance exchanges
• Encourage basic plans with very low premiums for low-income workers and “young invincibles”
• Mandate individual coverage
• Allow states flexibility to reallocate federal funds for vouchers
• Oligopolistic competition
• Expand or contract coverages in entitlement and categorical programs
• Allow states to reallocate federal uncompensated care funds
• Eliminate ERISA constraints on the states
• Expand the capacity of the system
Quality of Care
• Administered system
• Mandate participation in quality improvement efforts in federal plans and programs
• Add more pay-for-performance incentives
• Select providers and programs on the basis of quality excellence
• Consumer-driven competition
• Encourage or mandate transparency of quality reporting in federal plans and programs
• Oversee licensure and credentialing of foreign-trained providers
• Oligopolistic competition
• Work reporting of quality care and adverse events into purchasing specifications for federal programs and disseminate to the public
• Encourage wider use of health information technology
Cost of Care
• Administered system
• Use full bargaining power in negotiation of ...
Riportella priester 2013 the affordable care actMarissa Stone
This document provides an overview of the Affordable Care Act (ACA). It discusses key provisions of the law including expanding Medicaid eligibility, establishing health insurance marketplaces, mandating individuals have health insurance, and enforcing employer responsibilities. The document outlines how the ACA aims to increase access to health insurance through a combination of public programs, employer coverage, and online marketplace coverage. It also addresses ongoing implementation challenges and debates around the law.
The Affordable Care Act (ACA), signed into law in 2010, represents the most extensive healthcare reform in the United States in over 45 years. It aims to increase health insurance coverage and access to care while reducing costs. The ACA expands Medicaid eligibility and provides subsidies for private insurance plans. While increasing coverage, criticisms of the ACA include that its subsidies create incentives for certain behaviors and that costs are not equally distributed. Solutions proposed include making subsidies uniform across insurance sources to reduce distortions in the job market and healthcare system.
The document summarizes the Affordable Care Act and identifies some of its flaws and deficiencies. It discusses two main goals of the ACA - to increase the number of insured individuals while reducing overall healthcare costs. However, it notes the ACA has yet to achieve these goals. One deficiency is that individuals who remain uninsured face a penalty fee, which does not actually encourage accessing healthcare. Another issue is the "coverage gap" where many remain uninsured. The document proposes solutions like a state-run program to cover those in the gap and bundled payments to replace fee-for-service. It argues more reform is still needed to control rising costs while expanding access.
The document discusses the key aspects and goals of the Affordable Care Act (ACA). It explains that the ACA aims to reform the US healthcare system by expanding access to health insurance, establishing consumer protections, and attempting to reduce costs. Specifically, it prohibits insurance companies from denying coverage or charging more due to pre-existing conditions, allows children to stay on their parents' plans until age 26, and sets up health insurance marketplaces. The document also notes some of the criticisms of the ACA, such as its potential economic impacts through new taxes and regulations.
While the health care reform bill is a step in the right direction, medicare for all or single payer is what is really needed to control costs and insure all.
This document provides an analysis of the Patient Protection and Affordable Care Act (ACA). It discusses the goals and implementation of the ACA, including expanding health insurance coverage and controlling costs. It also examines the impacts of the ACA on various stakeholders in the healthcare system, such as hospitals, long-term care facilities, doctors, and patients. Challenges in implementing the ACA are also assessed, like increasing access to care and addressing shortages of primary care physicians.
Analysis of the Patient Protection and Affordable Care ActKaryssa Costagliola
This document provides an analysis of the Patient Protection and Affordable Care Act (ACA). It summarizes the goals of the ACA to increase availability of healthcare and reduce costs. It also discusses some of the challenges in implementing the ACA, such as people losing subsidies due to lack of documentation, narrow networks limiting choice of providers, and effects on jobs from the employer mandate. The document also compares the US healthcare system to Canada's single-payer system and their differences in achieving universal coverage, cost containment, and other factors.
The best of both worlds: Uniting universal coverage and personal choice in he...AEI
The document proposes a new health care reform plan called "Best of Both Worlds" that aims to balance universal coverage with personal choice. It would create a national health insurance exchange with standardized basic plans and income-based premium supports. It also calls for removing the tax exemption for employer-provided health insurance and implementing a safety-net tax to finance minimum emergency care for all Americans. The plan is estimated to reduce spending compared to the Affordable Care Act while expanding access and protecting low-income and sick individuals.
hCentive Health Insurance Exchange PlatformAlisha North
Take advantage of hCentive's deep expertise in the healthcare insurance industry. Browse through or download our white papers to get an in-depth understanding of the industry.
Affordable care act seniors, medicare, insurance plans and fundingAmy "Kat" McMasters
The Affordable Care Act impacts seniors in several key ways:
1) It expands Medicare benefits such as closing the prescription drug "donut hole" and adding preventive care coverage without costs.
2) While there are Medicare payment cuts, core benefits like hospital and medical insurance remain protected.
3) Medicare Advantage plans now have limits on administrative costs and better protections for seniors receiving certain treatments.
4) The law also improves nursing home transparency, strengthens elder abuse protections, and promotes home/community-based care.
Analysis of the patient protection and affordable care act paper, hcs410, hea...Paige Catizone
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Analysis of the Patient Protection and Affordable Care Act Paper, HCS410, hea...Paige Catizone
This document provides an analysis of the Patient Protection and Affordable Care Act (ACA). It discusses key goals and provisions of the ACA, including expanding health insurance coverage and controlling costs. It also examines the impact of the ACA on various stakeholders, such as individuals, employers, healthcare providers and facilities. Implementation challenges are outlined, such as difficulties insuring previously uninsured individuals, narrow provider networks, and workforce shortages exacerbated by the increase in insured patients. Overall effects on the US healthcare system are assessed.
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An Overview of the ACA (aka Obamacare), October 2013
1. An overview of the Affordable Care
Act, aka “Obamacare”
October 2013
1
2. A talk on “Obamacare” --- Why should you be interested?
As a citizen
• Healthcare is a large
and growing part of
our federal “balance
sheet.”
As a patient
• The quality and cost
of your personal
healthcare will be
impacted.
• Many fellow citizens
are cannot get the
care they need.
2
As a healthcare
market researcher
• Reimbursement and treatment
dynamics as well as usage
patterns may be affected, and
anytime our clients experience
change, they may need to do
research to understand it. We
should be prepared to discuss
intelligently.
3. Today’s Approach
Simplify and focus
on the main ideas
Stick to the facts
(and cut through the politics)
• The final law is over 2400 pages in
length detailing hundreds of separate
provisions.
• We will necessarily only focus on the
main ideas and issues.
• Much of the debate is heavily
politicized, and is related to differences
in philosophical ideologies (e.g. role of
government, how high taxes should
be, appropriate balance between
individuals and the state, etc.).
• We assume that you are not a policy
“wonk”, but just want to better
understand what all the buzz is about.
• We will focus on what is in the ACA,
why it is in there, and what the
expected impact might be.
3
4. Contents
●
Background: Our “Dysfunctional” Healthcare System
●
The ACA: An Overview
●
Main Points of Contention
●
Health Insurance Exchanges – A New Way to Buy Insurance
●
Impact on Different Stakeholders
4
5. Our dysfunctional healthcare system (I)
•
We spend far more on healthcare than other countries, even after adjusting for relative wealth.
5
6. Our dysfunctional healthcare system (II)
•
Despite the high level of spending, life expectancy at birth is far below the trend line
6
7. Our dysfunctional healthcare system (III)
•
Furthermore, our spending on healthcare is rising to unsustainable levels
7
9. The ACA was passed in an attempt to address all these problems
•
•
Goals are lofty, but are they achievable?
And are some of these goals conflicting?
Increase
the rate of
coverage
• Reduce the number of
uninsured and underinsured
Reduce
Healthcare
Costs
• For individuals
• For the government
9
Increase the
quality of
healthcare
10. Contents
●
Background: Our “Dysfunctional” Healthcare System
●
The ACA: An Overview
●
Main Points of Contention
●
Health Insurance Exchanges – A New Way to Buy Insurance
●
Impact on Different Stakeholders
10
11. The ACA: A High-Level Perspective (I)
•
Fundamentally the ACA has 3 main areas of reform, which are intimately related. These are: Restrictions
on Payer Policies, The Individual Mandate, and Increasing Accessibility to Coverage
Provision
Restrictions
on Payer
Policies
Key Elements
Motivation / Idea
• Guaranteed Issue: Insurers are prohibited from denying
coverage or setting rates based on health status (e.g. preexisting conditions). Rates can only be based on age and
geography. Also, payers cannot cancel policies if you fall ill.
• No annual or lifetime limits on coverage allowed
The
Individual
Mandate
• Everyone must get insurance, or pay a penalty.
• Penalty is greater of 2.5% of income or $695 ($2085 for
families), with some exceptions, and tied to inflation
Ensure that people that need care can get
coverage (and thus get care)
Insurers cannot “cherry pick” healthy
customers only
Without this, Guaranteed Issue would result in
people not buying insurance until they got sick,
which would result in skyrocketing premiums
(and defeat the whole point of insurance)
• Medicaid Expansion: Those that make less than 133
percent (up from 100 percent) of the federal poverty level
will qualify for Medicaid
• Federal Subsidies for individuals based on income level
Increasing
Accessibility
to Coverage
• States will set up insurance exchanges where people
(especially those that cannot get insurance through an
employer) can buy insurance.
• Children can be covered on parents policy up to age 26
• Employer Mandate: Those with more than 50 employees
must provide insurance, or be subject to fine. Those with
more than 200 employees must provide insurance
11
If there is an individual mandate for people to
get insurance, the system must also make
insurance relatively accessible (i.e. not too
costly) and easy to get, particularly for the
lower income, unemployed, etc.
12. The ACA: A High-Level Perspective (II)
•
Another way to understand the ACA is that it is based on the idea that “We are all in this together.”
Payers must accept everyone into the insurance pool, and everyone must participate in that pool.
Must provide affordable
insurance to all
(Guaranteed Issue)
Payers
Individuals
(i.e. Patients)
Must have insurance
(Individual Mandate)
12
Facilitate this union
(exchanges,
subsidies, employer
mandate, Medicare
expansion, etc.)
Government
13. ACA Impact on Coverage
•
The impact of many parts of the ACA is in dispute. However, practically everyone agrees that it will
reduce the number of uninsured individuals.
Number of uninsured in 2019
– CBO Estimate
55
Reduction of 25
million
million uninsured
• Medicaid Expansion: Requires states to offer
Medicaid to people with incomes up to 138
percent (133 percent plus a 5 percent income
disregard) of the federal poverty level (FPL)*
• Federal Subsidies: Premium subsidies and
limits on OOP spending for those with incomes
up to 400% of the FPL, for those that buy
insurance through exchanges
30
million
• Guaranteed Issue: Remove restrictions and
discrimination (pre-existing conditions, payers
cannot remove individuals if the get sick, etc.)
• Individual Mandate: Get insurance or pay
penalty
• Health Insurance Exchanges: Virtual
marketplaces where people can choose from a
wide set of policies, independent of their
employment
Before ACA
* Most, but not all states will comply with this (more on slide 20)
13
After ACA
14. ACA Impact on Overall Healthcare Costs – In Theory
Uninsured
•
Fewer uninsured should lead to more preventative care and less emergency care, reducing overall costs
to the healthcare system
“An ounce of prevention is worth a pound of cure” – Benjamin Franklin
Does not receive
regular, preventative
care
Suffering
Insured
•
Seeks out and
receives
regular, preventative
care
First interaction with the
healthcare system is an
emergency situation, which is
very costly.
By law, uninsured patients cannot
be refused emergency care, so
costs are passed on to payers
and insured patients anyways*
Few require emergency care
*Currently, uninsured people account for 20% of ER visits, costing hospitals as much as $56 billion / year
(http://articles.latimes.com/2012/jun/18/nation/la-na-emergency-care-20120619)
14
15. Other provisions in the ACA
•
The ACA contains hundreds of other provisions. Here are a few of the more impactful ones.
Provision
Motivation / Idea
Eliminating barriers to preventative services
All new insurance plans must cover preventive care and medical
screenings rated Level A or B by the U.S. Preventive Services Task
Force. Insurers are prohibited from charging co-payments, coinsurance, or deductibles for these services.
Encourage preventative care and screenings --- with hope
that this will reduce overall healthcare costs. “An ounce of
prevention is worth a pound of cure.”
Eliminating the Medicare “Donut Hole”
Manufacturers voluntarily agreed to provide $80 billion in
prescription drug discounts over 10 years for beneficiaries in the
Medicare donut hole. These discounts, coupled with federal
subsidies, will close the coverage gap by 2020.
The U.S. Department of Health and Human Services
estimates that more than a quarter of Part D participants
stop following their prescribed regimen of drugs when they
hit the donut hole. This can lead to poor health outcomes
which may cost the health system more in the long run.
Minimum Medical Loss Ratio for Insurers
Insurers must spend a certain portion of premium dollars on
healthcare (85% for large group plans; and 80% for
individual/small group plans), leaving only 20% and 15%
respectively for administrative costs and profits. If an insurer fails
to meet this requirement, a rebate must be issued to the policy
holder.
This prevents payers from price gouging, and provides a
disincentive for them to challenge / withhold coverage to
maximize their profit (beyond a certain level).
Governance of Biosimilars
Authorizes the FDA to approve generic versions of biologic drugs
and grant biologics manufacturers 12 years of exclusive use (data
exclusivity) before a biosimilar can be filed for approval.
Clears a pathway for biosimilars, allowing for potentially
cheaper versions of biologic drugs to become available.
15
16. Contents
●
Background: Our “Dysfunctional” Healthcare System
●
The ACA: An Overview
●
Main Points of Contention
●
Health Insurance Exchanges – A New Way to Buy Insurance
●
Impact on Different Stakeholders
16
17. Some History
•
•
The ACA had a difficult, partisan “birth.”
It was rammed through Congress, with not one Republican voting for it in the House.
2008
Obama identifies
fixing healthcare as
one of top 4
priorities in he wins
presidency.
2009
Congressional back and forth, House
and Senate with different bills.
Policy makers and
leading Democrats
convince Obama
Obama wins
that an individual
general
mandate is
election.
necessary to avoid
Obama proposes
the free rider
plan to cover 45
Republican
problem.
million uninsured
leadership directs its
using a subsidy, but
legislators to oppose
not a mandate.
the individual
Bipartisan
mandate, saying it is
committees
unconstitutional*.
formed to address
issues.
2010
Bill passes
House by 219
to 212 vote,
with all 178
Republicans
voting against
it.
The same
day, several
states file a
lawsuit
challenging the
constitutionality
of the ACA!
*Interestingly, previous Republican healthcare reform proposals included an individual mandate (most notably a 1993 Republican alternative
to the Clinton bill called the HEART act, as well as Romney’s state-level plan for Massachusetts in 2006).
17
18. The Individual Mandate Debate
•
There are arguments and counterarguments around the Individual Mandate, but at root the debate is
about the appropriate size and reach of the Federal government.
Arguments For
Arguments Against
The whole point of insurance is to
share and spread risks. If everyone
does not participate (or worse, if only
the riskiest people participate) –
insurance doesn’t work. Cannot have
guaranteed issue without the
individual mandate.
It is unconstitutional for government to
require people to purchase something.
Government cannot force commerce.
But governments already do this –
e.g. state laws requiring purchase of
auto insurance
Auto insurance is different because you can
choose to have a car or not.
…
This is the similar to a tax, and the
government is allowed to levy taxes
…
18
19. The 2012 Supreme Court Ruling
•
In 2012, the US Supreme Court upheld the Individual Mandate, but limited the Federal Governments
capability to force states to participate in Medicaid expansion
●
On March 23, 2010, the same day that the ACA was signed into law, several states
filed a lawsuit challenging the constitutionality of
o
o
●
The Individual Mandate
Medicaid expansion
In June 2012, the US Supreme court ruled as follows:
Individual Mandate
Medicaid Expansion
This is constitutional, as it is the
same as Congress’ power to tax.
Passed by a 5-4 decision.
Medicare expansion is fine, but the
Federal government cannot force states
to participate in Medicare expansion
under threat of withholding existing
funding
Had it not been ruled this
way, Obamacare would be dead, for
all intents and purposes.
19
20. State-by-State Participation in Medicare Expansion
•
Only about half of the states will participate in Medicare expansion, somewhat blunting the impact of
the ACA.
20
21. Contents
●
Background: Our “Dysfunctional” Healthcare System
●
The ACA: An Overview
●
Main Points of Contention
●
Health Insurance Exchanges – A New Way to Buy Insurance
●
Impact on Different Stakeholders
21
22. Health Insurance Exchanges – What are they?
•
An HIX is a regulated, virtual marketplace, administered by either federal or state government, where
private insurers may sell plans to individuals and small business starting January 2014.
Health Insurance
Exchange
• Individuals
(unemployed, selfemployed, or working for
companies that do not
offer insurance, etc.)
• Only approved plans that
meet certain standards (e.g.
no discrimination by preexisting condition, will be
allowed to be sold on the
exchanges
• Small businesses looking
for insurance
• States may charge insurers a
fee (up to 3.5% of premiums)
for the right to sell on the
exchange
• Those who require federal
subsidies for insurance
• Delinking insurance from
employment ensures that
people can have insurance
in between jobs.
22
24. Health Insurance Exchanges – State by State Approach
•
17 states are building their own HIXs, 7 others are assuming some responsibilities, and 26 states are
defaulting to a Federally administered exchange
Some states will
operate their
exchanges as a
clearinghouse
(i.e. all qualified
plans will be
available there).
Other states, like
California, will
only offer
selected
plans, based on
negotiated rates
with insurers
Reasons for states to set up their own exchanges: Federal subsidies, more local control
Reasons for states not to set up their own exchanges: Cost and administration, politics
24
25. Contents
●
Background: Our “Dysfunctional” Healthcare System
●
The ACA: An Overview
●
Main Points of Contention
●
Health Insurance Exchanges – A New Way to Buy Insurance
●
Impacts on Different Stakeholders
25
26. ACA Implications – Consumers (I)
•
More people will get covered, and coverage will be better
Cons
Pros
Financial support for many to get insurance
(Medicare expansion, subsidies)
Individual Mandate will mean some
healthy individuals who may not need
health insurance will be required to
purchase it (or pay a fine)
Guaranteed Issue prevents payers from “cherry picking”
healthy patients only
(no exclusions due to pre-existing conditions, no terminating
policies when patients get sick, etc.)
Insurance plans can no longer have lifetime limits or
maximums
Some high income consumers (>$200K
for individuals, >$250K for joint filers) will
have to pay more Medicare taxes
Elimination of Medicare “Donut Hole”
will help out many elderly patients who are otherwise
stopping treatment when they reach the “hole”
Insurance plans can no longer have copays/coinsurance
requirements for a long list of preventative measures
Health insurance exchanges will, in
principle, provide people with more choice of
plans, and help them find the most appropriate plan for
their situation
26
27. ACA Implications – Consumers (II)
•
There are strong reasons to believe that insurance premiums will increase, however, at least initially*
Reasons premiums will increase
Reasons premiums will decrease
Individual Mandate will bring some healthy people
into the pool who would otherwise not get insurance
Guaranteed Issue means that insurers
will have to take on anyone, including
those with pre-existing conditions and
other unhealthy individuals
Health Insurance Exchanges will increase
competition, increase transparency, in theory should
bring prices down
No lifetime limits or annual
maximums, no copayment of various
preventative measures --- payers will
pass on costs through increased
premiums.
An ounce of prevention is worth a pound of cure
As the number of uninsured and underinsured is
reduced (via Medicare expansion, federal
subsidies, etc., preventative treatments will
increase, and emergency treatments will decrease
?
Where this will “net” out is unclear. It may take some time for the “ounce of
prevention” dynamic to play out, so it may be that premiums will rise initially,
only to fall down the line.
* The Minimum Medical Loss Ratio for Insurers will prevent premiums rising to a level where Insurers make
unreasonably huge profits, though.
27
?
28. ACA Implications – Payers
•
Payers will feel the squeeze and will need to adapt as the market gets more competitive and increasingly
driven by individual customers (as opposed to employers)
Potential challenges
Potential benefits
Insurers have to accept high-risk individuals, those
with pre-existing conditions, etc.
More people covered will lead to more top line
revenues
Health insurance exchanges will heighten
competition for customers as the marketplace
becomes more transparent and customers have
more options.
Individual Mandate will lead to many healthy
individuals buying insurance that would otherwise
not do so
Compared to employers, individual customers will
more easily “churn” --- i.e. hunt for better rates and
customer service. The market will be more akin to
the wireless market
Minimum Medical Loss Ratio will cap payer
profits to a percentage of what they collect in
premiums. If they exceed these limits, they must
provide refund checks to policy holders.
28
29. ACA Implications – Payer / Premium Calculus
•
•
The ACA will increase the pool of insured individuals by about 25 million
Payer profits as well as whether premiums increase or decrease will depend on the shape of the risk/population curve
below.
Number of newly insured individuals
The ACA will increase the pool of insured
individuals by about 25 million
Some will be healthy
individuals that would not
have previously gotten
insurance before, but
now do so because of the
Individual Mandate.
Low
Some will be those
who now get
insurance because of
increased
accessibility through
HIXs, via federal
subsidies, and
through Medicaid
expansion.
Level of health risk /
Amount insurers will have to pay out
29
Some will be high-risk
individuals, those with preexisting conditions, etc., that
payers would have refused
coverage before, but now
have to accept because of
Guaranteed Issue.
High
30. ACA Implications – The Federal Budget
•
•
There is a lot of dispute about the net impact of the ACA on the Federal Deficit, but the CBO predicts the ACA will reduce
the deficit by about $100B over the next ten years.
However, a lot of this is due to cuts in Medicare spending, which are unlikely to stand.
$2T
Penalty payments from individuals
(who are not getting insurance)
Estimated Impact on Federal
Deficit over the next 10 years
(value are approximate)
Penalty payments from employers
(who don’t provide insurance)
Excise tax on “Cadillac” insurance plans
Other tax revenue increases,
e.g. to pharma companies
Federal
Subsidies
provided through
HIXs
Increasing hospital
insurance (HI) payroll
taxes for high income
individuals, and extending
it to investment income
$1T
Reducing Medicare
payments, particularly to
Medicare Advantage
programs
Medicare
Expansion
Will this really happen? Past reductions in Medicare payments have been
postponed time and again. Additionally, one in five physicians are restricting the
number of Medicare patients in their practice and one in three primary care doctors
– the providers on the front lines of keeping the cost of seniors’ care low – are
restricting Medicare patients, according to a 2010 AMA survey of more than 9,000
doctors who care for Medicare patients
30
Net savings of about
$100B over 10 years
31. ACA Implications – Providers
•
•
Providers will come under increasing pressure: More patients to treat, new paradigms to deal with.
As costs go down, providers will have a smaller pie to share and only the most efficient will survive.
Potential benefits
Increased demand for healthcare
by patients with insurance, and
likely reduction in uncompensated
care
Physicians are incentivized by
the 10% Medicare bonus
payment to treat in healthcare
shortage areas
Potential challenges
More covered individuals means more treatment, and more earlier
treatment. More treatment of chronic conditions, less of acute
conditions, more preventative treatment, less emergency treatment.
The increased demand for healthcare will worsen existing shortage
of providers, particularly PCPs, general surgeons, nurses, and
physicians assistants
Adding millions of people to the Medicaid system will aggravate
existing dilemmas with the system
• e.g., lower Medicaid payments for providers has resulted in
access problems for low-income individuals and worsened
hospital ER overcrowding
Reducing Medicare payments will hurt provider pocketbooks
High quality and cost efficient
providers can do better in a
fee-for-value system, e.g.
share in cost savings
New Medicare payment paradigms (cost savings sharing with
Accountable Care Organizations), will push providers to be more
cost efficient and focus more on quality outcomes vs. fee for service
models.
31
32. ACA Implications – Industry
•
The Pharmaceutical Industry supported the ACA, agreeing to contribute to its implementation via excise
taxes and rebates. In return, it gets potentially more than 30 million new drug customers.
Potential benefits
Potential challenges
Potentially more than 30 million newly insured who
will purchase prescription drugs, and who will not be
subject to annual or lifetime caps on coverage
Excise taxes assessed to manufacturers of
branded prescription drugs and medical devices.
Drug manufacturers required to provide 50%
discount on brand name drugs for Medicare
patients in the “donut hole.”
Increased sales of drugs from individuals who had
previously stopped taking them due to the
Medicare “donut hole”
Abbreviated approval pathway for biosimilars
12-year brand exclusivity for biologic drugs from
date of FDA approval
As more healthcare spending moves from
emergency to preventative, there may be a
shift in spending from certain types of drugs to
others
Move to “fee-for-value” from “fee-for-service” could
favor using drugs, especially preventative
treatments that would avoid more costly acute care
down the road
* Estimated contribution over the next ten years is in the range of $90B.
32
*
34. Reform Implications – Jobs
Potential job creation
Potential job elimination
If firm has more than 50 full time employees, must offer insurance
or pay a fine ($2-3K per worker)
Expanding Medicaid removes a
disincentive to work.
People may choose to work less. Subsidies to get insurance, and
ability to purchase it as an individual, will reduce incentive to get a
job (which for some people is the main motivation for having the
job)
By making it easier to get
insurance as an
individual, makes it less of an
issue to search for new job or
start a new business on ones
own.
If insurance becomes
cheaper, firms will have more
money to hire workers
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35. Health Insurance Exchanges – Benefits and Challenges
•
•
HIXs will increase competition, access and transparency.
Insurers will begin to sell increasingly to individuals, and less to employers.
Potential Benefits
Access: Make it easier for people to get insurance, especially
those who are unemployed or work for companies that do
not offer insurance (i.e. often those that are poorer and need
care the most). Delinking insurance from employment
ensures that people can have insurance in between jobs.
Transparency and Competition: Easy to compare plans side
by side, and make the market more competitive (and thereby
reduce costs) by offering more plans than a single employer
typically does. Reducing costs in turn will increase access.
Potential Challenges
Confusing: Too many options might be confusing to people.
Having to sort through all the different choices and
rules/regulations is likely to be frustrating.
Initial “kinks”: May be some initial confusion, particularly
since the exchanges must adhere to both federal and different
state regulations. Lack of coordination could be problematic.
Disintermediation: Brokers and agents could be threatened.
How will they (or how wont they) be integrated into the
system?
Revenue: States have the option of charging a fee (3.5% of
the premium) to insurers for the right to participate in the
exchange
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