healthcare in the u.s.: an overview. today’s plan i. problems with healthcare in the us ii. social...

Healthcare in the U.S.: An Overview

Today’s Plan

I. Problems with Healthcare in the US

II. Social Welfare Health Programs

III. Problems faced by SW Health Programs

Affordable Care Act

Major Problems Being Addressed The rapidly increasing costs of

healthcare Annual health cost increases exceed inflation

Poor population health Medicare – the baby boomers are

coming Medicaid – long term care & special

needs Commercial Insurance

Gradual decrease in employer participation

Pre-existing conditions + coverage caps

Business owners revolt at high premiums

Individual coverage is cost-prohibitive

Increasing numbers of uninsured

Source: HealtheConnections- http://uc.syr.edu/community/tmr/pdf/Sara%20Wall%20Oct%2017%20PPACA%20for%20TMR%20.pdf

Previous Health Budget 4x4

New Health Budget 2x10Spending

universal to broaden the base

Theoretical Approach- Bronfenbrenner’s Ecological Systems

http://capitaled151.wikispaces.com/Social+and+Cross-Cultural+Skills

Individual Health BehaviorHealth Care

Providers

Community Factors: poverty,

racial segregation, unhealthy homes, neighborhoods,

workspaces , schools


The “Prevention & Public Health Fund” provides funding to: •Help control the obesity epidemic •Fight health disparities •Encourage healthy living •Reduce tobacco use •Prevent the spread of HIV/AIDS •Improve access to behavioral health care •And many more initiatives… www.BeTobaccoFree.gov

National Culturally and Linguistically Appropriate Services (CLAS) Standards: a blueprint for healthcare organizations. U.S. Department of Health and Human Services Office of Minority Health www.thinkculturalhealth.hhs.gov

Incentives for Providers ◦Expands the number primary care providers ◦Increases payment for rural health ◦Small private practices will be able to purchase health insurance for themselves and their employees via the new marketplace ◦There are small business tax credits for a limited time

Innovation & Demonstration Projects ◦Grants to states for tort reform ◦Encourages coordinated care via medical “teams” – Accountable Care Organizations ◦Electronic Health Information Exchanges ◦Standardized billing format ◦Paperwork reduction ◦Secure & confidential (HIPAA & HITECH)


Health Benefit Levels Plans will be organized based on coverage levels; percentage of ‘actuarial value’ of the plans •Platinum 90% •Gold 80% •Silver 70% •Bronze 60% •Catastrophic Only for people under 30

Essential Health Benefits: –Office Visits with Physician –Emergency Department –Hospitalization –Maternity/Newborn –Mental health/Substance use –Prescription drugs –Laboratory/Radiology –Prevention/Wellness –Chronic disease management –Pediatric services –Oral & Vision care for children –Rehabilitation & habilitation

https://www.healthcare.gov/ Source: HealtheConnections- http://uc.syr.edu/community/tmr/pdf/Sara%20Wall%20Oct%2017%20PPACA%20for%20TMR%20.pdf

One portal will process applications for: –Medicaid –Child Health Plus –Individual Marketplace –Small Business Marketplace

Qualified Health Plan Highlights •Choice of plans in all areas of the State •Increased competition gives consumers new health plan options •Premiums for people who buy coverage for themselves and their families decreases by an average of 53% compared to today’s premiums •You will not be denied health insurance on the basis of a pre-existing condition •All plans are required to have adequate networks •All plans cover the Essential Health Benefits

Regulations for Insurers ◦Allow pre-existing conditions Children 2010 Adults 2014 ◦Extend coverage to young adults on parent plan ◦Prohibition on rescinding coverage ◦Cover preventative services without deductible, co-pay or coinsurance ◦Eliminates life-time coverage limits ◦Eliminates annual coverage limits ◦Government review of premium increases


https://www.healthcare.gov/

2 main types of customers



•Individuals may enroll in health plans during open enrollment (October 1, 2013 - March 31, 2014) or with a qualifying event •Individuals who qualify for Medicaid/Child Health Plus may enroll any month of the year •Small employers may choose open enrollment dates for their employees any month of the year

https://nystateofhealth.ny.gov/

Previous Health Budget 4x4

New Health Budget 2x10Spending

universal to broaden the base

Also to lower cost,

disincentives for Cadillac

care


Health Benefit Levels Plans will be organized based on coverage levels; percentage of ‘actuarial value’ of the plans •Platinum 90% •Gold 80% •Silver 70% •Bronze 60% •Catastrophic Only for people under 30


Small Business Choices ‘Small’ Business = 50 or fewer FTE employees Small businesses may purchase insurance for their employees through the system. Businesses may continue to offer traditional coverage. •There is no penalty for small business that do not contribute to their employee’s premiums •¾ of enrollees will be eligible for subsidies

Small Business Choices •Only 50% of businesses with 3-9 employees and 27% of businesses with 10-24 employees offer health insurance. •Of the uninsured people in CNY; more than half are employed - this is more than 50,000 people. •Employers may opt out of coverage entirely – let employees purchase insurance as individuals •Employers may choose to offer a ‘defined contribution’ toward employee health coverage


In 2014: •Small employers can receive 50% tax credit for employer-paid insurance •Not-for-profit employers get 35% •Must have fewer than 25 FTE •Must contribute at least 50% of premium •Average salary less than $50,000/year


Navigator Grants •Conditional grants totaling $27 Million •50 organizational awards –96 subcontractors for a total of 430 FT staff –48 languages spoken among all Navigators •Publicly available directory will include site schedules, hours, languages spoken http://www.nystateofhealth.ny.gov/IPANavigatorMap


The Market Will be Facilitated


The Market Will be Regional

The Market Will be Informed

The marketplace will assign quality ratings to qualified health plans based on an existing data base based on the Quality Assurance Reporting Requirements


State by State Updates

http://www.hhs.gov/intergovernmental/acaresources/

The Market will be Mandatory The Individual Mandate •Upheld by the Supreme Court •A person must carry insurance for at least ten of

twelve months during 2014 •Penalty may be as much as 1% of income


Large Employers •Large employer penalty postponed to 2015 •New protections and opportunities apply •Large employers must offer “affordable” and “adequate” coverage to all full-time (defined as 30 hours/week) employees and their dependents

The Market will be Subsidized How is the PPACA Paid For? •New Taxes •Health Insurance Tax (HIT) •Patient-Centered Outcomes Research Institute (PCORI) fee to fund research •Transitional Reinsurance Program fee •10% tax on tanning salons •2.3% excise tax on medical device manufacturers •3.8% surtax in “investment income”* •0.9% surtax on Medicare taxes* •Flex account cap $2500; removed OTC meds •Medical deduction 10% •Penalty for HSA withdrawal 20% •40% tax on ‘Cadillac’ plans starting in 2018


The Market Will be Affordable.. Not Free

–Financial Assistance •Many individuals and families will be eligible for financial assistance to reduce the cost of coverage •Financial assistance is available in two forms: –Advance premium tax credits will subsidize the cost of premiums for most single adults earning less than $45,960 and for families of four earning less than $94,200–Cost-sharing reductions will lower co-payments and deductibles for single adults earning less than $28,725 and for families of four earning less than $58,875 •Tax credits and cost sharing reductions are estimated at the time of application and applied immediately

Single resident earning $25,000

Parent with two children earning $50,000

Silver Plan Gold Plan

$141.58 premium tax credit $471.42 premium tax credit

Responsible to pay $144.28 - $319.81 per month

Responsible to pay $451.07 - $1041.51 per month

Sample Rates


The Market will be Political – states opting out of 100% then 90% reimbursed Medicaid Expansions

Changes to Government Health Insurance ◦10% Medicare bonus for primary care ◦10% Medicare bonus for general surgery in shortage areas ◦Closes the “doughnut hole” for prescription drug coverage under

Medicare ◦Medicare will cover preventative services without deductible, co-pay or

coinsurance ◦Medicaid reimbursement will increase to match Medicare for primary

care visits ◦Adds funding to States for Medicaid expansion

Wall Street Journal The Affordable Care

Act is a regulated free-market approach (so understanding the market as discussed earlier is critical)

A key part is creating a market forum known as Health Insurance Exchanges

This may take some time

See video at: http://on.wsj.com/1asOYbQ Or http://live.wsj.com/public/page/video-popup.html?

currentPlayingLocation=0&currentlyPlayingCollection=News&currentlyPlayingVideoId={D7306724-18B8-45A6-A120-4E67B1DA67A4}

http://online.wsj.com/article/SB10001424127887324520904578553871314315986.html

Timeline2010 -2012 •Protection for pre-existing conditions •Eliminating lifetime limits •Small business tax credits •Filling the ‘donut hole’ •Providing free preventative care (no co-pay) •Extending coverage to young adults to age 26 •Expansion of Medicaid coverage •New service models for seniors

2013-2015 •Expands ‘bundled’ payments •Increase visit payments to doctors who accept Medicaid •Open enrollment in the Health Exchange marketplace begins •Ensuring people in clinical trials •Tax credits up to 400% of poverty •More small business tax credits •Promote individual responsibility •Pay physicians for ‘value’ not ‘volume’


For different sub populations

http://www.hhs.gov/intergovernmental/acaresources/

The Buzz on Health Homes• Health Homes: The Affordable Care Act enhances the primary

care and care coordination services provided in the doctor’s office as well. The law provides States with a new Medicaid State Plan Option to support Health Homes. For individuals with chronic illness, many of whom are older Americans or individuals living with disabilities, Health Homes will integrate and coordinate all primary, acute, behavioral health (mental health and substance use) and long term services and supports to treat the person across the lifespan. Through this program, patients may receive comprehensive care management, health promotion education, comprehensive transitional care and follow-up, family support, and referrals to community and social support services. As of August 1, 2012, six States (Missouri, Rhode Island, New York, Oregon, North Carolina and Iowa) have approved Health Home State Plan Amendments.

http://www.healthcare.gov/news/reports/community-living-09112012a.html

Accountable Care Organizations (ACOs) At its heart, an ACO is a network of doctors and hospitals that share the responsibility to care for patients, agreeing to attend to the health care needs of at least 5,000 Medicare eligible beneficiaries. The ACO would bring together the many and varied components of the health care system such as hospitals, primary care, specialty care, home health, and laboratory and radiology services. The intended effect of this cooperative effort, if achieved, would result in overall cost savings and also achieve the stated goal of improved quality of care. According to the Affordable Care Act (section 3022) ACOs may begin to contract with Medicare in January 2012. The rules make ACOs responsible, and hold all providers jointly accountable, for the care of their patients while at the same time providing financial incentives to implement coordinated care. The cost savings goals would be realized through avoiding unnecessary tests and procedures as well as improved care coordination though shared information systems.

Additional savings would be found in paying special attention to patients with chronic conditions. Simply keeping patients healthy and out of the hospital would result in cost reduction. For ACOs that are not able to save money, that cost burden would be assumed by all members of the ACO. It is this shared risk that has created much of the anxiety regarding ACO implementation. How an ACO is implemented throughout the country is also quite varied. Depending on where one resides or practices, such as California or many large east coast cities, the infrastructure is already in place in the form of large multi-specialty organizations. In other regions, large insurers, hospitals or other regional systems are purchasing practices as they prepare to form their own ACO

http://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice%20Resources/ACO_Joint_Task_ForceDRTRACYV3.pdf

healthcare in the u.s.: an overview. today’s plan i. problems with healthcare in the us ii. social...

Documents

health insurance

department of health

behavioral health care

medicaid child health

essential health benefits

prevention public health

healtheconnections http

educommunitytmrpdfsara