Healthcare Reform

North Carolina Dietetic Association

September 12, 2014

Duke Medicine

Take home messages

• Healthcare [and health insurance] is transforming at an accelerating pace

• Key metrics of concern relate to quality, consumers’ experience/engagement, access, and cost

• “If you’re not at the table, you’re on the menu.” -Michael Enzi

Duke Medicine

Key features of the ACA [health insurance reform]

• Guaranteed issue – everyone who applies must be accepted

• Individual mandate, with weak penalty

• Modified community rating with limited rating factors (age, gender)

• No health underwriting/no pre-existing

• Established Exchanges/Marketplace

• Premium and cost-sharing subsidies (for individual coverage only and only on Exchange)

• State option for Medicaid expansion (SCOTUS)

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Key features of the ACA [health insurance reform] (2)

• Preventive care coverage

– USPSTF Grade A or B recommendations

• “Offer or refer to intensive behavioral counselling interventions to promote a healthful diet and physical activity. Grade: B”

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Kaiser Family Foundation, April, 2013 USPSTF, August 2014

Medicaid Expansion, March 2014

Note: The Centers for Medicare and Medicaid Services (CMS) has approved waivers for expansion with variation in Arkansas, Iowa, and Michigan. Pennsylvania’s waiver is currently under review by CMS. Source: Avalere State Reform Insights; Center of Budget and Policy Priorities; Politico.com; Commonwealth Fund analysis.

TX

FL

NM GA

AZ

CA

WY

NV

AK

OK

MS

LA

MT

TN

WA

OR ID

UT CO

KS

NE

SD

ND

MN

WI

MO

IL IN OH

KY

WV VA

NC

SC

AL

NY

ME

DC

MD

DE

NJ CT

RI

MA

NH VT

HI

Expanding (22 states + D.C.)

Not expanding (19 states)

Options under discussion (5 states)

Expanding with variation (4 states)

MI

IA

AR

PA

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Adults ages 19–64 who selected a private plan or enrolled in Medicaid through the marketplace

or have had Medicaid for less than 1 year

No 34%

Yes 60%

Adults ages 19–64 who have used new health insurance plan

Have you used your new health insurance plan to visit a doctor, hospital, or other health care provider,

or to pay for prescription drugs?

Use, prior affordability of care with ACA plans

No 62%

Yes 36%

Don’t know or refused

2%

Note: Segments may not sum to 100 percent because of rounding. Source: The Commonwealth Fund Affordable Care Act Tracking Survey, April–June 2014.

Prior to getting your new health insurance plan, would you have been able to access

and/or afford this care?

Plan has not yet gone into effect

6%

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Health Risks of New Enrollees (Early Indications)

• More chronic conditions than non-ACA customers

– Enrollees with chronic conditions – diabetes, depression, asthma, arthritis, cancers, heart disease – cost six times more than enrollees of similar age without chronic conditions

– Significant, because insurers can no longer rate a person differently because of health status

• Higher use of health care services than non-ACA customer population

– More Primary Care and Specialist visits

– More In-Patient Admissions and requests for Advanced Imaging

• Seeking prescription drugs for chronic conditions

– Diabetes, mental health and mood disorders, Multiple Sclerosis, HIV, infectious hepatitis

7 Duke Medicine

Source: Blue Cross and Blue Shield of North Carolina, July 2014

Where we are:

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• U.S. health care spending at 18% of GDP and climbing • 75% of healthcare costs related to chronic conditions • Life expectancy 38th in the world-70% of deaths due to chronic conditions •Nearly half of US adults live with at least one chronic condition •Only 55% of needed care is delivered

SOURCES: Health Affairs; United Nations World Population Prospects; CDC; McGlynn Duke Medicine

Obesity Rates, 2013

NC= 29.4%

Duke Medicine Trust for America’s Health, 2014

Healthcare Reform- Emerging approaches [payers]

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• Bridging from current fee-for-service to value-based payment

• Patient-centered medical homes

• Accountable care organizations (ACOs)/ population health

• Episodic bundled payments, outpatient prospective

payments

• Limited and/or tiered networks [and formularies]

• Transparency, consumerism and self-management

• On-line and digital care

• Alternative providers of care

• Joint ventures with providers

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NCQA-recognized PCMH Practices in North Carolina April, 2013

CCNC, April 2013

Proportion of lives in ACOs 2014

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Transparency and consumerism in healthcare

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o People seeking health information online and on mobile devices has more than doubled in the past decade- 80% have a cell phone o check provider reviews, costs,

or ratings o validate doctor

recommendations

o Find a provider, e.g. urgent care

o Prescription drug information o Benefits and claims status

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*Pre-visit data sharing, risk stratification with payer *Wi-fi home monitoring of weight, activity, blood glucose, blood pressure *E-visits *Video consultations *Point of decision finger stick lab *Automated quality and performance reporting * MD, PA, RDN, MSW, CSP team care

Expanding horizons

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Take home messages

• Healthcare [and health insurance] is transforming at an accelerating pace

• Key metrics of concern relate to quality, consumers’ experience/engagement, access, and cost

• “If you’re not at the table, you’re on the menu.” -Michael Enzi

Duke Medicine

References

• Healthcare Reform Summary- Kaiser Family Foundation, April 23, 2013 http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf

• USPSTF, August 2014- nutrition recommendation http://www.uspreventiveservicestaskforce.org/uspstf13/cvdhighrisk/cvdhighrisksumm.pdf

• CCNC, April 2013 PCMH growth https://www.communitycarenc.org/emerging-initiatives/pcmh-central1 /

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