Lance T. Laurence, Ph.D. Associate Professor, Dept of Psychology & Director, Univ. of...
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Health Care Reform Developments in Tennessee: Your Options at Present Lance T. Laurence, Ph.D. Associate Professor, Dept of Psychology & Director, Univ. of Tennessee-Knoxville Psychological Clinic Director, Professional Affairs, Tenn. Psychological Association TPA Convention 11/1/12
Lance T. Laurence, Ph.D. Associate Professor, Dept of Psychology & Director, Univ. of Tennessee-Knoxville Psychological Clinic Director, Professional
Lance T. Laurence, Ph.D. Associate Professor, Dept of
Psychology & Director, Univ. of Tennessee-Knoxville
Psychological Clinic Director, Professional Affairs, Tenn.
Psychological Association TPA Convention 11/1/12
Slide 3
Health Care Reform in Tennessee: Important Developments Patient
Protection & Affordable Care Act (2010) Supreme Court rules on
critical component of PPACA: that is, CAN require individuals to
buy health insurance (tax authority interpretation) Tennessee now
in the process of creating Health Exchanges which will be run by
Tennessee, not the federal government (some states passing on
state-run option and looking to the Feds to do it) Commissioner
McPeaks state-wide solicitation of opinion on which plan to use as
standard/benchmark for the Health Exchange
Slide 4
Health Care Reform Developments The 2012 Election in November:
Will it affect PPACA? Answer: Probably Not. Neither candidate is
going to win by a substantial amount and the voting control of the
House and Senate not likely to change much. Hence, PPACA law that
has already been passed not likely to be overturned substantially.
Also, private sector already moving in same direction as PPACA.
More blurring of distinctions between providers, hospital systems,
and insurance companies. More provider-insurance company risk
sharing, global payments (patient care paid with fixed annual fees
in health homes), more providers of different disciplines owning
health care companies. Efforts to maximize prevention and disease
management increasing.
Slide 5
PPACA: Intentionalities Reduce number of uninsured Reduce
health care costs Curb unsustainable rise of health care costs in
the public sector (Medicare and Medicaid) Improve patient care
Eliminate waste and fraud (2007 OIG Report on 2003 MH Audit: 47% of
care did not meet program requirements; spent 2.14 billion in 2003
so $1.01 billion waste) Incentivize organizations/providers who
provide quality, cost-effective care Support prevention and disease
management programs Encourage integrated mind-physical health
care
Slide 6
PPACA: Early Effects Has already eliminated pre-existing
conditions Has extended coverage for dependents from age 24 to age
26 #1 and #2 probably has contributed to drop in uninsured in 2011
to 15.7% (44% of the population) from 16.3% in 2010 (46%) Health
care costs increase declined from 5.6% increase in 2010 to 5.3% in
2011 Massive cuts in provider wages in public and private sector
being considered Creation of new entities, particularly Accountable
Care Organizations (ACOs)
Slide 7
Why Do Health Care Reform? Three primary factors: increased
costs of health care relative to Gross Domestic Product, aging
population, increasing uninsured population (recession recently
increased these numbers) Simply has to happen. Costs in the public
sector are unsustainable and increasingly so in the private sector
so that more and more employers consider abandoning the social
contract of providing employees with health insurance (i.e., legacy
costs of General Motors major reason for their bankruptcy). Simply
must contain Medicare, Medicare and uninsured costs of health care,
yet alone those in the private sector
Slide 8
Health Care Costs 1960s: 28 Billion 1970s: 75 Billion, $326.00
per person, 7.2% of GDP 1980s: 253 Billion 1990s: 714 Billion
(remember Clinton Reform Efforts?) 2008: 2.3 Trillion, $7,681.00
per person, 16.2% GDP 2009: 17% GDP 2010: 20.3% GDP 2018 Estimate:
$13,000+ per person
Slide 9
Unsustainable Cost Increases & Population Shifts Since
1980s, cost increases in health care greater than increases in GDP
rate and galloping gap continues to widen; didnt used to be that
way In 2010 cost increases in health care 200% higher than
increases in GDP rate; by 2018 increases in health care are 350%
more than increases in GDP rate We are aging, and fast: - In 2010,
those 60 and older make up 18% of the population, 65+ 13% and 85+
2%. - By 2030, 60+ are 25% of population, 65+ 20% and 85+ 3% - By
2050, 60+ are 25% of population, 20% for 65+, and 5% for 85+
Slide 10
PPACA: How It Includes People Keeps employer-based systems
Expands Medicaid in order to try to cover poor, low-income
uninsured people or uninsured working poor. Opens door to introduce
managed care to this population (in Tennessee, Tenncare) Begins the
process of introducing managed care into Medicare population which
is critical for aging population If you dont fit into any category
above, you buy an insurance product through the exchange rather
than be uninsured Combination of the above captures most
people
Slide 11
PPARC: What It Does/Attempts It is NOT a single payer system
(like Canada). Some believe it is an incremental step toward an
eventual single payer system; others deny such an intentionality
With the requirement of everyone having to purchase insurance, you
either purchase it through your employer or if you cant get it
there, you buy it through a state-approved exchange which provides
the basic plan available to all in the insurance exchange. State
approves what a basic plan is, which includes all PPARC mandated
benchmarks (mental health and substance use disorders included),
and you purchase it from the exchange
Slide 12
Most Visible Development: Creation of Accountable Care
Organizations Two already in Upper East Tennessee: Mountain States
and Highlands 154 ACOs already approved by CMS, covering 2.4
million people with more ACOs on their way Largely provider (i.e,
independent practice associations) or hospital controlled. Thinking
is that it is preferable to have these organizations more
physician-controlled organizations promote more patient engagement
and better quality care than traditional managed care plans run by
largerly for profit managed care firms ACOs? What are they? Think
Modernized HMO ACOs are carve-in, not carve out benefits like
managed mental health plans: integrated care emphasis
Slide 13
ACOs: 33 Standards Prescribed quality standards all ACOs must
meet. 26 physician determined, 3 hospital-based, 4 hospital-
physician based Attempts to keep patients healthy and out of more
high cost settings while providing quality care How save? 1)
Decreased avoidable hospital readmissions and readmissions (2)
avoid unnecessary procedures (3) promote healthy lifestyle PCP key
in this operation: quarterbacks the care These 33 quality standards
not always present in todays managed cost marketplace
Slide 14
Another Entity: Patient-Care Homes What is that? Think
Modernized Nursing Homes Multidisciplinary care in care center s to
improve patient care and reduce costs Goal is bona fide integrated
care versus fragmented care offer in one facility Will include many
different providers and types of services Eventually payment will
come to bundled fashion to providers and then distributed amongst
them; initially retains fee-for-service with spending targets
Slide 15
Payment in ACOs and Patient Care Homes Once actualized,
payments to move away from traditional fee-f0r-service and towards
bundled payments and payments per episode of care Bundled and Per
Episode Payments: (1) Sounds a lot like capitation, doesnt it (2)
risk of financial incentive to emotionally strip-mine care (ACOs 33
Standards work against that dynamic) and (3) likely to push care
for these populations towards time-limited, protocol-driven
treatment packages
Slide 16
Ok, How Exactly Does It Work ACOs likely to start their
operations by initiating the program with the traditional,
non-managed Medicare populations (not Medicare Advantage Plans).
The non-managed plans are the most costly and where the most
savings can occur After Medicare application and expansion of the
Medicaid program, start the program with the Medicaid population
(already managed in Tennessee)
Slide 17
ACO/PCC Calculus Commercial plans likely to watch what happens
with health care reform in public sector before they decide whether
or not to play; will cherry-pick those things that work and pass on
others Those private employers who cannot sustain rising health
care costs will abandon providing insurance for their employees,
pay the fine, and encourage their employees to purchase insurance
through the State Approved Health Exchange These exchanges will
also run either as free-standing ACOs or increasingly connect with
existing ACOs
Slide 18
ACOs and Medicare Office of the Actuary from the Center for
Medicare and Medicare Services assigns the average Medicare cost
figure per patient per geographical area Audience Question: What is
the amount allowed per patient for a non-traditional Medicare
patient in the Upper East Tennessee geographical area?
Slide 19
Per the Office of the Actuary Answer: $8200.00 per patient ACO
is created. Membership assigned by Medicare: one primary care
physician. PCP can belong to only one ACO. Specialists can join as
many as they want Initially you join the ACO, care is referred to
you by PCP, you see the patient, you are still paid directly by CMS
in the initial stages
Slide 20
ACO Calculus Likely to be a participation fee based on revenue
collected to help fund the ACO management ACO will have target
savings goals the ACO will attempt to meet, set by CMS. If savings
achieved, ACOs and their providers receive their share of savings
per directives of the ACO Board Eventually payment from CMS will
move from fee-for- service to bundled payments (any kind of health
care) or payment per episode of care (so much money for this
exacerbation of the patients chronic bipolar condition). By this
time ACO is expected to be good enough at integrated care that they
can treat the patient with this prescribed amount of money for this
event
Slide 21
ACOs and the Private Sector Inevitable that if successful,
these systems of care for the public sector will begin sprouting up
in the private sector At present time, so much unknown about how
well these ACOs will work that the next few years will be a time of
much uncertainty and constant change Lot like the early beginnings
of managed care but will two CRITICAL differences: (1) carve-in of
mental health and substance disorders, not carve-out and (2)
financial incentives change with new payment structures. In short,
MUCH more difficult to execute
Slide 22
Ok, What is TPA Doing? What Do you do? TPA actively engaging in
shaping future directions of health care in Tennessee TPA provided
input on the Value and Cost-Offset Effects of Mental Health Care to
the Commissioner of Insurance and provided testimony to
Commissioner McPeak on these matters. TPA trying to secure a
Psychologist representative on the State Insurance Committee
governing any and all ACO operations TPA engaged in national
efforts with APAPO to prevent massive cuts in provider
reimbursement
Slide 23
Cost-Offset & Testimony to Commissioner McPeak Contact
Michelle, Lance ([email protected]) or TPA website if you want that
[email protected] Contains good information to take to your
emerging ACOs and other new health care systems Golden opportunity
to secure full-seat at the table and to finally get mental health
care an important place in the treatment of the whole person, mind
and body Key is the carve-in factor: these new systems have to have
good mental health care coverage or they will lose money do you
remember Hawaii? Irony is that the money will finally drive mental
health care to a good seat at the table Note in the recommendations
the importance of getting Psychologists as full-partners in
decision-making
Slide 24
What For You to Do Personally Rethink how you are going to
practice every year for the next ten years: the nature of it. Stay
the same? Join an integrated care practice? Better networking? Need
to conduct this type of professional due diligence For professional
psychology, the task of how to proceed in the future more difficult
than in the past. HIPAA, managed care those developments generally
affected practitioners in generally similar ways. Not the case with
PPACA and as such more difficult to advise colleagues on what to do
Future options f(x) early, middle or late career stage and whether
you are going to participate or not in the emerging new
developments. See Milbank Memorial Fund handout which we will
discuss as a group
Slide 25
What to Do Personally Dont panic Dont worry about not
understanding what is happening; nobody has all the answers to this
new way of being Find out where you are on the Milbank grid Changes
will start with Medicare; youll have time Begin to move toward
using outcome measures in your practice Hook up with medical
offices and reaffirm your relationships with them. Some will stay
in independent offices with strong connections to PCPs; others will
join together in more integrated, side-by-side office arrangements
Diversify your practice
Slide 26
What to do Personally Stay connected to TPA and help us You
cant talk about certain fee structure issues due to anti-trust
issues so be careful BUT you can actively participate in shaping
what is happening with Medicare. Respond to those TPA alerts to
stop Medicare cuts (3% cut coming in January, again), to expand
definition of physician in Medicare law. What happens there WILL
substantially affect your reimbursement rate in any system as well
as your scope of practice
Slide 27
Goodbye Thank You A Brief Look at the Value and Cost-Offset
Powerpoint if you want it: Note savings in ERs, chronic medical
conditions !! That is where huge savings can occur