9/30/2013

1

The Patient Protection Affordable Care Act

What Does it Mean for the Orthopaedic Trauma Surgeon?

Manish K. Sethi, M.D.Director of the VOI Center for Health PolicyAssistant Professor of Orthopaedic Surgery

Division of Trauma, Department of OrthopaedicsVanderbilt University

Goals

Why are we talking so much about healthcare?

The PPACA

The PPACA and Trauma

How will the PPACA shift practice patterns in trauma

Why are we talking about this?

9/30/2013

2

Healthcare Spending Out of Control

The Healthcare Battle of 2010

The 2010 Patient Protection and Affordable Care Act:

The Promises…

Make Health Insurance Affordable and essentially universal

Increase Medicaid Funding to States

Save Medicare for Seniors

Focus on Prevention

Decrease Costs Dramatically

9/30/2013

3

The Individual Mandate

Supreme Court Ruled Mandate Constitutional

If no insurance … you pay tax…

Individual mandate takes effect on Jan 1st, 2014

By 2016…$695 per year up to a maximum of $2,085 per family or 2.5% of household income

Employer mandate delayed one year From Jan 1st, 2015 employers with >50

employees must provide insurance

$2000-$3000 penalty/employee

The Employer Mandate

FINES FOR UNINSUREDEMPLOYEES

25-49 Employees

<25 Employees

>50Employees

TAX CREDITSFOR SMALL

BUSINESSES

Health Care Insurance Exchanges

State Agency Run EXCHANGE will offer one stop shop to buy insurance

Will offer to individuals and employers

Decided on Feb 15th, 2013 whether State or Federal Gov. will Build

Pay to Play….

4 different categories of plans offered

Final agreement for insurance plans sold through federal exchanges delayed from 9/5-9/9 to late September

Open for enrollment on October 1st, 2013 Some states, such as Oregon, may have to

delay opening

Marketplace coverage begins on Jan 1st, 2014

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Health Care Exchanges

Medicare and Obama Cutting Costs…..ABC’s

Reduce rates of payment to physicians/hospitals…Medicare Parts A and B ($170 Billion)

Between 2011-2014 Dramatically Reduce Payments to Medicare Advantage… Medicare Part C ($130 Billion)

Means Testing for Medicare Part D i.e. for those with incomes above $85,000/individual and $170,000/couple

Reduce Payment for Re-Admissions, Infections, etc.

Decrease Medicare Fraud

Independent Payment Advisory Board (IPAB) and Medicare

15 Individuals Appointed by the President

Will Essentially Decide Medicare Payments, etc.

Will Guide Future of Medicare

These Individuals are not accountable to Congress

First proposal may be in January 2014.

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The Big Cuts

American Hospital Association/AMA Backed a $500 Billion Medicare Cut

Also supported 100 million/state cut in the Medicaid Disproportionate Share Hospital funding

Why Would Hospitals Ever Go For These Cuts?

American Hospital Association/AMA Backed a $500 Billion Medicare Cut

Also supported 100 million/state cut in the Medicaid Disproportionate Share Hospital funding

WHY IN THE WORLD WOULD YOU DO THIS?

Dramatic Medicaid Expansion

Expand Medicaid eligibility to extend coverage to all individuals with incomes at or below 133% of the Federal Poverty Level

Expand eligibility level for children ages 6-19 from 100% FPL to 133% FPL.

Creation of expansive prescription drug plan within Medicaid

Planned start date of January 1st, 2014

• HOSPITALS STAND TO MAKE SERIOUS CASH

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Dramatic Medicaid Expansion

Supreme Court Ruled Medicaid Expansion Unconstitutional

Not Everyone Expanding…

The PPACA and Trauma

$224 Million in Federal Funding

The National Trauma Center Stabilization Act 200 million

Trauma Care Systems and Planning Development Act

24 Million

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$224 Million Gained but…$5.1 Billion Lost

Given that the majority of trauma patients are uninsured, Medicaid Expansion is CRITICAL FOR FINANCIAL Survival of Trauma Centers in the face of 1)Medicare cuts and 2) Medicaid Cuts

In States Where There Is No Expansion….

But as a Nation Can We Afford an Expansion????

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Dramatic Changes Will Occur

Healthcare Reimbursement Models and Orthopaedic Trauma: Will There Be Change in Management?

12.00%

24.00%

33.00%

0.9%

21.3%

17.6%

0.4%

20.0%

19.0%

0%

5%

10%

15%

20%

25%

30%

35%

Scenario A Scenario B Scenario C

Per

cent

Res

pons

e

Case 1 Case 2 Case 3

Rates of Transfer to Tertiary Care Centers will Rise

It is Time For Orthopaedic Trauma Surgeons to Get

Involved

The PPACA will impact us unlike any other legislation since the Great Society

Right now other “players” like the insurance companies and hospitals are making their voices heard

No one knows healthcare better than you.

We are doctors, but more importantly we are citizens.

9/30/2013

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MULTIPLE AVENUES TO GET INVOLVED

Trauma Surgeons Involved in Policy-making Patient Care

ORAdvocacy

If We Get Involved We CanImpact the Future

Thank you