learner outcomes compare patterns and trends in the future healthcare environment. describe the...

Learner Outcomes

• Compare patterns and trends in the future healthcare environment.

• Describe the impact of budget driven changes to health care.

• Identify political changes to health care i.e. Obama Health Care.

• List new “out of box” concepts for future health care.

A Perspective on Health Care Reform for the HomeTown Health Fall

Conference

Kirkland McGhee, VP and Regional Counsel, Kaiser Permanente

November 18, 2011Callaway Gardens

A Perspective on Health Care Reform for HomeTown Health

• When We Decide Who We are, We will Know Where We are Going

• A Few of the Changes

• Implications for Care Delivery

• Will Health Care Reform Stick? Law and Politics


When We Decide Who We are, We will Know Where We are Going:

• Clinton Care• The Great Debate Engaged• HIPPA

– Portability– Security– Privacy– Transaction Code Sets


When We Decide Who We are, We will Know Where We are Going

• Children’s Health Insurance Program

• Medicare Part D

• Steady March Toward Universal Coverage

• From Medicare to “Obama Care,” The 2008 Election


A Few of the Changes:• Expansion of coverage to the uninsured

• Requires states to maintain benefit levels for Medicaid & CHIP (children) – effective March, 2010

• Requires states to expand the Medicaid & CHIP eligibility to <65 years with income up to 133% of federal poverty level (implementation by 2014)

• Requirement that health plans guarantee issue of coverage for all applicants

• Individuals and groups that apply for coverage must be accepted (implementation by 2014)


A Few of the Changes:• Employer Mandate

• Requires all employers >50 employees to offer health insurance or pay penalties (implementation by 2014)

• Tax credits for employers <50 employees – effective March, 2010

• Individual Mandate – implementation by 2014• Requirement that individuals maintain coverage -Tax

penalties if not• Example penalty exclusions: Native Americans, less than

100% federal poverty level


A Few of the Changes:

• Lifetime and Annual Limits - new restrictions• Lifetime limits prohibited – implementation within 6 months• Annual limits / restrictions for essential benefits –

implementation by 2014• Benefit Standards

• Defines “essential services health benefits package” and 4 levels of coverage (bronze, silver, gold, platinum) – implementation by 2014

• Medicare Advantage Pay for Quality – implementation in 2012• Quality bonuses available, based on Medicare 4 or 5 Star

Ratings • Star ratings are based on quality, member satisfaction and

outcomes


A Few of the Changes:

Emphasis on Primary Care


• "I don't know of any (congressional member) who disputes the centrality of primary care and coordinated care and, therefore, the medical home," says Len Nichols, Ph.D., director of the health care policy program for the New America Foundation, a bipartisan think tank in Washington. "There are lots of different ways to think about how to fund it, lots of different ways to think about payment structure and lots of different ways to think about how to coordinate care." But in the final analysis, he adds, the concepts of nurturing primary care and encouraging coordinated care are "definitely front and center."


• Section 5501 (a) of the Patient Protection and Affordable Care Act creates an incentive payment program for primary care providers that calls for incentive payments equal to 10 percent of a "primary care practitioner's" allowed charges under Medicare Part B for primary care services provided on or after Jan. 1, 2011, and before Jan. 1, 2016.

Many see this provision as evidence of the government's realization that primary care is the engine that will drive successful health care reform.


Implications for Care Delivery

• Primary care physicians are already in short supply and the most popular ones have closed practices or have long waits for new patients. Imagine when 2014 hits and all of those patients come calling. Who is going to be available to treat them?



• If many of the expected 40 + million are added to the system, primary care will not be available, but that might not be the immediate issue for them.

• Many of them have been chronically ill for years.



• They are not going to fit into the primary care and prevention will save the world mold.

• Rather they will create a significant demand for specialty services.



• An aging population assures that this issue will not quickly dissipate.

• Medicare Advisory Board and fairness concerns will further complicate the issue.



• Do we need to rethink what “primary care” should be in the new health care reform world?

• Significant financial and structural changes have to be considered by all parts of the delivery and financial system.


Implications for Care Delivery:

• The Competitive Market Place

– Accountable Care Organizations

– A look in the Mirror Kaiser/WellStar

– Piedmont’s Claim



• Why Accountable Care?– Payment Reform– Quality Metrics– Systems Integration– Competition



• Challenges for ACOs:– Who is in Charge

– Physician Independence – How do We Split the Money

– The Right Regulators



• Implementation of the 2014 Insurer Tax

• Self-funded Health Plans

• Exchanges

• Implications for Rural Providers


Will Health Care Reform Stick? Law and Politics

• Sixth Circuit Court Finds Healthcare Reform's Individual Mandate Constitutional

• After hearing arguments from both sides, the panel found, by a 2-1 vote, that the minimum coverage provision is a valid exercise of legislative power by Congress under the Commerce Clause because the mandate regulates economic activity with a substantial effect on interstate commerce.



• Eleventh Circuit Decides Health Care Reform Individual Mandate Is Unconstitutional

• The Eleventh Circuit upheld a lower federal court’s decision that Congress exceeded its commerce clause powers in enacting the individual mandate because Congress cannot “mandate that individuals enter into contracts with private insurance companies for the purchase of an expensive product from the time they are born until the time they die.”



• However, the lower court had declared the entire health care reform law invalid because it found the unconstitutional individual mandate to be legally non-severable from the rest of the law. The Eleventh Circuit disagreed, deciding that the individual mandate could be severed from the rest of the health care reform law.



What do the People Believe?

CNN Poll: Majority oppose individual mandate

As you may know, that legislation included a provision that will require all Americans who do not have health insurance to get it. Do you favor or oppose that provision?

June 3-7 2011Favor 44%Oppose 54%No opinion 2%


Health Care Reform Stick? Law and Politics

With Strong Public Opposition to the Health Care Reform Bill, can it Survive?



Do the Politics Matter?– 2012– McDonald’s

• Do the Court Decisions Matter?– Race to “The Court”


• Major Law Changes Tend to be “Sticky”

Voting Rights and Public Accommodations

Medicare/Medicaid

Americans with Disabilities Act

Patriot Act


Major Law Changes Tend to Be “Sticky”

Brown vs. Board of Education

Right to Counsel

Prayer in School

Roe v Wade

Occupy Wall Street

Tea Party



• Voters in Ohio have overwhelmingly rejected a law curbing union bargaining rights for public employees, dealing a blow to the Republican establishment in a state that could prove pivotal in deciding the outcome of next year's presidential election.



• Legal analysts predict that the Supreme Court will take up the health care law this fall and rule by June. Then, finally, it will be clear whether the "individual mandate," the provision that requires nearly every American to buy health insurance by 2014 or face a tax penalty, is constitutional.



But might it undermine the perception that the court is above politics if it rules right before the country heads to the polls?



• Who Would be Helped/Hurt by a Decision Just Before the Election?



What will Congress do After the Supreme Court Rules?

ExchangesMeaningful UseBillions SpentThe Hemophiliac


When We Decide Who We are, We will Know Where We are Going

Elmore James, Allman Brothers Solution: Ain't but one way out, baby…..

Get Everyone Covered

Get and Keep Everyone Healthy

Reform the Payment System

Learner Outcomes

• Compare patterns and trends in the future healthcare environment.

• Describe the impact of budget driven changes to health care.

• Identify political changes to health care i.e. Obama Health Care.

• List new “out of box” concepts for future health care.

Thanks!


Questions?


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