THE BASICS: EXPLORING THE ALPHABET SOUP OF

ADVOCACY AND HEALTH POLICY

Jasmeet Dhaliwal, MD MPHChief Resident, Denver Health

Legislative Advisor, EMRA Board of Directors@DenverDhali

YOUR CHALLENGE FOR LAC

Find your pothole

OBJECTIVES

• Define advocacy• Review key provisions of the ACA and SGR Repeal (MACRA)• Highlight opportunities for advocacy

WHAT IS ADVOCACY?

“The act or process of supporting a cause or proposal”- Merriam-Webster

REGULATORYLEGISLATIVE

ADVOCACY

- Lobby legislators to support or oppose

- Build coalitions- Support campaigns

- Regulations = the nuts and bolts

- Lobby appointed officials- Provide feedback to regulators

AN EXAMPLE: ALL GOOD RESIDENTS GET $500

ADVOCACY IN REAL LIFE

The ACA and MACRA

THE PATIENT PROTECTION AND AFFORDABLE CARE ACT

AKA “PPACA”, “ACA”, “Obamacare”, “Spice” or “Blue Crystal”

OBAMACARE: WHAT’S IN IT?

• Obamacare = HEALTH INSURANCE REFORM

• Individual mandate• Expand Medicaid to 133% of FPL • Premium and cost-sharing credits for 100-400% of FPL• State-based exchanges for individual/family insurance plans• New regulations on health plans• Essential Health Benefits• Emergency services ---> (1) Same cost-sharing for OON care, (2) No

pre-auth

There’s still a lot of work to do!

NOTES: Current status for each state is based on KCMU tracking and analysis of state executive activity. *AR, IA, IN, MI, MT, NH and PA have approved Section 1115 waivers. Coverage under the PA waiver went into effect 1/1/15, but it has transitioned coverage to a state plan amendment. Coverage under the MT waiver went into effect 1/1/2016. LA’s Governor Edwards signed an Executive Order to adopt the Medicaid expansion on 1/12/2016, but coverage under the expansion is not yet in effect. WI covers adults up to 100% FPL in Medicaid, but did not adopt the ACA expansion. See source for more information on the states listed as “adoption under discussion.” SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated March 14, 2016.http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

CURRENT STATUS OF STATE MEDICAID EXPANSION DECISIONS

WY WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT*

MO

MS

MN

MI*MA

MD

ME

LA*

KY KS

IA* IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (32 States including DC)

Not Adopting At This Time (19 States)

AREAS RIPE FOR ADVOCACY

• Medicaid expansion• Did your state expand Medicaid?

• Out-of-network emergency services• “Greatest of 3” Rule genesis of Balance Billing issue

• High deductible plans• Consumer education• Health plan regulations

SGR REPEAL

Medicare and CHIP Reauthorization Act (MACRA)

MACRA = HUGE SUCCESS

• 750 physician membership organizations• Physicians involved in drafting• Bipartisan support

SGR BASICS

• Sustainable Growth Rate

• Balanced Budget Act of 1997

• Medicare spending linked to GDP growth

• 65 million people, 20% of health care dollars!

• Threat of large cuts starting in 2002

• 17 short-term fixes

ONWARD INTO THE WEEDS OF BILLING!

• Resource-based Relative Value Scale (RBRVS)

• Current Procedural Terminology (CPT)

• Relative Value Unit (RVU)

• Geographic Pricing Cost Index (GPCI or “gypsy”)

• Medicare Correction Factor (CF)

BILLING SIMPLIFIED….KIND OF

Chart +ICD-10 CPT Code RVUs

x Conversion Factor

Billable Amount

SGR2015 Medicare Conversion Factor- With SGR = $28.22- After repeal = $35.74

2016 = $35.80!

Example: Level 5 = 4.9 RVUs x $28.22 = $138

= 4.9 RVUs x $35.74 = $174

WHAT DID MACRA ACTUALLY DO?

• SGR replaced with +0.5% 2015-2019, 0.0% for 2020-2025

• Replaces PQRS, VBM and EHR MU with MIPS

• CHIP funding extended 2 years (9/30/17)

• Delayed phase-out of DSH payments by 1 year (20172018)

• Incentive for APMs - 5% increase if 25% of patients by 2019

• “Physician Compare” website --- comparative performance and quality of individual physicians

MACRASGRCMSPQRSVBMEHRMUCHIPDSHAPM

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS)

• Replaces:• Physician Quality Reporting System (PQRS)• Value Based Modifier (VBM)• Electronic Health Record Meaningful Use (EHR MU)

• Goal is to reward value instead of volume• Shift from Medicare fee-for-service to value-based and APMs

• Performance in 4 Categories• (1) Quality, (2) Resource Use, (3) Meaningful Use/Advancing Care Information, (4)

Clinical Practice Improvement Activities• Composite score determines incentive/adjustment• Scores will eventually be posted

MIPS INCENTIVES

‘15 ‘16 ‘17 ‘18 ‘19 ‘20 ‘21 ‘22 ‘23 ‘24 ‘25 ‘26+

Base 0.5% increase per year No base increase 0.25%

PQRS -2% per year

VBM -2% -4% -4% -4%

MIPS +/- 4%

+/- 5%

+/- 7%

+/- 9%

+/- 9%

+/- 9%

+/- 9%

+/- 9%

How will system work?

Proposed rule released 4/27Comment period until 6/27

AREAS RIPE FOR ADVOCACY

• Legislative• CHIP Reauthorization in 2017• DSH phase-out (particularly in states without Medicaid expansion)

• Regulatory • MIPS metrics• Role of EM in Alternative Payment Models (eg ACOs, PCMH, etc)• CPT codes, RVU assignment

• Legal• Role for lawsuits fighting unfair regulation

SUMMARY

• PPACA/ACA improved insurance but.....• SGR is gone, MACRA is here• MIPS is replacing PQRS, VBM and EHR MU

• Advocacy around the ACA and MACRA is still needed

HOW TO LEARN AND GET INVOLVED

• Join the ACEP 911 Network at www.acepadvocacy.org

• Get involved with your state chapter

• Do research! How do we determine if an ED visit was necessary? What metrics are true markers of quality?

• Donate to NEMPAC• Give-a-shift $120 for residents

• EMRA Health Policy Committee

• ACEP Committees: FGA, SLA, QPC

• Follow the HPC on twitter at @EMadvocacy

THANK YOU!