Affordable Care Act by wuzhenguang

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									 Affordable Care Act
WHAT AN HIV PROVIDER NEEDS TO KNOW

          Steve O’Brien, MD
          September 30, 2012
                    Agenda
•   What is ACA?
•   What can Providers & Patients expect?
•   How will patients access care?
•   How do we prepare for ACA?
              Affordable Care Act
                            (ACA)
• Goals:                       • HIV treatment
  – Expand access to care        expansion
  – Reduce uninsured                – Individual Benefit
                                       • Early treatment

• Implement 2010-2014               – Community Benefit
                                       • Transmission VL related
                                       • 37% in treatment
                  Affordable Care Act
                                (ACA)
• Despite the fact that HIV patients areHIV treatment
                                           a       % of everyone
                                        •havesmallpatients in care with
  affected by the ACA, it is critical to      HIV
                                           expansion
  a goal of undetectability for public health reasons
                                           – Individual Benefit
                                                         HIV
                                               • Early treatment
                                           – Community Benefit
                                               • Transmission VL related
                                               • 37% in treatment

                                                         Non-HIV
     National HIV/AIDS Strategy
• Goals of NH/AS:
  1. Reduce new infections
  2. Increase access to care
  3. Reduce HIV health disparities


• ACA key to achieving these goals
How Does ACA Effect Access ?
                            Health Access
                                 Before 2010
• Employer sponsored insurance
   – Most prominent source of insurance
   – Less with HIV pts
• Individual private insurance
   – mostly shut out HIV pts due to pre-existing condition or unaffordable
• Medicaid/Medicare/RW
   – More important for HIV than general pop
   – Medicaid eligibility:
       • Income & Categorical (kids, parent with kid, preg, disabled)
       • Before ACA, federal law excluded non-disabled adults w/o kids unless a waiver
   – Medicare – eligibility >65 or permanently disabled
   – State “high risk” pools
   – Ryan White
       • RW also wraps around other services
HIV Patient’s Insurance Coverage
              2010
                   Health Access with ACA
                Coverage Expansion: 2010-2014
• Medicaid                           • Insurance Protections
   – Allows Coverage for Childless      – No lifetime limits or
     Adults                               rescissions
       • 133% FPL                       – Pre-Existing Condition
       • Optional by state                Insurance Plan (PCIP)
   – Medical Homes                      – Dependents covered to 26
       • Not HIV
   – Primary Care Pay
                                     • Small Business Coverage
       • 100% Medicare 2013-14         Subsidies
• Medicare
   – ADAP Counts towards TrOOP
   – Closes Drug Coverage Gap
       • Donut-hole rebate
       • Drug discounts
                               Medicaid
   Childless Adult Coverage & ADAP Waiting List
        State    Medicaid        More Limited   Early ACA   ADAP Waiting
                 Coverage       Coverage Than   Medicaid        List
                                  Medicaid      Expansion

Arizona         Yes (closed)

California                           Yes           Yes

Hawaii          Yes (closed)         Yes                        Yes

Nevada

Oregon                               Yes

Washington                           Yes           Yes

Total                9               20            8            20
                  Health Access with ACA
           Coverage Expansion:2014 and Beyond
• Medicaid up to 133% FPL             • US citizens & legal residents
   – No categorical qualification       must have insurance
     – Enhanced Federal match            – Individual mandate
                (100% -> 90%)                • Up to 6mil may be penalized
   – States cannot be penalized                (avg $1200/yr)
     for not enacting this part       • No Pre-Existing Condition
• Health Insurance Exchanges            denial
   – Income based premium &              – PCIP dissolve
     cost-sharing subsidies           • No annual limits
       • (via tax credits)
   – Individuals & businesses up to   • FQHC funding increase
     100 employees                    • New Insurance Regulations
• Basic Health Plan                      – Essential Health Benefits
   – Optional State plan 138-200%
     FPL
         Essential Benefits Package
   Ambulatory patient services
   Emergency services
   Hospitalization
   Maternity and newborn care
   Mental health and substance use disorder services,
    including behavioral health treatment
   Prescription drugs
   Rehabilitative services and devices
   Laboratory services
   Preventive and wellness services and chronic disease
    management
   Pediatric services, including oral and vision care
             What are the potential service gaps?
Services                                 Allowed in current RW            In EHB?
HIV Medicines                            Yes, plus co-pay and premium     Yes, but might have limits
                                         cover in some places - core

Outpatient/Ambulatory Medical Care       Yes, core                        Yes

Medical Case Management*                 Yes, core                        No
Emergency Financial Assistance           Yes                              No
Mental Health Services                   Yes, core                        Yes
Substance Use Disorder Services          Yes, core                        Yes

Food/Nutrition Services                  Yes (medical nutrition is a      No
                                         core service)
Psychosocial Support Services*           Yes                              No
                                  *Could be part of new structures for reaching “3 aims” such as PCMH
       What are the potential service gaps? (cont.)
Services                              Allowed in current RW            In EHB?
Oral Health                           Yes, core                        No
Early Intervention Services*          Yes, core                        No
Legal Services                        Yes                              No
Home Health Services                  Yes, core                        ?
Child Care                            Yes                              No
Non-Medical Case Management*          Yes                              No

Housing                               Yes                              No
Transportation*                       Yes                              No

Hospice                               Yes, core                        ?
Vision Care                           Yes                              No

                               *Could be part of new structures for reaching “3 aims” such as PCMH
Huge Portions of Traditional RW
    Programs and Services
     are NOT Covered!!!!
                  Health Access with ACA
                              Financing & Quality
• Delivery Systems Reform               • Financing
   – Prevention                            – Tanning salon tax
       • New Prevention/wellness fund
                                           – DRG adjustments
       • Free Prevention Services
            – USPSTF                       – Medicare Advantage payment
            – HIV screening                  restructuring
   – Pt-centered outcome research          – Insurance industry fees
   – Community transformation              – New taxes: Medicare, passive
     grants
                                             income, medical devices
   – Value Based Purchasing
                                           – Individual/Employer penalties
   – Medicare shared savings
     program (ACO’s)                       – DSH payment adjustments
   – Hospital readmission reduction        – Excise tax on “Cadillac” health
   – Bundled payment pilots                  plans
   – HACs payment reduction
              Bottom Line:
   Reducing the Number of Uninsured
                          Medicaid: 16 million
                          Income Under 133% FPL
Estimated 32 Million
will gain coverage by
         2019




                          Exchange: 16 million
                          Income 133%-400% FPL
             Supreme Court & ACA
  Constitutional Discussion          Supreme Court Decision

• Individual Mandate:             Upheld
   – Can the Feds compel             – Under Congress’ power to
     individuals to purchase           impose taxes
     health insurance?

• Medicaid Expansion:             Upheld but…
   – Is the ACA’s Medicaid           – Feds can’t withhold existing
     expansion a violation of          Medicaid funds if states forgo
     state’s rights?                   expansion

• Severability:
   – Should the remainder of      The remainder of the law stands
     the ACA stand if a portion
     is struck down?
                 ACA-HIV Concerns
• Exclusion of immigrants
• Ryan White – What’s the future
   • Payer of last resort
   • Wrap-around services
• Provider reimbursement rates
   • Hospitals hit hard….some will close
   • Medicaid & HIE vs RW
• Cost containment
   • Critical Focus
• Doesn’t cover dental, vision
What are the practical implications
    of ACA implementation?
Larry   Moe   Shirley
EMPLOYER                MEDICAID              OTHER
   OR                      OR               AFFORDABLE              RYAN
 PRIVATE                MEDICARE             COVERAGE               WHITE
              NO                      NO                       NO
INSURANCE?              ELIGIBLE?           AVAILABLE?



        YES                   YES                     YES




EMPLOYER-                                       OTHER COVERAGE:
 BASED OR                                       • STATE HIGH RISK
  PRIVATE          MEDICAID     MEDICARE              POOLS
                                              • STATE-ONLY FUNDED
INSURANCE                                         PROGRAMS




                   RYAN WHITE WRAP-AROUND SERVICES



                   BEFORE 2010
EMPLOYER                      MEDICAID             OTHER
   OR                            OR              AFFORDABLE              RYAN
 PRIVATE                      MEDICARE            COVERAGE               WHITE
              NO                            NO                      NO
INSURANCE?                    ELIGIBLE?          AVAILABLE?



        YES   ACA ALLOWS STATE     YES                     YES
              MEDICAID EXPANSION
                TO 133% FPL




EMPLOYER-                                            OTHER COVERAGE:
 BASED OR                                            • STATE HIGH RISK
                       MEDICAID       MEDICARE             POOLS
  PRIVATE                                          • STATE-ONLY FUNDED
INSURANCE                                              PROGRAMS
                                                          •PCIP




                        RYAN WHITE WRAP-AROUND SERVICES



                        2010-2013
EMPLOYER                     MEDICAID             SUBSIDY
   OR                           OR               ELIGIBLE?           RW
 PRIVATE                     MEDICARE               OR               ??
              NO                           NO                   NO
INSURANCE?                   ELIGIBLE?          AFFORD HIE?



        YES     ACA MANDATES      YES                   YES
                STATE MEDICAID
              EXPANSION TO 133%
              FPL W/ NO PENALTY


EMPLOYER-
 BASED OR                                             HEALTH
  PRIVATE             MEDICAID       MEDICARE       INSURANCE
INSURANCE                                           EXCHANGES




               ????? RYAN WHITE WRAP-AROUND SERVICES ?????



                             2014+
         Larry


                          PMD


Private Doctor’s Office
         Moe


                            KC, MD




Any County Medical Clinic
        ACMC
   Shirley


                           SOB, MD


Every Body’s AIDS Clinic
        EBAC
 Winners &                         Private         RW          FQHC

  Losers
           Service
      More Medicaid                      -    +++       +/-         +++
             HIE                  +     +/-             ?-    ?     +/-
 Ryan White wrap around           ?      ?     -        --     -      -
 (not all services covered)
        {legal, CM etc]
High variation in coverage        +/-    -    +/-        -    +/-     -
(Formularies, covered services)
         Complexity               +/-    -     -         -     -      -
   More Managed Care              +     +/-    -        --     -      -
                              Worries
• Managed Care                         • Who will help with complex
                                         transitions?
  – Private, Medicare, Medicaid
                                       • Ryan White
  – Are providers/patients ready?         – Reauthorized 4 times
      • Formulary issues                  – Will it survive?
          – ADAP rebate heavy             – What will it look like
          – Managed care – data                • Unlikely to be undocumented
            driven & generic focused             immigrant, vision & dental
                                                 program
      • Authorizations
      • Focus on Care
                                       • Will RW Providers survive?
        Transitions/Cost-                 – Medicaid expansion favors FQHC’s
        containment                       – RW Providers are expensive
                                          – With increased Insurance choices,
      • Contracting                         patients may leave or at least
      • Auto-assignment                     healthiest may leave
          Solutions to Consider
• FQHC alignment
  – Become an FQHC 
  – Align with an FQHC
     • Co-manage patients
     • Disseminate care to specific FQHC’s and build expertise
• Managed Care experience
  – Partner with Medicaid managed care providers
• Demonstrate Cost Effectiveness
  – This means REAL data
                       Reason to…
         Celebrate                          Worry
• Expanded Healthcare for         • Challenges to HIV
  Americans                         exceptionalism

• Focus on cost-containment       • Focus on cost-containment

• Focus on Quality                • Will our HIV standards be
   – we have lots of experience     compromised?
     with that in HIV

								
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