the basics: exploring the alphabet soup of advocacy and health policy - jasmeet dhaliwal, md mph...
TRANSCRIPT
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!