Why Health Care Reform Should Matter

to YouPreparing for practice in an evolving

health care system

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THE STATUS QUO OF THE U.S. HEALTH CARE SYSTEM

A Typical Month of Health Care in the United States

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Adapted from Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021-5.

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Current U.S. Health Care System

• A non-system• Uncoordinated• Fragmented care• Emphasizes intervention, rather than prevention

and comprehensive management of health• Unsustainable costs that are rapidly increasing• Access is declining• Quality is far from idealSource: Health care for all: a framework for moving to a primary care-based health care system in the United States. American Academy of Family Physicians, 2008. Accessed August 30, 2013.

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WHAT A “HEALTHY” HEALTH CARE SYSTEM WOULD LOOK LIKE

Triple Aim• Better patient experience of care• Better health outcomes• Lower Cost

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Health Insurance Coverage

+ Access to Usual Source

of Care =Improved Health

Outcomes

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“Right care, right time, right place, every time”

Source: Nowak NA, Rimmasch H, Kirby A, Kellogg C. Right care, right time, right place, every time. Healthc Financ Manage 2012 Apr;66(4):82-8.

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Key Elements of a High-functioning Health Care

System• Health care coverage for all, including catastrophic

protection• Patient-centered medical home for every patient• Health care a shared responsibility of:

– Individual– Employers– Government– Private and public sectors

Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American Academy of Family Physicians, 2008. Accessed August 30, 2013.

What Does This Mean for Me As a Medical Student?

• You are training at a pivotal time• You have a responsibility to be change

agents for a system that will deliver better care

• Your patients will look to you as a guide

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Health Insurance Coverage

+ Access to Usual Source

of Care =Improved Health

OutcomesDeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.

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50 Million Uninsured• Approximately equals the population of OR,

OK, PR, CT, IA, MS, AR, KS, UT, NV, NM, NE, WV, ID, HI, ME, NH, RI, MO, DE, SD, AK, ND, DC, VT, WY combined

Or • The population of Sweden, Austria,

Switzerland, Denmark, Finland, Norway, and Ireland combined

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Insurance Coverage Alone Is Only Part of the Solution

• Giving people coverage alone is like giving everyone a bus ticket and not having enough buses.

• Improved health outcomes must also address workforce needs

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Health Insurance Coverage

+ Access to Usual Source

of Care =Improved Health

OutcomesDeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.

Primary Care Health Professional Shortage Areas

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Primary Care Health Professional Shortage Areas (2006)

Primary Care Health Professional Shortage Areas, Family Physicians Removed (2006)

Source: Interact For Health and the American Academy of Family Physicians. Health Landscape Primary Care Atlas (healthlandscape.org), 2006 – 2013.

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Improved Health Outcomes When the Usual Source of

Care Is Primary Care• Increase accessibility• Promote prevention• Proactively support patients with chronic

illness• Engage patients in self-management and

decision-makingSource: Health care for all: a framework for moving to a primary care-based health care system in the United States. American Academy of Family Physicians, 2008. Accessed August 30, 2013.

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States That Rely More On Primary Care Have…

• Lower Medicare spending• Lower resource inputs• Lower utilization rates• Better quality of care

Dartmouth Medical School Center for the Evaluative Clinical Sciences. The Care of Patients with Severe Chronic Illness. Trustees of Dartmouth College, 2006. Accessed August 30, 2013.

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Key Changes Needed• Reinvigorate the primary care infrastructure

in the U.S.• Redesign the manner of primary care

delivery• Re-emphasize the centrality of primary care

Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American Academy of Family Physicians, 2008. Accessed August 30, 2013.

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WHAT IS THE PATIENT PROTECTION AND AFFORDABLE CARE ACT AND HOW DOES IT ADDRESS THE EQUATION?

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Health Insurance Coverage

+ Access to Usual Source

of Care =Improved Health

OutcomesDeVoe JE, Tillotson CJ, Lesko SE, Wallace LS, Angier H. The case for synergy between a usual source of care and health insurance coverage. J Gen Intern Med. 2011 Sep;26(9):1059-66. doi: 10.1007/s11606-011-1666-0. Epub 2011 Mar 16.

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What is the Patient Protection and Affordable

Care Act?• Comprehensive health reform• Signed into law March 23, 2010• Includes measures to:

– Cover at least 30 million of the 60 million Americans projected to be uninsured by 2022

– Increase access to affordable care– Improve care quality and lower cost

• Sound familiar? Echoes the three key elements of a high-functioning, primary care-based health system

Source: Health care for all: a framework for moving to a primary care-based health care system in the United States. American Academy of Family Physicians, 2008. Accessed August 30, 2013.

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Year-by-Year: 2010• New funding for scholarships and loan repayments for

primary care physicians working in underserved areas• Tax incentives for primary care physicians working in

underserved or health professional shortage areas• Increased payments for rural health care providers• New funding for community health centers• Creation of $15 billion Prevention and Public Health Fund

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Patients can Insurance companies can’t• Compare coverage options online• Appeal insurance company decisions• Access customer assistance from

their states for enrollment, education, and appeals

• Stay on parents’ insurance until age 26

• Access preventative care services such as mammograms and colonoscopies without charge

• Retire early and receive coverage• Receive coverage through Medicaid

expansion

• Deny coverage of children based on pre-existing conditions

• Rescind coverage for an error or technical mistake

• Impose annual limits or lifetime dollar limits on coverage

• Unjustifiably hike rates

Year-by-Year: 2010

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2011• For seniors:

– Prescription drug discounts– Free preventative care– Improved post-hospitilization care and

coordination• Funding for home and community-based,

rather than institutional, care for disabled covered through Medicaid

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2011• Testing of new care delivery models that

highlight care quality, cost control, to propose a new national strategy

• Regulations to control insurance premiums and overpayment

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2012• Payment linked to quality outcomes through the

Value-Based Purchasing Program in Traditional Medicine.

• Incentives for creation of Accountable Care Organizations (ACOs) to coordinate patient care.

• Standards for billing and electronic health record (EHR) use

• Increased information gathering on health disparities

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2013• Increased Medicaid payments for primary care

doctors• Open enrollment in Health Insurance

Marketplace begins• Payment bundling to incentivize provider

coordination and improve quality of care• New funding for state Medicaid to cover

preventative services

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2014• Establishment of the Health Insurance

Marketplace• Expanded Medicaid (in states that choose)• Uninsured Americans who are not exempt pay a

fee to help offset the costs of caring for uninsured Americans

• Tax credits for middle class to afford insurance

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2014• Prohibit insurance discrimination due to pre-

existing conditions or gender• Eliminate annual limits on insurance

coverage• Ensure coverage for individuals

participating in clinical trials

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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Year-by-Year: 2015• New provision to tie physician payments to

care quality.

Source: Key Features of the Affordable Care Act by Year. United States Department of Health and Human Services, 2010. Accessed August 30, 2013.

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What Are the Insurance Marketplaces (Exchanges)?

• Federally run, state-run, or partnership exchanges.

• Composed of private insurance plans and federal plans, including Medicaid and the Children’s Health Insurance Program.

• Allow Americans to compare, find, and enroll for health insurance coverage in one place, with one application.

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Options for Saving• Based on income level and family size,

patients can qualify for:– Reduced premiums or co-pays through a plan

in the Marketplace– Expanded Medicaid programs for people who

make up to 133% of the federal poverty level

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Gaps in Coverage• Some American’s won’t qualify for Medicaid or

reduced-cost insurance through the Marketplaces– In states that chose not to expand Medicaid coverage– Income level too high for Medicaid coverage, but– Income level too low for Marketplace cost reductions

• These patients can1. Pay full price for coverage through the Marketplace, or2. Go uninsured and qualify for exemption from the

fee, fitting into the gap and remaining uninsured.

Source: healthcare.gov

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Covering the Gap• Primary Care stepping up to the plate• Community health centers providing

essential care in states that choose not to expand Medicaid to cover uninsured patients

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WHAT DOES THIS MEAN FOR FAMILY MEDICINE?

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More Patients Will Need Family Physicians

• Insurance marketplaces and expanded coverage will create a new insured patient population – This is good for patients and for physicians

(access and reimbursement)• Patients entering this population want a family

doctor. They want a shepherd to navigate their personal health care and the system.

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Market Forces Will Drive Demand For Family

Physicians• Demand for family physicians will increase

steeply, highlighting undersupply of family physicians

• Programs and policies both new and already in development will focus on producing more family doctors

• Care will focus on prevention and disease management, saving cost

Family Physicians in Demand

• “Primary care physicians remain at the top of the wish list for most hospitals, medical groups and other health care organizations.”

• The most recruited specialty in 2012; at the top of the list for 7 straight years

Source: 2012 Review of physician recruiting incentives. An overview of the salaries, bonuses, and other incentives customarily used to recruit physicians. Merritt Hawkins, 2012. Irving, Texas.

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What Is the Future of Family Medicine?

• Patient-centered medical home (PCMH)– Population health– E-visits and online appointments– Web-based patient education– Group visits– Team approach to care; systematic

approach to care– Chronic disease management– Joy in practice through innovation

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Resources on Health Care Reform

• Healthcare.gov• CMS.gov• HHS.gov/healthcare• Familydoctor.org• Health Care for All: A Framework for Moving

to a Primary Care-Based Health Care System in the United States