CRAM Set

What is the subsidy based on?

The subsidy amount is determined by a sliding scale based on: -income level -The insured's benefits, including state-mandated benefits See slide 53

What is the typical ACO patient look like?

They are NOT low-income, < 80 years old, black, Medicaid-enrolled, and disabled....(favorable selection?)

What is largest cause of death? Second Largest?

Tobacco , poor diet/lack of exercise

What do the different tracks of the MSSP model dictate?

Track I Model: Shared Savings Only Track II Model: Shared Savings and Shared Losses

Managing Patients with Chronic Disease : What Works?

Transitional care Comprehensive medication management Health coaching Team based whole person care Ability to refer at risk patients to evidence based lifestyle programs

Name a few public health acheivements

Vaccination Motor vehicle safety Safer workplaces Control of infectious diseases Decline in deaths from coronary heart disease and stroke

What is the definition of the value-based insurance design? What 3 things does it hope to accomplish?

Value-based insurance design uses evidence of effective procedures, treatments, drugs, and providers and appropriate incentives/disincentives to design health benefits that: -Motivate those covered to alter their behavior in a positive manner or engage in a health management activity -Encourage the use of a provider or specific health care service, test, or drug that is shown to be more effective or provide higher quality than other options -Discourage the use of health care services, tests, drugs, and providers when the evidence does not justify the cost or their use

What are some things to consider when designing a payment bundle?

Who would be paid? How would financial risk be accounted for and shared? How would success be determined? How are financial risk and other payment adjustments made?

What happened to the number of sick days when Asheville patients were enrolled in the benefits program? What was the dollar value of the increased productivity that year?

Within the first year of the new benefits program, the participants reduced their number of sick days by 6.6 days per person. Further, the reduction in sick days continued over the course of the 5 years of the program. The number of people enrolled in the program changed for various reasons (eg, dropped out, left employment, died), but data were available for 37 patients for all years from 1996 (baseline) through 2001. The estimated value of increased productivity was $18,000 per year.

Key Issues with young adults

Young adults are about a quarter of the uninsured—11 or the 48 million To keep premiums stable, will be important to enroll as many healthy young adults as possible Depending on income ($20,000) a bronze package could be as cheap as $45 to $50 per month. Yet at $30,000 this goes to $170 per month.

What is the prevention and public health fund?

a fund, to be administered through the Office of the Secretary at HHS, to provide for an expanded and sustained national investment in prevention and public health programs

Most people who were uninsured before the ACA had been uninsured for how long?

a year or more

What is the care triad in the primary care medical home?

acute illness management preventive care services chronic condition management

Do insurers believe payers prefer a broader network or affordability? What percent of all plans are ultra-narrow? What does ultra-narrow and narrow mean?

affordability 38% Ultra narrow means that 70% of 20 largest hospitals are excluded. Narrow excludes 30%.

Where was the greatest decrease in hospital-acquired conditions?

central-line associated bloodstream infections

Within the most popular tier, what influences decision on which insurer to choose?

cost, 43% go for the lowest cost plan.

what were companies not allowed to do in 2015 regarding the employer mandate?

couldn't reduce workforce to below 100

For private insurance enrollees, what have increases consumer OOP lead to?

decline in utilization of services 9

What are the results of the finnish diabetes prevention study?

decrease incidence by 20%...40% to 20%

What is the trend of Diabetes-Related Health Care Costs at Varying Levels of Medication Adherence? What about Diabetes-Related Hospitalization Risk at Varying Levels of Medication Adherence?

decreases in both as adherence increases

What happens to cost care when a patient is readmitted?

doubled 9

The uninsured rate among nonelderly population has been on a _______ trend since 2010.

downward, since 2012 especially

Describe category 1 of the payment taxonomy framework.

fee-for service: no link to quality Description: Payments are based on volume of services and not linked to quality or efficiency -Limited in Medicare fee-for-service -Majority of Medicare payments now are linked to quality

What are the conditions with the highest period prevalence rates?

hypertension (57%) and hyperlipidemia (47%)

What is the trend in terms of what deductible level people are more likely to choose now?

increase 9

Trends in Obesity and diabetes?

increasing since early 90s

What was the change in all-cause 30-day hospital readmission rates from Jan 10' to Jan 13'?

it decreased

What is happening to the amount of employers facing the excise tax in the future?

it is increasing ~25% in 2018 ~30% in 2023 ~40% in 2028

Two conditions that account for most of treated prevalence of disease?

lipids, hypertension 9

What needs to be changed for the health system in 2020?

need to develop a national framework for averting, detecting and managing chronic and other medical conditions need to reforming more than the health insurance system and marketplace

Where has prevention interventions been less successful?

obesity alcohol

The CBO projects to reduce the deficit by how much through increased taxes and decreased Medicare payments?

over $150 billion

Trends in Premiums compared to inflation and workers earnings

premiums are usually higher

was the pioneer program successful?

relatively....9 out of 32 dropped out

primary care medical homes all lead to high ___ .

savings

Since the 80s, chronic disease as a share of total health spending has risen from ____ to ___.

since the 80s, chronic disease as a share of total health spending has risen from 2/3 to 86%. 9

How do we know prevention programs work?

smoking cessation has worked even though smoking rates are too high

what will happen to spending in 2019?

spending will exceed revenues slide 46?

In order for prevention programs to be successful what is required?

understanding of -what is driving growth in spending -where the gaps in quality care are

How successful have lifestyle intervention programs been?

very effective, 71% reduction in DM in 60+ age group 9

Would prevention plans through Medicare be free for both patients and ACOs?

yes

What is the deductible for gold and premium plans? what is the actuarial value for each plan type?

zero starts at 60% for bronze, goes up by 10% for each higher plan

What is the difference between the pioneer ACO and MSSP model?

♦ First two years of Pioneer are shared savings payment with higher levels of savings and risk than Shared Savings Program ♦ By end of second year, Pioneer ACO must enter into similar payment contracts with insurers and health plans constituting 50% of ACO revenue.

According to the Congressional Budget Office (CBO), the cost of health reform is over______ the next decade

$1.38 trillion

What is the median and max deductible for 2014?

$2500 and $6,250

How much is the net increase in total health care spending of raising medicare age to 67?

$5.7 billion

what is the most popular deductible amount chosen on the health exchange?

$6k

What is the medical loss ratio? what question does it answer? What does the ACA mandate? So far, how much have consumer rebates been worth?

(HC Claims + QI expenses)/ (Premiums- administrative expenses and taxes) answers the question: where is all my money going? The ACA mandates MLRs of: 80% in the individual and small group markets 85% in the large group market Insurers that fall short of those minimums will owe rebates to consumers Estimate: 9m consumer rebates worth $1.4b Stronger state laws allowable

how to calculate your poverty level

(income/ poverty guideline)100= e.g. a man with a $20,000 income level, state poverty line is for a single person household is $11,770 (20000/11,770)100= 169= thus his income is at 169% of the poverty level

What is missing in population based approaches and what can we do to fix this?

- link between community/ population/public health initiatives and the traditional medical care sector -create a national set of health care "connectors" that will integrate across the whole spectrum of community based and more traditional medical approaches to care

How much percentage wise has worldwide obesity increased? Number wise? How much of that percentage is US responsible for?

-28% -857 million to 2.1 billion -13%

What number of US families are within of how many miles of a YMCA? What does the YMCA have a strong history of? What is unique about its fee system?

-42M U.S. families within 3 miles of a Y -Strong history of disseminating structured programs nationally (arthritis) -Operate to achieve cost recovery only -Policy to turn no person away for inability to pay for a program (financial assistance)

For all states, what was the increase in deductibles for silver plans? for out-of-pocket limits for silver plans?

-5.90% 5.80%

What are the focuses of the CMS Innovation Center?

-Accountable Care -Bundled Payment for Care Improvement Primary Care Transformation -Initiatives Focused on the Medicaid and CHIP Population -Initiatives Focused on Medicare-Medicaid -Enrollees -Initiatives to Accelerate the Development and Testing of New Payment and Service Delivery Models -Initiatives to Speed the Adoption of Best Practices

Out-of-Pocket Caps: Key Points

-All new health insurance plans will have OOP caps beginning in 2014 applied to the silver plan -Caps apply only to covered services -Initially set at HSA limits (if they were to go into effect in 2011 - $5,950/ind and $11,900/family) Lower caps for those with income below 400% FPL

Explain the penalties associated with the employer mandate. Also how is the maximum penalty determined?

-Are not penalized for the first 30 employees -Are charged a penalty if one or more employees receive a subsidy through the exchange. -Penalty assessment up to $2,000 annually per full-time employee if employer doesn't offer coverage at all -Penalty assessment of up to $3,000 for employers if they provide unaffordable coverage and EMPLOYEE OPTS OUT Penalty maximum= $2,000 (# FTEs - 30)

What would some of the functions of connectors be?

-Assure patients have appropriate screenings and vaccinations -Provide evidenced-based care coordination services (coaching, transitional care, comprehensive medication management and adherence) and empower patients and families to effectively adhere to their care plan and "live well" -Link individuals to social services, economic programs and economic services. -Assist with issues that may affect health by directing families to healthy food stores, walking paths, smoking cessation and lifestyle programs and developing appropriate diets for chronically ill patients

Tax Exclusion of Employer-Based Health Coverage Why did it begin? Are health benefits subject to federal income or payroll taxes? Why was it included in the PPACA? How much per year in federal tax subsidies does the tax exclusion provide?

-Began in response to WWII wage freezes meant to control inflation -Today, health benefits still are still not subject to federal income or payroll taxes -Included as part of the PPACA to help slow the growth rate of health costs and finance the nationwide expansion of health coverage -Estimated that the tax exclusion currently provides more than $250 billion each year in federal tax subsidies

What would bowles-simpson prohibit concerning Medigap? What savings does CBO expect because of this? Who and how many would it affect?

-Bowles-Simpson would prohibit Medigap from covering first $500 of cost sharing and limit coverage to 50% of next $5,000. - $53.4 billion over 10 years -Would affect all beneficiaries with first-dollar Medigap. Today, more than 8 million Medicare beneficiaries have a Medigap policy, most of whom have first-dollar coverage

Name some other programs or awards aimed at improving prevention programs and healthcare

-Community-based Care Transitions Program -State Innovation Models Awards -Bundled Payments for Care Improvement: -Pay for performance programs like VBP -Health IT

What three things must a successful evidence based health system offer?

-DETERS the rise in disease incidence and prevalence -IMPROVES disease detection -More effectively ENGAGES and manages patients with chronic disease

Value-Based Insurance Design Approaches

-Design by service Waive or reduce copayments or coinsurance for selected drugs or services, such as statins or cholesterol tests, no matter which patients use them. -Design by clinical condition Waive or reduce copayments or coinsurance for medications or services, based on the specific clinical conditions with which patients have been diagnosed. -Design by disease management participation or disease severity Waive or reduce copayments or coinsurance for high-risk members who would be eligible for engagement in or who actively participate in a disease management program.

Cadillac Excise Tax What is it? How much is it? When does it go into effect? who is it allocated to?

-Effective in 2018 -excise tax is a tax charged on each unit of a good or service that is sold -40% nondeductible excise tax on high-cost health coverage -The tax is allocated to the insurer or to the party that administers the plan if self-funded. Ultimately, the plan sponsor will bear the cost of the tax unless it is passed along to the employee.

What was added to the health care reform in 2014?

-Exchanges (Public & Private)are open for business -Plans outside the Exchanges are modified -New rating rules (Age, Wellness, Smoking, Territory) -Multi state qualified health plans -Maximum deductible $2,000 individual/$4,000 family -Employee waiting period, maximum is 90 days -Full time employees, work 30 hours/week -Premium increases a criteria for carrier exchange participation -CHIP reauthorization 2 year extension

Whom do medical homes center around in terms of providers? Emphasis is on what type of care? How are payments arranged? What are some concerns?

-Facilitates care coordination through primary care physicians -Emphasis on care coordination, use of HIT -Add-on payments are typical in addition to FFS payments to account for additional work done by docs, including investment in technology -Concerns include lack of provider capital/capacity to cover initial increased investments

Tobacco and Excise Taxes

-Federal excise tax raised from 39 cents to $1.01 in 2009 -State taxes range widely but average around $1.50 per pack -Each 1 percent increase in the excise tax reduces smoking by approximately 0.5%

What effects do Bowles-Simpson and Domenici-Rivlin expect from their medicare cost-sharing restructuring? How does this restructuring differ from the MA plans?

-Federal savings expected due to new coinsurance requirements (for some) and higher deductible (for many) -Out-of-pocket spending expected to decrease for small share, but increase for the majority who use relatively few services -CBO estimates similar proposal would save $32.2 billion, 2012-2021 -It is higher than the maximum allowed for MA plans ($6700)

Name some exemptions to the individual mandate

-Have a religious conscience exemption. -Have a coverage gap of less than three months. -Are incarcerated. -Are in a hardship situation, as defined by Health and Human Services. -Are undocumented aliens -Reside outside of the U.S. -Have a household income below the tax-filing threshold. -Cannot afford coverage.* -Are members of an Indian tribe. -Are members of a Health Care Ministry

What was added to the health care reform in 2013?

-Health Insurers file new rates -HHS Secretary and states approve -(or disapprove) premium rate increase requests -Insurer administrative simplification requirements -Limits on contributions to flexible spending accounts to $2500/year

How do high deductibles affect doctors and other providers?

-High out-of-pocket costs discourage appropriate utilization -Large patient obligations lead to more bad debt, charity care -Price-sensitive patients more likely to seek lower-cost options

For what quality benchmark did most ACOs meet the maximum quality benchmark? For what quality benchmark did most ACOs not the minimum quality benchmark?

-How well doctors communicated -ACS admissions for heart failure

Challenges to Value-Based Insurance design

-Human resource concerns: Patients may object to different copays -Legal and tax issues: Always a concern, but existing programs illustrate that options may be considered to address these concerns -Privacy concerns: Some VBID programs require identification of patients with specific diagnoses; HIPAAb compliance is a must. -Unintended incentives: Incentives should steer patients toward healthy vs unhealthy behaviors -Adverse selection: Sicker patients may be attracted to plans that have VBID components

What are the four implications for implementation of Value-Based Insurance Design?

-Improve adherence with evidence-based care -Drive greater employee engagement in managing care -Promote value with health care provider/practitioner community -Perceived inequality in designs, fully insured regulations

Explain Population/Community/Medical System Integration

-Integrated networks linked to community resources capable of addressing psycho social/economic/ medical care needs -Population-based reimbursement

What are some benefit that could be added to Medicare?

-Intensive lifestyle programs like the diabetes prevention program could be added (much broader than current IBT coverage) -Pharmacotherapy-induced weight loss of 10% to 15% could produce significant savings for Medicare if covered -The combination of lifestyle change and pharmacotherapy is generally more successful than either treatment alone -Add Medicare Integrate as part of original Medicare and strengthen the MA program

Many uninsured adults continue to lack awareness in what?

-Marketplace -Financial Assistance -Medicaid Expansion

Issues with Intensive Lifestyle Interventions

-Not covered by Medicare and most health plans so no national funding source -Participation rates and incentives to enroll -Need a national capacity to provide the intervention (needs funding) -Need focus on scaling and replicating the DPP style model

What type of DPP has the YMCA created? What does it offer? By how much does it lower the direct intervention costs? Cost-savings?

-Offers groups of 10-12 -Enhances social support and accountability -Lowers direct intervention costs by 50-85% -Allows cost-savings within 2 years of coverage for health plan that pays intervention fees (greater ROI if cost-sharing)

What are some challenges related to lifestyle programs>

-Population health and most prevention funded through patchwork of taxes and grants. Spend less than 3% on prevention through traditional health insurance -Infrastructure and tools for population health improvement are not well developed -Risk that new payment models will not include a population health focus or measures -Need to build integrated service models for clinical care, public health and community based resources

Proposals to modify IPAB ACA? Boweles-Simpson? Domenici-Rivilin? Rep. Roe? What does the CBO say it would cost to take this action?

-President's plan(ACA) would lower the target growth rate from per capita GDP +1% to GDP+0.5% beginning in 2018; IPAB would make recommendations to promote "value-based benefit design" -Bowles-Simpson would allow IPAB to make recommendations for all providers (no exceptions); if costs grow faster than targets, could consider changes to cost sharing and benefits and look beyond Medicare for savings -Domenici-Rivlin would require IPAB to review Medicare benefit structure every 2 years and recommend conforming changes to private market (to become law unless blocked by Congress) -Rep. Roe (and others) - repeal IPAB (CBO says this would COST $2.4 billion from 2018-2021)

What are some approaches to decreasing spending through prevention?

-Preventing rise in chronic disease prevalence—DPP -Value based insurance design -Team based care—community health teams

Comprehensive Health reform must include:

-Promoting long-term efficiency and a sustainable path of per capita spending -Improved quality of care and outcomes -Covering all Americans with insurance

How long will the ACA freeze income levels? What needs to happen to ____% of beneficiaries before premium contributions increase by ____ in 2017? what is the proposed savings due to this freeze?

-Proposal would continue to freeze income-related premium thresholds beyond 2019 until 25% of beneficiaries pay the income-related premium, and would increase premium contributions by 15%, beginning in 2017 -$20.0 billion

How would you measure quality of these lifestyle programs? How would payments be distributed?

-Quality measures would include traditional medical markers but also population based measures as well (such as obesity rates, chronic disease incidence and prevalence) -Payments would be based on a per capita basis for a catchment area that the teams and providers would be responsible for. This could start with Medicare first

what are the premium levers beyond benefit design?

-Scope of Non-Essential Benefits -Negotiated Payment Rates to Providers -Utilization Patterns, Trends

What was added to the health care reform in 2012?

-Standardization -developed Essential Benefits (effective January 1, 2014) -Federal Partnership for Exchanges

What were the conclusions of the VBID?

-The combination of VBIDa with a diabetes DMb program produced improvements in the use of diabetes medications and adherence to medical guidelines. -Results showed the combination of VBID and DM had a greater impact on prescription use and adherence to recommended medical services guidelines than DM alone -These effects not only were sustained, but they grew over time -The program showed modest cost savings over 3 years

What are two types of medicare models in ACOs? What are providers held responsible for in this type of care? What parts of medicare use this type of organization? What are some concerns?

-Two Medicare models: Pioneer and Shared Savings Program -Providers accountable for costs and quality of care for defined patient population -Covers Part A and B, not yet D -Concerns include shifting patient ACO assignment, inadequacy of measures to account for innovation

Under the ACA, people with incomes above______pay a larger share of______. Income levels are frozen until what year?

-Under current law, individuals with incomes above $85,000, or couples with incomes above $170,000 pay a larger share of Part B and D premiums; income levels are frozen through 2019

Cadillac Excise Tax What types of plans does it apply to? What is the threshold amount? What is the threshold based on? Does it include HSA or FSA contributions? What are the adjustments applied to the threshold?

-applies group health plans excluding stand alone vision and dental programs and those programs paid exclusively with after-tax dollars by the employee -increases according to consumer price index - The initial annual threshold amounts for the tax are: $10,200 for self-only coverage $27,500 for family Threshold does include employer and employee contributions made to a HSA or FSA The initial threshold amounts are subject to different adjustments: -Health cost adjustment percentage (2018 only), -Cost-of-living adjustment (calendar years after 2018), and -Age and gender adjustment (applicable to 2018 and later)

What is the eligibility critieria for CMS MSSP program?

-assume responsibility for Medicare patient population of 5000 or more beneficiaries for at least three years -adequate primary care physician participation -a formal legal structure for receipt/distribution of shared savings -shared governance over clinical and administrative processes -processes to promote evidence-based medicine, coordinated care and patient engagement

How would lifestyle programs function?

-be national available and covered by all plans - schools would adopt diet programs/phys ed -connectors work with providers to provide prevention programs

what are some concerns over bundled payments

-challenge of coordinating care across unaffiliated organizations -lack of incentives for preventive care

What two things has determine to the healthcare spending

-change in treated prevalence, eg. rising clinical incidence -Change in spending per treated case interactions 9

What are the 7 global burdens of disease?

-childhood and maternal undernutrition -Other nutrition-related risk factors and physical activity -Sexual and reproductive health -Addictive substances -Environmental risks -Occupational risks -Other selected risks (e.g. Mental health)

What are the four major funding goals of the prevention and public health fund?

-clinical preventions -community preventions -workforce infrastructure -research and tracking

In order to correct the federal deficit, what are the three options?

-cut benefits -trim payments -pay smarter ( efficient use of care, use technology) 9

Why have funding levels for prevention reduced over time?

-deficit reduction -to extend funding for other pieces of the ACA -to fund the federal health insurance exchange

What are the structural changes that are affecting growth in spending?

-higher cost sharing in private health insurance (which discourages the use of health care services), -the loss of employer-based coverage (with people moving to lower-paying coverage or no coverage), -lowering of payments to providers in public programs (lower prices reduce growth), -less use of expensive technologies, and -providers producing care for less cost (spurred on by decreased reimbursement or payment changes such as reduced payments for readmissions). 9

What accounts for the increase in healthcare spending from the 1940s to 90s?

-medicare/medicaid -more people are insured -technological advances 9

Managing Patients with Multiple Chronic Conditions

-needs team based interdisciplinary care -reduced readmissions by 50% - Vermont and North Carolina spending by over 10 percent.

Regarding multiple chronic conditions, do most people have one or more chronic disease or 2 or more chronic diseases? What age group has the greatest amount of chronic disease? By what percentage?

-one -65+, 90.7%

Options for Slowing the Growth in Medicare Spending

-prevention -care-coordination

How do Bowles-Simpson and Domenici-Rivlin propose restructuring medicare cost-sharing? What does the ACA allow IPAB to consider in their restructuring?

-propose combining the Part A and B deductibles (~$550), -adding 20% coinsurance for all services (inpatient hospital, home health, etc.), - new limit on out-of-pocket spending IPAB is allowed to consider value-based benefit designs

What has caused the decrease in health care spending in the past few years? What is going to cause the projected increase in spending in coming years?

-recession, structural changes -economic recovery, more people signed up for insurance 9

Where are ACOs more likely to form?

-where providers have previous experience with integration, capitation, and coordination among primary care physicians (i.e., in large groups) -ACOs more common in the Northeast and Midwest -Mixed evidence about whether ACOs are more likely to form in areas with high medical spending -Hospitals in ACOs are more likely to be large, academic, and non-for-profit than non-ACO hospitals. -ACOs are more likely not to include a hospital than to include one

Review slide 5 table 9.1

...

Name 5 of the 10 essential benefits that insurance companies are required to provide.

1. Ambulatory Patient Services 2. Emergency Services 3. Hospitalization 4. Maternity and Newborn Care 5. Mental Health and Substance Use Disorder Services, including behavioral health treatment 6. Prescription Drugs 7. Rehabilitative Services and Devices 8. Laboratory Services 9. Preventive and Wellness Services and Chronic Disease Management 10. Pediatric Services, including oral and vision care

Grandfathered plans Before what date? What makes a plan ineligible for this provision? What are some differences these plans may have from post-ACA plans?

1. Be in force before March 23, 2010. 2. Not be changed in any way that: -Reduces benefits or employer contributions. -Increases employee-paid deductibles. -Increase the employee's coinsurance or copay 3. Grandfathered plans: -May have lower rates initially compared to plans sold through health insurance exchanges. -May not include some ACA benefit reforms. -Are exempt from certain reform provisions. -Employer plans that are grandfathered, may change insurance companies.

What's plan progression of payment reform? Like what models are CMS using to push delivery reform?

1. FFS 2. P4P 3. Value-Based Purchasing (adjusts payments to reward hospitals based on the quality of care that they provide to patients.) 4. Episode Based Payments (bundled payments) 5. Global Capitation ( pays a physician or group of physicians a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care) Moving to so that the level of financial risk borne is shifted from payer to provider

What are the steps to payment and delivery system integration?

1. FFS and DRGS 2. Comprehensive Primary Care Initiative 3. CMMI Acute Episode Bundled Payment Pilots 4. Medicare Shared Savings Plan 5. Pioneer ACOs 9

What was the historical timeline of the ACA?

1. House passed Senate's Health Care Reform Bill March 21, 2010 2. House passed the reconciliation bill, H.R. 4872 "Health Care and Education Reconciliation Act" on Sunday, March 21, 2010 3.The President signed PPACA into law on March 23, 2010

What was added to the health care reform in 2011?

1. MLR requirements enforced 2. $250 Donut hole rebates for Medicare D enrollees 3. Over-the-counter drug costs reimbursement restrictions in flexible spending accounts and account based health plans 4. Increased tax on non-medical distributions from health savings accounts (HSAs) 5. Establish national, voluntary insurance program for purchasing community living assistance services and supports (CLASS program)

Types of ACOs

1. Medicare -Medicare Shared Savings Program (MSSP) -Advanced Payment Model 2. Commercial (Private Insurers/Payors Health Systems) 3. Pioneer - Hybrid Advanced Model

List all taxes and deductions which happened due to the healthcare reform.

1. Medicare Payroll Tax - Increase from 2.9% to 3.8% for wages exceeding $250,000 for couples. 2. Medical Device Tax - New 2.3% excise tax on gross sales. 3. Medical Itemized Deductions - Increase of current 7.5% to 10% of AGI to qualify for deduction. 4. "Cadillac Tax": In 2018 a 40% excise tax imposed on high comprehensive health plans. 5. Flexible Spending Accounts: cap of $2500 will apply 6. Subsidies are available to those with a household income of up to 250% of the federal poverty level.

what are the 8 new changes or provisions that the ACA brought on in 2010

1. New national risk-pool 2. Small business tax credit 3. Prohibits lifetime benefits limits 4. Annual limits* for essential benefits 5. Rescissions are prohibited 6. Preventative services without copays 7. Dependent coverage up to age 26 8. No Pre-existing condition exclusion for dependent children *Annual limits are the total benefits an insurance company will pay in a year, can't put a dollar limit on essential benefits

How will the health reform law produce savings from Medicare Advantage payment reforms? What did congress notice was the difference between beneficiaries in MA and traditional medicare?

1. Reduces Payments to plans -Freezes benchmarks (maximum Medicare payment per county) for 2011; phases in reductions in payments to align more with fee-for-service costs in county -Reduces share of rebate retained by plan from 75% to 50% for most plans (2012) 2. Begins to reward plans based on quality ratings (2012) 3. Includes new consumer protections -limits cost-sharing for certain medicare-covered services -establishes new loss ratios requirements for plans (2014) Congress saw they paid more for MA. and 24% of all medicare beneficiaries are in MA. Higher payments have allow plans to offer more benefits thus increasing spending and creating solvency problems, and increasing part b premiums for all beneficiaries. see slide 42 for more info

What 2 major components will the medicare payment bundle have? Who can amend this bundled payment plan?

1. The acute care hospital "index" admission, which triggers the start of the bundle The bundle is clinically defined by the acute care hospital index stay Diagnosis Related Group (DRG) 2. All care provided within 30 days of patient discharge from the index acute care hospital admission The secretary can change it

What three goals do payment bundling seek?

1. To incent the provision of quality care in the most cost-effective setting 2. To improve system efficiency, with less reliance on fee-for-service payments 3. To reduce hospital readmissions and other use of facility-based services (e.g. SNFs/IRFs) through enhanced care coordination

What is the purpose of the exchange?

1. Transparency 2. Ease of comparing coverage 3. Federal partnership 4. Includes Platinum, Gold, Silver, Bronze Plans 5. Provide information on quality of plans 6. Determine eligibility for Medicaid etc 7. Includes Essential Benefits 8. "Strength in numbers" (what does this mean?)

Employer mandate 1. What type of employees does this mandate apply to and what is the criteria that defines this group? 2. What must employees do every year during tax season? 3. What 2 features must the coverage that the employers offer have?

1. mandate only applies to full-time-equivalent employees (30hrs/week) 2. Employers must report certain information to the IRS and to individuals annually. 3. The coverage must be "affordable" and provide "minimum value." -Affordable: The employee's cost must be less than 9.5% of his or her income. -Minimum value: The insurance must pay at least 60% of costs for covered services.

Describe the new prevention triangle from top to bottom

1. tertiary medical care 2. care coordination 3. primary medical care 4. clinical preventive services 5. population oriented prevention

1. What does the proposal to raise the age of medicare eligibility to 67 reflect? Who first proposed it? 2. What does Bowles-Simpson suggest? 3. What will happen to the 65-66 age group if they are denied Medicare? 4. What will happen if they are offered medicare? 5. What does the CBO project the savings will be.?

1. that people are living longer than in 1965; Alan Enthoven in 1978 2. Bowles-Simpson suggested raising the eligibility age as option to consider if federal health spending exceeds targets (November 2010) 3. Numerous studies have documented potential for large increase in uninsured 65 and 66 year olds if without Medicare - pre ACA 4. -Medicare achieves savings, but savings would be partially offset by new costs of coverage for 65 and 66 year olds in the exchange and Medicaid -Costs would be shifted to other Medicare beneficiaries (higher Part B premiums), individuals in the exchanges (higher insurance premiums), employers and Medicaid 5. CBO (March 2011) projects federal savings of $124.8 (2012-2021) assuming gradual phase in beginning in 2014 of 2 months per year

Why Premiums Change Under the ACA

1. ↑ as people with pre-existing conditions get insurance (potentially offset by greater enrollment among young and healthy people). 2. ↑ because coverage will get better for some. 3. ↑ and↓ due to limits on age rating and prohibition of health and gender rating. 4. ↓ with rate review and the 80/20 medical loss ratio threshold. 5. ↓ through price competition. 6. ↓ for most purchasers due to federal premium subsidies.

Steps to payment reform

1.FFS 2.P4P 3. Medical Home 4. Bundled Payments 5. Total cost of Care 9

What do plans need to offer to qualify to sell on the exchange?

1.Must cover "essential health benefits" 2. Must offer certain levels of value ("metal levels") 3. Must include "essential community providers," where available, in their networks 4. Must comply with ACA insurance reforms

What is Primary Prevention? Secondary? Tertiary?

1.Reduce or Eliminate Risk Factors and Avert Disease 2.Find and Treat Disease in Its Earliest Stages to Stop Its Progression 3.Manage Disease to Avoid Complications and Disease Progression 9

How much of the rise in health care spending is due to obesity?

10%

What did the 10 year followup study say about diabetes prevention?

10-year follow-up after the Diabetes Prevention Program found that prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years. In the former placebo and metformin group, diabetes incidences fell to equal those in the former lifestyle group, but the cumulative incidence of diabetes remained lowest in the lifestyle group

What was the average weight loss in the DBP program? Percentwise? How cost-effective was it?

11 pounds, 58% decrease in diabetes $1100/QALY

By how long will the health reform law extend the life of medicare part A trust fund?

12 additional years slide 47

After the end of the second open enrollment period, what percent of US adults remained uninsured?

13%

Since medicare readmission has declined, what is the number decrease in readmission that has resulted in hospitals?

130k 9

Roughly, how much of the federal budget does Medicare account for? What about the GDP

15-17% 3.6-5.1% 9

What is the individual penalty for health insurance? in 2015 and 2016

2015 Penalty is $325 per adult and $162.50 per child (up to $975 for a family) or 2.0% of family income, whichever is greater. 2016 Penalty is $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of family income, whichever is greater.

Explain employer mandate based on company size and year. What happens to those with less than 50 employees? Those with less than 25 employees? Less than 10 employees?

2015: 100 or more FTEs are required to cover 70% of FTEs and dependents to age 26 2016: 50 or more FTEs are required to cover 95% of FTEs and dependents to age 26 For those with less than 50 employees, no direct penalty. For those with less than 25 employees and average wages up to $50,000, they may be eligible for a 25% tax credit if they pay at least 50% of employee's premium. Full tax credit for those with less than 10 employees and avg annual wages of less than $25,000

What percent of premium reduction is due to network narrowing?

26%

How many people in Medicare advantage are in care coordination? Was care coordination apart of original Medicare?

27%; no 9

______Uninsured Adults Who Were Aware of the Marketplaces Didn't Visit Because They Didn't Think They Could Afford Health Insurance

3 out of 5 Uninsured Adults Who Were Aware of the Marketplaces Didn't Visit Because They Didn't Think They Could Afford Health Insurance

What percent of growth in spending is chronic disease responsible for?

35-52%

What was the difference in weight loss between people who were in group DPP and those who received only a small amount of advice?

4% increase in weight reduction among those who were in group DDP compared to those who weren't 6% reduction in weight loss of 6 months, 12months

What type of cancer is especially potentially preventable by lifestyle changes?

40%, lung cancer

In the MSSP, what was the most popular outcome in terms of percent? Second most popular?

46 percent (102 ACOs) did not achieve savings 27 percent (60 ACOs) reduced spending, but not enough to earn shared savings bonus

What is the projected enrollment number from 2014 to 2016 in the insurance exchange market?

6 million in 2014 to 24 million in 2016 Slide 5

What is the baseline medicare spending growth rate from 2010-2019 before the health reform act? After?

6.8%; 5.9%

What percent of patients are discharged without a post-acute care referral?

64%

Would raising the Medicare Age of Eligibility to 67 increase the out-of-pocket spending costs for most? For what percent would it increase spending? What percent would it decrease?

66% would pay more 31% would pay less

What is the projected enrollment number in Medicaid and CHIP from 2014 to 2016?

7 million in 2014 and 1 million more for every year until 2017 where it will plateau at 12 million for one year and then rise to 13 million in 2018 and will plateau again until 2024 Slide 5

FQHC Medical Home Demonstration, what were the early results?

73% of 492 participating health centers achieved Level 3 Patient-Centered Medical Home recognition based on standards set by National Committee for Quality Assurance, short of 90% goal set in 2011.

By what avg percentage did the tax credits reduce the premiums?

76%

How much of medicare spending does prevalence of treated disease account for?

78% 9

How much of healthcare spending is associated with chronic disease?

86%

What percent of exchange enrollees recieved a federal tax credit?

87 percent of the nearly 10 million exchange enrollees received a federal tax credit to buy insurance

Within medicare, what percent of growth in spending is chronic disease responsible for?

90%

cadillac tax example

A $12,000 individual plan would pay an excise tax of $720 per covered employee: $12,000 - $10,200 = $1,800 above the $10,200 threshold $1,800 x 40% = $720

Possible ways to transform system for 2020

A bold proposal would develop models that integrate -Population and community based interventions -Medical and clinical interventions -Health insurance, employers, employees and families

Which conditions and by what percent can they be prevented through a lifestyle change?

About 80% of new cases of heart disease, stroke, and T2 diabetes are potentially preventable through lifestyle change

Describe category 3 of the payment taxonomy framework.

Alternative Payment Models Built on Fee-for-Service Architecture Some payment is linked to the effective management of a population or an episode of care. Payments still triggered by delivery of services, but opportunities for shared savings or 2-sided risk -Accountable care organizations -Medical homes -Bundled payments -Comprehensive primary care initiative -Comprehensive ESRD -Medicare-Medicaid Financial Alignment Initiative Fee-For-Service Model

ACA effects on a... An uninsured young person? An older person with employer-sponsored health insurance? A small business owner? An insurance company? A physician? A hospital?

An uninsured young person? affordablity, easy shopping, might qualify to Medicaid An older person with employer-sponsored health insurance? Employer mandate may affect your wages, least affected by ACA, old health care system catered to you A small business owner? Exchange can be used to find insurance for your employers, Positive incentives but not penalized otherwise An insurance company? MLR, more wary of adverse selection, preventive services A physician? Medicaid Expansions, more uninsured patients, greater focus on reducing readmissions, more incentive to coordinate A hospital? Quality Reporting requirement, Reduction of DSH, Prevention of Hospital Acquired Conditions

What was the timeline of healthcare reforms in 2010?

April: State option to expand Medicaid to adults to 138% FPL July: Temporary high risk pool; Employer retiree health benefits reinsurance Sept: Young adults on parent's plans, Small business tax credits, No pre-existing condition exclusions for children, Prohibitions against lifetime benefit caps & rescissions End of 2010: Annual review of premium increases, Public reporting by insurers on share of premiums spent on non-medical costs, Coverage and no cost-sharing for preventive care in Medicare and private plans, $250 rebates for Medicare D enrollees in "Donut hole" See Slide 9

What is the clinical and economic impact of nonadherence?

As many as 60% of chronically ill patients have poor adherence to treatment -Nonadherence results in an estimated 10% of all hospital admissions and 23% of all nursing home admissions Costs that result from poor medication adherence have been estimated to exceed $100 billion annually

Discuss Pitney Bowes and Clopidogrel when copay was reduced.

As was seen with statin adherence following the introduction of a new copayment policy at Pitney Bowes, the reduction of copayment for clopidogrel stabilized adherence in the intervention group. Ultimately, the stabilized adherence resulted in a 4% difference between the intervention and control cohorts.

How are patients assigned a doctor within an ACO? How many ACOs can a primary care doctor be in? What about specialists? What two rights do patients within an ACO have?

Assigned retrospectively by which primary care doctor did a pleurality of their care recently Primary care doctors can only be in one ACO Specialists can be in several ACOs Patient must be notified that doctors are in an ACO Patients must not be restricted to the ACO

Hospital Value-Based Purchasing What does it build on? How much of hospital payments does it affect? What happened to the hospital payments that were affected?

Builds on measures used in Inpatient & Quality Reporting (IQR) and Hospital Compare programs. 1% of hospital payments affected. Incremental increase to 2% of hospital payments affected in 2017 and beyond.

Hospital Readmissions Reduction Program What does it build on? How much of hospital payments does it affect? What happened to the hospital payments that were affected?

Builds on the measures used in IQR and Hospital Compare programs. Up to 1% of hospital payments affected. Based on readmissions for heart attack, heart failure, pneumonia. Incremental increase to 3% of hospital payments affected in 2015 and beyond. Additional conditions included: COPD and elective hip & knee replacements.

What were the long-term clinical and economic outcomes of the Asheville Project?

Clinical outcomes -Lower hemoglobin A1C and improved cholesterol levels -Increased percent of patients reporting having had a foot exam Economic outcomes -Decreased costs for inpatient and outpatient services -Increased costs for pharmacy benefits -Direct medical costs decreased by $1,200 (to $1,872) per patient per year compared with baseline -Decreased number of sick days -Increased employee productivity

What does Value-Based Insurance design look like in practice in companies like Pitney Bowes and Marriott Intl. and Chernew? Advair? Diabetes Drugs? Outcome? Chernew and adherence?

Companies like Pitney Bowes and Marriott International have reduced or eliminated copayments for all users of drugs for chronic conditions, such as diabetes, asthma and hypertension Value-based benefit design reduced Advair from 50% co-insurance (~$60/mo) to 10% (~$12/mo) Diabetes mellitus (DM) drugs all moved to 10% co-insurance resulted in increased pharmacy expenditures, increased adherence and decreases in medical expenditures compared to benchmark Chernew copay value benefit reduced from $5/$25/$45 to $0/$12.50/$22.50. Adherence increased an absolute 3% antihypertensives, 4% DM, 3% statins, and 2% inhaled steroids

Who is the HHS inviting to match or exceed HHS goals

Consumers Businesses Payers Providers State and federal partners

What key issues still remain with the ACA after king v. burwell?

Covering remaining uninsured Affordability of premiums and health care - 2016 changes. Financial sustainability of state-based marketplaces Legal challenges Federal and state legislation to fix, change, block provisions. 1332 state innovation waivers

National Diabetes Prevention Program -Which agency is it within? -what type of program is it?

Creates a CDC National Diabetes Prevention Program targeted at adults at high risk for diabetes, which entails a grant program for community-based diabetes prevention program model sites.

Projected Medicare spending has ______ since the enactment of the ACA. By what percent?

DECREASED Projected spending before ACA: 6.8 percent Projected spending after ACA: 4.8 percent

Who lost the most weight according to mode of delivery?

DPP program administered by Medical and Allied Health Professionals, electronic-media assisted programs were the second best

What influences decision between metal tiers? What does not? What metal tier is most popular?

Deduction copay, out of pocket expenses all influence choice. Non-Essential Services Covered, network composition, negotiated rates do not. Silver (65% chose this tier)

Domenici-Rivlin would increase beneficiaries' Part B premiums to cover how much of the program costs? Predicted savings over 10 years by the CBO?

Domenici-Rivlin would increase beneficiaries' Part B premiums to cover 35% of program costs (up from 25%) $241.2 billion in savings over 10 years (CBO)

What has happened to average patient deductible since 2006?

Doubled 9

____ of obesity since the mid-1980s accounts for ___% of the rise in spending

Doubling of obesity since the mid-1980s accounts for 10% of the rise in spending 9

What percentage reduction in healthcare costs occurred in the Asheville project?

Even though prescription costs increased owing to waived copays, the project demonstrated an overall reduction in total health care costs of approximately 34%.

What was added to the health care reform in 2018?

Excise tax on high cost employer plans

Why have smoking rates declined?

Excise taxes Bans and regulation Self-help, counseling and pharmacotherapy combined

Why would proposals regarding the medigap coverage prohibit first dollar medigap coverage?

Exposing beneficiaries to higher cost-sharing services would be expected to reduce their utilization of Medicare-covered services; as utilization of services declines, Medicare spending would decrease and as a result, Medigap premiums should decrease Forces beneficiaries to hold more of the cost-sharing

Describe category 2 of the payment taxonomy framework.

Fee for Service—Link to Quality -At least a portion of payments vary based on the quality or efficiency of health care delivery -Hospital value-based purchasing -Physician Value-Based Modifier Readmissions/Hospital Acquired Condition Reduction Program

How is the health reform law going to affect Part B and D premiums to save money?

Freeze income threshold for the income-related Part B premium, and establish a new income-related Part D premium slide 43

What's the relationship between GDP and the hospital prices?

GDP has exceeded growth rates of hospitals prices 9

For the Multi-Payer Advanced Primary Care Practice Demonstration, what were the early results?

Generated $4.5 million in savings across eight states.

What are the two goals of a diabetes prevention program? How is the program setup?

Goal #1: > 7% loss of body weight and maintenance of weight loss Goal #2: > 150 minutes per week of physical activity Delivered through 16 hour long weekly sessions plus 8 weekly maintenance per month

What are the five goals for primary prevention?

Goal #1: Reduce weight > 5% Goal #2: decrease fat < 30% energy Goal #3: decrease saturated fat < 10% energy Goal #4: increase fiber to 15 g/1000 kcal Goal #5: increase to > 30 minutes moderate exercise/day

What are the two goals that HHS has for value-based payment targets?

Goal 1: 30% of Medicare FFS payments are tied to value through alternative payment models by the end of 2016, and 50% by the end of 2018 Goal 2: 85% of all Medicare FFS payments are tied to quality metrics by the end of 2016, and 90% by the end of 2018

what makes up the governing body of an aco? Who can terminate an ACO agreement?

Governing body: 75% ACO providers; at least one Medicare beneficiary. the ACO itself or CMS

Which type of health organization offered care at less cost than FFS?

HMOs at 8% less 9

Who is at highest risk for diabetes according to BMI by gender, race and age?

Hispanic Female, 35+

Explain what the Hospital Readmissions Reduction program is

Hospital Readmissions Reduction Program (HRRP), which requires CMS to reduce payments to IPPS hospitals with excess readmissions within 30 days of discharge effective for discharges beginning on October 1, 2012.

Why is there decline in the growth of hospital prices?

Hospital consolidation 9

For the Comprehensive Primary Care Initiative, what were the early results?

In year 1, initiative generated nearly enough savings to cover $20 care management fee paid, although not enough for net savings. Across all seven regions, emergency department visits decreased by 3% and hospital admissions by 2%. Quality results mixed.

What are the ACA provisions affecting physicians?

Increased demand for physician services, esp. primary care Increased payment rates for select services & providers Funding for physician training, Federally Qualified Health Centers Expanded Physician Quality Reporting Initiative (2015) CMMI demos: Comprehensive Primary Care Initiative, Multi-Payer Advanced Primary Care Practice Pressures to integrate with larger care systems

Medicare Shared Savings Program Describe it. What does it measure?

Initial members join program. Pay-for-reporting in first performance year. Option for shared-savings only in first three years of participation. Measures transitioned to pay-for-performance (shared savings only).

Where does ACA primarily increase coverage?

Insurance Exchanges and Medicaid/CHIP

Current Medicare Coverage for Obesity

Intensive behavioral therapy (IBT) For one year, provided patients lose 6.6 lb in six months (~3% body weight, based on clinical trials) Does not cover evidence-based cost saving programs like the diabetes prevention program Bariatric surgery For BMI ≥ 35 with one weight-related comorbidity Pharmacotherapy is excluded from Medicare Part D coverage, resulting in a significant treatment gap Despite recent FDA approval of pharmacotherapy that can produce 10% to 15% weight loss 9

What about the older prevention triangle is confusing?

It may be confusing in its use of the term "tertiary prevention" to mean secondary and tertiary medical interventions such as surgery, chemotherapy and long-term care.

What is meant by primary prevention? give examples

Lifestyle interventions: -Physical activity -Diet and nutrition -Exercise -Tobacco control -Alcohol control

What accounts for the rising prevelance of disease?

Longevity Technology Definitions/Threshold for Disease changing Number of New Cases 9

DPP lead to what in these three metabolic measurements? Body weight BMI Total cholesterol

Mean 6% reduction in baseline body weight Mean 5.8% reduction in BMI Mean 21.6 mg/dL in change in total cholesterol

Do Medicare and Medicaid have their own payment plan? What is bad about this if this is true?

Medicare and Medicaid each have unique payment systems, with little incentive to coordinate care and every incentive to shift costs from one to the other

What is it about the payment plan in the Medicare/Medicaid that is flawed?

Medicare and Medicaid-both different, both little incentive to coordinate care

What is the percent of medicare payments are spent on medical care compared to investor owned private insurance companies in 2007?

Medicare: 97.9% Investor-owned Insurers: 81%

What kind of hospitals is the hospital readmission reduction program most likely to affect?

More likely to affect small hospitals and rural safety-net hospitals, though critical access hospitals exempted (also psych, rehab hospitals)

How many adults enrolled in marketplace plans or medicaid were uninsured before getting their new plan?

More than 50%

Independent Payment Advisory Board How is it formed? When is it active? What does it do? When is the Board's proposal put into action? What isn't it allowed to do? What would Bowles-Simpson allow it to do?

New board, 15 full-time members, appointed by President, confirmed by Senate Board submits proposals if growth rates exceed targets of the 5-year average based on inflation (before 2018) and per capita nominal GDP+1% (beginning 2018) Creates formula for required Medicare savings if spending exceeds target, lesser of the following -amount projected Medicare per capita costs exceeds the spending target -0.5% of projected Medicare spending in 2015, rising to 1.5% in 2018 Secretary implements Board's proposals unless Congress enacts alternative with equivalent savings Secretary submits proposal to implement savings if Board fails to do so Board proposals cannot ration care, reduce benefits, increase cost-sharing, modify benefits, eligibility, or premiums, raise taxes, or before 2020 reduce payments for certain providers. Bowles-Simpson would allow IPAB to make recommendations for all providers (no exceptions); if costs grow faster than targets, could consider changes to cost sharing and benefits and look beyond Medicare for savings

What are some of the issues that will need to be dealt with if bundled payments are to be established?

New types of organizations will need to be established to receive and distribute bundled payments and to determine: -How evidence-based standards of appropriate care will be determined. -How adherence to clinical guidelines will be monitored and enforced. -How the performance of individual service providers will be monitored and evaluated. -How clinical outcomes data will collected and reported. -What new billing and collections systems will be needed. -What new information technology capabilities will be required

Are most employers planning to take action against the excise tax or have they done so already?

No but are considering it (40%), those with more than 10K are taking action the most

Did lifestyle interventions result in the greatest decrease in percentage in chronic incidence reduction compared to all other interventions?

No, but it was significant, up to 60% decrease which is nearly as much as Pioglitazone which had a incidence reduction of 72%

Who could be consider to be a connector?

Nurse Coordinators Social Workers Nutrition Specialists Community Health Workers Public Health Specialists Pharmacists Mental health professionals

Obese patient spend how much more on health care and add how much more to health care spending? For each dollar spent on health care costs, how much is lost in productivity?

Obese workers spend nearly 40% more on health care than normal weight adults, adds about 20 percent to health Care spending For each additional dollar spent to treat health care costs associated with chronic disease, there is an additional $4 lost in productivity 9

explain the MSSP ACO one sided model and two sided model

One Sided Model -Regular FFS payment -Eligible for shared savings in years 1 & 2 -Become at risk for losses in year 3 -Only available for the first agreement period Two Sided Model Regular FFS payment Shared savings and losses in all 3 years

How much does the health reform law stand to save in the next 10 years? Where will most of the savings be?

Over $500 billion ($425 bil net savings) Payment to providers is where most of the savings will be at 37% ($219 billion) , Medicare Advantage reform is the next provider of savings at 26% ($136 billion)

A bonus payment is a part of what type of healthcare model?

Pay for performance

Name the four features of patient-centered medical homes.

Personal physician Physician directed medical practice . Whole person orientation - Care is coordinated and/or integrated across all elements of the complex health care system

What was the incidence rate for each: Metaformin Placebo Lifestyle Intervention

Placebo: 11%/year incidence Metformin: 7.8%/year incidence* Lifestyle intervention: 4.8%/year incidence*

Describe category 4 of the payment taxonomy framework.

Population-Based Payment Payment is not directly triggered by service delivery so volume is not linked to payment. Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (e.g. >1 yr) Eligible Pioneer accountable care organizations in years 3-5

Describe defined contribution, what's a synonym for it? Bowles Simpson? Domenici-Rivlin? Rep. Paul Ryan?

Premium support plan; this plan is where the medicare enrollees would choose a private health plan and the federal government would pay a predetermined contribution to that plan Bowles-Simpson suggested premium support as an option to consider, if costs grow faster than federal health spending targets (Nov. 2010). Domenici-Rivlin endorsed premium support, with traditional Medicare as a default option (Dec. 2010). Rep. Paul Ryan proposed a defined contribution system, beginning in 2022; also reflected in the House Concurrent Budget Resolution (April 2011).

What does the ACA regarding Medigap? What does the OMB predict will be savings will be? Would it apply to current beneficiaries?

President's plan would impose 30% Part B premium surcharge on new enrollees who purchase first dollar* Medigap policies, beginning in 2017 -OMB (Sept 2011) estimates $2.5 billion in savings over 10 years -Would not apply to current beneficiaries *means it covers both the Part A and the Part B deductible

Prevention can only succeed if

Prevention policies affect behavior. Behavior affects health. Health affect spending, life expectancy, and quality of life.

What are Patient Centered Medical Homes Classified as?

Primary care practices

What are the pros and cons about the tax exclusion?

Pro: Encourages employers to offer health coverage and workers to want it Results in "risk pooling" at the workplace Con: Raises health care costs Disproportionately benefits people with higher incomes

What are the focus areas for CMS health system reforms?

Provider payment Care Delivery Information Distribution

How many uninsured Americans will be affected by the ACA being passed? Over the next 10 years (2014-2024), what does the CBO project the ACA will do?

Reform affects 26 (of 57) million uninsured Americans Over 2014-2024, CBO projects ACA will reduce the number of uninsured Americans by almost half

What is the STAAR Program? what types of interventions are hospitals in the program more likely to adopt? What is trend for hospitals in the STAAR program?

STAAR stands for State Action to Reduce Avoidable Rehospitalizations. Hospitals in STAAR are more likely to have: -enhanced assessments -patient education -activated the post-acute care delivery system prior to discharge The trend in STAAR program hospitals is that Top performers show up to 50% reduction in readmissions for targeted patient population on specific units (e.g. high risk patients with CHF).

how do premiums vary across states? what does the gov't end up paying as a tax credit?

Single adult at 133% poverty = $15,654 in income and pays 2% of that for coverage = $313 So... single premium in Burlington is $4,956 (413 x 12) and Portland, Or. Is $2,412 (202 x 12). In either location the adult pays $313 but the federal government contributes $4,943 for the Burlington adult and $2,099 for the Portland Oregon adult

Is smoking in an upward or downward trend? what about obesity?

Smoking downward obesity upward

What is the STAAR? What are STAAR hospitals more likely to have done?

State Action to Reduce Avoidable Rehospitalizations Preliminary national survey of hospitals suggests that STAAR hospitals are more likely to have adopted interventions and have reduced readmissions 9

what is the benchmark used by ACO's shared saving program also a measure of?

Surrogate measure of what the Medicare FFS Parts A and B expenditures would otherwise have been in the absence of the ACO.

What are steps that HHS will need to take to reach goals?

Testing of new models and expansion of existing models will be critical to reaching incentive goals Creation of a Health Care Payment Learning and Action Network to align incentives

How are consultants using the value-based approach? (Hewitt Value Report Card)

The Hewitt Value Report Card requires insurers and PBMs to assess utilization of key drug classes and ensure self-funded groups of the efficient use of medications in each drug class

What was the predicted effect of VBID Program on Total Drug and Medical Spending?

The investigators measured spending based on eligible charges for prescription drugs and inpatient and outpatient medical services. Although the difference in spending between groups was not significant in the first year, this difference grew over the following 2 years (nearly $5000 difference)

What three conditions is the CMS most focused on and why?

The most frequent diagnostic categories accounting for both total admissions and readmission: Heart Failure - 1st Pneumonia - 2nd AMI ranks 9th in frequency of admissions and 8th in frequency of readmission

What is the significance of the population oriented prevention being placed at the bottom of the triangle?

The placement of population-oriented prevention at the base is significant in - its focus on all of the people as recipients - its broad, long-lasting impact on health - its role in defining and facilitating the whole system to work