The Affordable Care Act (ACA)

1. The Affordable Care Act (ACA) What health reform means for Emergency Physicians

2. Main Provisions of ACA • Expanding Insurance Coverage • Health Insurance Reform • Improve Quality • Contain Costs • Consumer Protections

3. Expanding Coverage • Individual Mandate • Own qualifying health insurance or pay fine • Multiple exemptions (financial, religious, etc) • Employer Mandate • 50 employees: Penalty/shared responsibility requirement for not offering adequate insurance • Some premium subsidies for businesses with 25 employees who choose to offer insurance • Expansion of Medicaid • 133% of FPL • Simplified CHIP enrollment

4. Other Expanded Coverage • Dependent coverage up to 26y • Federal funding to preserve employer insurance for early retirees • Prescription drug discounts and tax rebate for seniors who hit Medicare donut hole

5. Access to Primary Care • Increased loan repayment and funding for primary care physicians and mid-level providers practicing in shortage areas • Increased payments to rural health providers • Increased payments to primary care physicians under Medicaid

6. Health Insurance Reform • State-based/Regional Health Insurance Exchanges • Income-based premium and cost sharing (up to 400% FPL) • Separate exchanges for small businesses • Medical Loss Ratios • 80-85% of premiums must be spent on patient care

7. Improving Quality • Comparative Effectiveness Research • Patient-Centered Outcomes Research Institute (PCORI) • Demonstration Projects • Center for Medicare and Medicaid Innovation • Bundled payment pilot program • ACO development • Medical Home

8. Cost Containment • Medicare payment reform and restructuring (selected provisions) • Shared cost-savings for ACOs • Cost of care of single patient shared between all parties within ACO (clinic & hospital based physicians, ancillary staff) • Also shared losses • Value-based purchasing program • Payments linked to quality outcomes • Reduced payments for readmissions & hospital-acquired infections • Potential for bonus payments • Independent Payment Advisory Board (IPAB) • Recommendations on cost-reduction (primarily of physician services)

9. Cost Containment • Reduce Medicare and Medicaid Disproportionate Share Hospital payments • Prohibit federal Medicaid payment to states for health-care acquired conditions • Increased anti-fraud activities

10. Consumer Protections • Removal of pre-existing condition exclusions • Prohibit arbitrary rescissions of health care • No lifetime limits on coverage • Regulation of annual limits on coverage • Patient choice of provider within network • Removal of barriers to emergency care • No higher co-payments for out-of-network emergency care • Health plans must reimburse out-of-network providers rendering emergency care

11. Emergency Medicine & ACA • Essential Health Benefits Package • Primary, preventative, emergency services • Prudent Layperson • Reimbursement provided for person with average medical knowledge who presents to ED with presumed emergency • Pilot projects for trauma regionalization • Increased funding for emergency medicine and systems research

12. The ACA does a lot more… For Further Information: http://www.healthcare.gov/law/about/order/byyear.html http://www.kff.org/healthreform/8061.cfm

13. Impact of ACA on EM

14. Insurance ≠ Access • ACA does little to improve immediate physician supply or access to care • Demonstration projects (eg. medical home) only promise to improve efficiency • influx of newly-insured patients will increase demand for health resources before increases in efficiency realized • Exacerbation of projected physician shortages • Shortage of 91,500 physicians by 2020 and 130,600 by 2025 (AAMC 2008) • Crosses all specialities: -46K primary care • Fewer practices taking Medicaid (and Medicare) due to poor reimbursements, though ACA expands the number covered

15. Strain on Emergency Systems • Closure of ~27% of EDs over last 20 years, while ED visits continue to increase (Hsai 2011) • Insured patients utilize emergency services more than uninsured (NCHS 2010; Tang 2010) • Medicaid patients have highest annual rate of ED visits • Reflects difficulty in obtaining access in to primary care services in the community • Increasing number of insured under the ACA will increase demand for emergency services

16. ACOs • Current payment system focuses on individual services and providers • More services/tests, more pay • Does not amount to better quality • Attempt to incentivize higher quality, more efficient care (lower costs, higher pt satisfaction) • Rewards coordinated care based on outcomes • Income incentives apply to primary physicians only • Hospitals/specialists still reimbursed by volume • Bundled payments currently only demonstration project • Provider responsibility to improve outcomes, no patient responsibility

17. ACOs, Where is the ED? • Will emergency services be bundled with hospitals or outpatient services? • ED plays a transient role in care > outcomes depend on subsequent hospital or outpatient care • Income redistribution without control • Often difficult to coordinate care between ED and primary care practices • PCP’s not always able to be contacted • Patients often don’t f/u • Out-of-network patients

18. Medicare/Medicaid Payment • EDs often provide care at or below actual costs • low reimbursement rates • ACA increases patients covered without increase in tax revenue > likely increase in non-reimbursed care • new penalty programs (eg. hospital acquired infections, poor outcomes) • No solution for SGR

19. ACEP’s position You can find ACEP’s position statements at: http://www.acep.org/advocacy/federalissues/ (under the Health Reform heading)

20. References • Hsia, R., Kellerman, A., Shen, Y. Factors Associated With Closures of Emergency Departments in the United States Renee JAMA. 2011; 305(19): 1978-1985. • The Complexities of Physician Supply and Demand: Projections Through 2025 (PDF). 2008. AAMC • Garcia, TC., Bernstein, AB., Bush, MA. Emergency Department Visitors and Visits: Who Used the Emergency Room in 2007? NCHS Data Brief. May 2010; (38) • Tang, N. etal. Trends and Characteristics of US Emergency Department Visits, 1997-2007. JAMA. 2010 August 11; 304(6): 664–670. • Kaiser Family Foundation. Summary of New Health Reform. 2010. http://www.kff.org/healthreform/8061.cfm • Gerardi, M. The ACA-Driven ACO Movement: Implications for Emergency Medicine - EM Practice Management & Health Policy Section Newsletter, March 2011. http://www.acep.org/Content.aspx?id=77674