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Mass. healthcare reform and CHA

Mass. healthcare reform and CHA. David Bor MD Cambridge Health Alliance Harvard Medical School. Disclosures. No financial conflicts of interest

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Mass. healthcare reform and CHA

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  1. Mass. healthcare reform and CHA David Bor MD Cambridge Health Alliance Harvard Medical School

  2. Disclosures No financial conflicts of interest Doctors are the natural attorneys for the poor because within the examination room or on the wards we are forced to confront the stark and painful reality that inequality contributes to our patients' illnesses and early mortality. Rudolph Virchow

  3. Agenda • What’s new? • Our setting: • CHA: 2004-2013 • Romnicare • CHA experience with Romnicare • The future?

  4. The safety netIf you’ve seen one, you’ve seen one • Health centers and public hospitals • Serve uninsured & low income persons • Special services • trauma, burns, psychiatric care, interpreters • Special locales: • Inner-city, rural • Special roles: • train future work force • Innovators in delivery, public health • contribute to advocacy

  5. Our setting: CHA 2004-2013 • An Island of Sanity • Integrated academic healthcare system • Covenant with the Commonwealth • Free care pool & DSH funds • Romnicare • The Recession • Three World Series Championships

  6. Cambridge Health Alliance, 1996…

  7. The covenant with CHA’s communities • Develop Neighborhood Health Centers • Rescue mental health and addictions care • Rescue secondary care hospitals • Provide for special needs: • seniors, homeless, house-bound, victims of violence, immigrants, those with addictions and mental illness • Program public health functions: • , TB, HIV, School health, disaster preparedness

  8. Romnicare: Massachusetts healthcare reform • Expand access, reduce disparities through insurance: • Funding • Mandate insurance with minimal penalties • Repurpose disproportionate care funds & FCP • Share costs with beneficiaries • Cost controls - • Cost sharing • Restrain Medicaid growth • Experiment with incentives • Triage by inconvenience • Unregulated market • ACO consolidation

  9. Impact of Romnicare on CHA • Financing formula fractures safety net • It’s a revenue problem • Challenge to/of “underserved” • Health care system • Social care system • Market culture infects CHA

  10. Mass Hospital MarginsFY 2012

  11. CHA financial performancepre and post reform

  12. CHA financial performancepre and post reform

  13. Medicaid payment to cost trendsMassachusetts Hospitals 2001-2012 (CHA gets ~60% NPSR from low income public payer)

  14. Medicare payment to cost trendsMassachusetts Hospitals 2001-2012 CHA gets about 20% NPSR from Medicare c/w 29% mean

  15. Unregulated “marketplace”Relative payments by commercial insurers 2012

  16. The patient experience: • Insurance hassles: • Lapses – in and out of insurance • Tiered insurance: • Eligibility determination hassles • No retroactive coverage • Underinsurance: • More no-shows • Inability to fill scripts • Deferred care

  17. The patient experience • New health care barriers • Hospital requires payment at PCP visit • Long waits, esp. for psychiatric and SA care • Lost access to post-acute care • New social care barriers • Don’t qualify for the ride • Restricted housing assistance • Psychiatric day programs, drop in centers

  18. MD experience • Attempting to predict out-of-pocket costs • Attempting to arrange alternate care • Attempting to conform to: • Clinical speedup • Perverse financial incentives • Micromanagement • Consultants • New ethical considerations: • OK not to serve uninsured? • OK to send poor to collection?

  19. CHA going forward . . . • New compact with Commonwealth • Transition toward ACO/PCMH • Tertiary affiliation • Expand population served • National model • Population health • Advocacy • Austerity

  20. . . . Still • Best place to work, • Best place to innovate • Best setting from which to advocate • Restore DSH … fully fund Medicaid • End P4P • Restrain/regulate consolidation • Single Payer ! “Power concedes nothing without a demand. It never did and it never will”. Frederick Douglass

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