Slide 1. Slide 2. Slide 3. Washington Policy Update & the ACA. Learning Objectives

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1 Slide 1 Washington Policy Update & the ACA th Annual Symposium Missouri Group Management Association October 3 rd, 2017 Kansas City Cora Butler, JD,RN,CHC Slide 2 THE CONTENT OF THIS PRESENTATION IS INTENDED FOR EDUCATIONAL PURPOSES ONLY, NOT LEGAL ADVICE OR THE INSIGHTS OF A CRYSTAL GAZER Slide 3 Learning Objectives Discuss status of the Trump Administration and Republican Party leadership relative to healthcare policy changes as reflected in proposed or enacted legislation. Discuss current posture of the Democratic Party relative to healthcare policy changes as reflected in proposed. Identify key distinctions between the Affordable Care Act (ACA aka Obamacare) and the current proposed. Describe the likely impact of the status of the proposed legislation on key stakeholders. Recognize key strategies for future success regardless to changes in US healthcare policy and law.

2 Slide 4 Why Repeal? The Republican Rationale Slide 5 True Impact on employment: 2 million FTE will be out of work force by Congressional Budget Office Increased health care premiums by 25% in New York Times True 19.2 million taxpayers chose to pay a penalty/seek exemption rather than enroll in ACA exchange- IRS CLICK HERE True Lack of options- ⅓ of US Counties have only 1 insurer- Time.com True Individual Mandate- American taxpayers paid $3 billion for individual mandate penalties affecting 8 million people in Investor s Business Daily True ACA cost Americans over $1 trillion in taxes- Congressional Budget Office Penalty for a family- Maximum $2085- Healthcare.gov Source: QUIZ: How has Obamacare failed? (n.d.). Retrieved April 11, 2017, from Slide 6 Washington, What s going on! Glimpse of the Rollercoaster ride

3 Slide 7 Donald Trump wins the election ( ) Nov 9, 16 Noon: Trump takes the Presidential Oath of Office 2:00 pm: Trump signs the Executive Order Minimizing the Economic Burden of the PPACA Pending Repeal Jan 12, 17 Jan 20, 17 Senate voles allowing the repeal of the ACA through the budget reconciliation process; disallows a filibuster Source: Efforts to repeal the Patient Protection and Affordable Care Act. (2017, April 07). Retrieved April 11, 2017, from Slide 8 Scheduled vote for the GOP bill, later postponed to March 24,2017 Mar 6, 17 Mar 23, 17 Mar 24, 17 House Republicans publicly release The American Health Care Act Introduced the Phase One of the 3- phase plan to repeat ACA The AHCA bill was withdrawn- failure to gain sufficient House Republican support Slide 9 House Speaker Paul Ryan- still moving forward with health care with no scheduled timeline Mar 28, 17 Republicans add a new amendment to the AHCA- Federal Invisible Risk Sharing Program adding $15 billion fund to help insurers pay claims for the sickest customers Apr 4, 17 Apr 6, 17 House Speaker Paul Ryan- Proposal under conceptual stages

4 Slide 10 Apr 7, 17 Apr 24, 17 Post Spring Recess WHO (Donald Trump) picks up the healthcare policy ball and throws it to WHAT (Paul Ryan). WHAT throws it to I DON T KNOW (House Republicans) and I DON T KNOW (House Republicans) throws it to Spring Recess A bona fide triple play! Slide 11 Jul 28, 17 Skinny Repeal - Strikes Out with 49 to 51 votes Skinny Repeal/ Repeal/ Delay tactic Elimination of ACA Requirements Individual mandate and tax penalty Employer-sponsored health insurance (=>50 employees) Funding for Preventative Health Services Reimbursement for Medicaid Beneficiaries for Planned Parenthood services 1 year Plan Aimed Steer funding to Community Health Centers End 2.3% Tax on medical device manufacturers 3 years Empowered States to allocate Medicaid funding pooling with other programs Increase the limit on contributions to tax-exempt HSAs 3 years CBO stated: Skinny repeal of Obamacare would leave 16 million more people uninsured in a decade McCain cast the deciding vote based on his desire for a fully legislated bipartisan effort to repeal and replace the ACA Source: The Washington Post. Senate rejects measure to partly repeal Affordable Care Act retrieved September 18,2017, ec48ec4cae25_story.html?tid=a_inl&utm_term=.455c251ef746 Slide 12 Sep 5, 17 What s Going on in the Outfield? Senate Health, Education, Labor, and Pensions Committee Hearings Goal: Passing a modest bill to help stabilize the Obamacare health insurance markets for 2018 Then move on to broad reforms to attract more insurance companies to compete in the individual markets and potentially lowering the prices for consumers Committee Chairman Lamar Alexander said "State insurance commissioners have warned that abrupt cancellation of cost-sharing subsidies would cause premiums, copays and deductibles to increase and more insurance companies to leave the markets in 2018" "Congress now should pass balanced, bipartisan, limited legislation in September that will fund cost-sharing payments for 2018 Federal government should make it easy for the states to get waivers to implement health policies that differ from Obamacare Insurance Companies have until Sep 27 th to sign contracts offering health plans on ACA exchanges and the prices for next year President Trump has threatened to end the payments and has refused to even say whether the government will make them for the final four months of this year Source: Chastened Lawmakers Aim For Small, Bipartisan Health Care Victories retrieved September 18, 2017,

5 Slide 13 Sep 13, 17 A New Pitcher Starts Warming Up for the Opposing Team Bernie Sanders proposes a New Single Payer Health Plan Essentially its Medicare for all Every American would eventually get insurance from Medicare instead of private companies or other public programs Provision are tucked into Title X of the bill 4 year transition period from current policy to Sanders Medicare-for-all system During the transition young folks may have to access the traditional Medicare program Provision creates an option for Americans to buy access to a Medicarelike government plan, which are to be sold on the Obamacare Exchanges Parts of the bill lead to a road map for what some of the strategies might look like Elimination of Employer health insurance system ACA Exchanges Most of Medicaid Source: The New York Times. How the Bernie Sanders Plan Would Both Beef Up and Slim Down Medicare retrieved September 18, 2017, Slide 14 Sep 13, 17 A New Pitcher Starts Warming Up for the Opposing Team Source: The New York Times. One-Third of Democratic Senators Support Bernie Sanders s Single-Payer Plan Slide 15 Sep 18, 17 Squeeze Play - The Graham-Cassidy-Heller-Johnson Bill 17 days left to accomplish something Budget Reconciliation Process Senators Graham, Cassidy, Heller, and Johnson introduce bill Bill leaves policies of ACA in place Quality, Value, Compliance Focuses on the insurance components Shifting to block grants Insurance regulation up to the discretion of each State Bill puts a ban on insurer s refusing to cover pre-existing conditions Larry Levitt, senior vice president of the Kaiser Family Foundation Over time, it s less federal money than is being spent now on health care, but it s still a huge pot of money available to states with very few strings attached If this bill passed, it would get Congress off the hot seat of figuring out how to deal with health care but unleash 50 debates in state capitals around the country Source: The Washington Post. GOP tries one more time to undo ACA with bill offering huge block grants to states retrieved September 18, 2017,

6 Slide 16 Sep 18, 17 Trump s late-night tweet Slide 17 Sep 25, 17 Graham-Cassidy Bill Hearing Senate Finance Committee s hearing was on the updated version of the bill The changes to the bill were said to be just correcting drafting errors by Graham, who also suggested it s OK to vote. It s OK to fall short, if you do, for an idea you believe in Cassidy on the other hand suggested that lawmakers would not makes any changes to the bill The changes in the language of the bill left lawmakers and healthcare experts uncertain No cuts to Medicaid. Save our liberty! was chanted by the protesters during the hearing, which was adjourned to escort protesters out CBO s preliminary score suggests Medicaid spending would fall by about $1 trillion from 2017 to 2026, compared with current law Millions would be left without comprehensive health coverage due to the ACA individual mandate and cuts to Medicaid funding and subsidies for private coverage Standard & Poor's Global Ratings suggests Reduction in coverage levels, particularly for those between 133 percent and 400 percent of the federal poverty line The economy would face a $240 billion loss by 2027 and that 580,000 jobs could be affected Source: The Advisory Board. GOP abandons planned vote on Graham-Cassidy. (2017, September 26). Retrieved from briefing/2017/09/26/graham-cassidy-projections? WT.mc_id= %7CDailyBriefing%2BHeadline%7CDBA%7CDB%7C2017Sep26%7CATestDB2017Sep26%7C%7C%7C%7C&elq_cid= &x_id=003C R VwpIAG Slide 18 Sep 26, 17 The Vote on Graham-Cassidy Bill Abandoned A decision not to hold a vote on the revised bill to repeal and replace large portions of the ACA and overhaul Medicaid was made Most significant development Sen. Collins joined with Sen. John McCain in opposing the bill Collins said, the both the versions of the bill will open the door for states to weaken protections for people with pre-existing conditions, such as asthma, cancer, heart disease, arthritis, and diabetes McCain appeared to be a hard no and disagrees with the process being used to pass an ACA repeal bill September 30 th Hard ACA repeal deadline is past Source: The Advisory Board. GOP abandons planned vote on Graham-Cassidy. (2017, September 26). Retrieved from briefing/2017/09/26/graham-cassidy-projections? WT.mc_id= %7CDailyBriefing%2BHeadline%7CDBA%7CDB%7C2017Sep26%7CATestDB2017Sep26%7C%7C%7C%7C&elq_cid= &x_id=003C R VwpIAG

7 Slide 19 Sep 27, 17 ACA Repeal come back next month? The FY 2017 budget reconciliation process which would allow the GOP to pass the ACA repeal with a filibuster-proof majority, runs out on September 30 th Senate Republicans variety of ways to keep the option of 50- vote ACA repeal after September 30th: Could later pass a new, revised budget resolution for FY2018 Could pursue less sweeping (but still impactful) ACA changes that might not require reconciliation instructions for all four committees Could employ the so-called "nuclear option" and overrule the parliamentarian to forge ahead with 50-vote repeal Could include a provision in the FY2018 budget resolution "extending the 'life' of the current ACA repeal effort Bottom line, GOP still has an option of doing the health reform, tax reform or both after September 30 th, just has to pass the FY2018 budget resolution which cannot be filibustered Slide 20 Sep 28, 17 Unanimous Approval on a Health Bill The bill was initially introduced in April by the Senate Finance Committee s Chronic Care Working Group, but failed to gain traction Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act wants to reduce costs and improve the Medicare payments for care The new bill implements Medicare payment policies Expansion of Medicare Advantage plans Expansion of ACO coverage Provision for telehealth services home dialysis and stroke assessments Extend by two years the demonstration period for CMS' Independence at Home program Increase the number of allowable Medicare beneficiaries in the program from 10,000 to 15,000 Permanently extend the MA Special Needs program for beneficiaries who are chronically ill Medicare reimbursements for additional non-health and social services, such as meal deliveries and transportation to doctors' appointments CBO projected that this bill would Generate $80 million in savings And help offset the measure s cost Bill heads to the House, where its unlikely to be pass Several provisions of the bill have been proposed HR 3727, which would expand telemedicine under MA HR 1148, which includes the CHRONIC Care Act's tele-stroke provisions HR 3178, which includes the CHRONIC Care Act's kidney dialysis provisions Senate Finance Committee Chair Orrin Hatch (R-Utah) in a statement said, "This legislation will improve disease management, lower Medicare costs and streamline care coordination services all without adding to the deficit Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) on the day of the bill's passage said, "Today is a big day in the ongoing effort to update and strengthen Medicare's guarantee to seniors Source: The Advisor Board. ACA repeal is dead for this month. Here's why it could come back next month or next year. (n.d.). Retrieved from 203&x_id=003C RVwpIAG Source: The Advisory Board. The Senate unanimously approved a health bill yesterday. (No, not that health bill.). (2017, September 28). Retrieved from RVwpIAG Slide 21 #RepealAndReplace The American Health Care Act

8 AIMS APPROACH Slide 22 Dismantle the Obamacare taxes Eliminate the individual and employer mandate penalties Prohibit health insurers from denying coverage/charging more money Help young adults access health insurance and stabilize market placeallow coverage until age 26 Modernize and strengthen Medicaid- Transition to per capita allotment Establish a Patient and State Stability Fund- provide states with $100 billion to design programs that meet their unique population Empower individuals and familiesenhance and expand Health Savings Accounts Help access affordable, quality health care- providing a monthly tax credit between $2000 and $14,000 Step I- RECONCILIATION The American Health Care Act: Introduction of the Bill, Consideration by the House, Pass legislation through regular order Step II- ADMINISTRATIVE ACTION HHS Secretary????? may deregulate the marketplace to stabilize it, increase choices and lower costs Step III- ADDITIONAL LEGISLATION Pass conservative-minded bills to allow shopping across state lines, medical liability reform, and more. Source: Pass the American Health Care Act. (n.d.). Retrieved April 11, 2017, from Slide 23 ACA vs Proposed Bills Differences & Similarities ACA Medicare for All Paul-Stanford Bill Slide 24 Individual mandate No Individual or Employer No Individual or Employer Insurance Mandates Employer mandate on larger companies Mandate Mandate. Paul advocates Associations/Cooperatives offering group health options across state lines. Financial Supports Income-based subsidies for premiums that Not applicable No subsidies, but more (subsidies) for limit after-subsidy cost to a percent of affordable benefit plan income. Tax credits for out-of-pocket options. insurance consumers expenses Medicaid Matching federal funds to states for anyone Medicaid expansion not Paul supports the idea of who qualifies Expanded eligibility to 138% of applicable state-by-state Medicaid poverty level income waivers Health Savings Accounts Essential Health Benefits Individuals can put $3,400 and families can put $6,750 into a tax-free health savings account Insurers are required to offer ten essential health benefits HSAs not applicable Expand HSAs There would be a essential Eliminated minimum health benefits package similar standards to leave more to what Medicare offers, for all flexibility around benefit plan design for affordability Pre- existing conditions Dependents staying on plan Risk sharing Insurers are banned from denying coverage Not applicable for pre-existing conditions Dependents can stay on health insurance plan Not applicable until age 26 Federal risk sharing program Protects them if they have continuous coverage for 2 years

9 Slide 25 Remarks: Republican Leaders Slide 26 Remarks: Democratic Leaders Slide 27 Reactions: Primary Care Physicians

10 Slide 28 It is not addressing tort reform, cost of medications or payments to PCPs Raju Patnam MD, Family Medicine, Greenville SC We need to go single payer or we need the individual mandate that would have made the ACA easily able to stand on its own two feet without skyrocketing premiums from some people. Vikki Stefans MD, Pediatrics, Little Rock AK Trump-Ryan care is quite a step backward If there is any value to Trump-Ryan care it will be that in its crashing we may see the country move to single payer, national healthcare. Scott Helmers, MD, Family Medicine, Spirit Lake IA Providers who took in many Medicaid patients under the ACA will be left with deciding to continue caring at a big discount or dumping them and then having many empty patient slots. Jeffrey Kagan, MD, Internal Medicine, Newington CT This is my simple request: whatever the reconstructionist design, they have the same healthcare policy options, and pay the same premiums as the rest of us, with no exceptions for the wealthy or the elected. Sue Osborne, DO, Family Medicine, Floyd VA Source: Martin, K. L. (2017, March 16). Primary care physicians react to AHCA. Retrieved April 11, 2017, from Slide 29 Road Ahead Slide 30 What seems certain?

11 Slide 31 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Strong bipartisan support Delay would be tied to budgetary implications Bending the Medicare cost curve is not a partisan issue Move from FFS to value- based care I believe all options should be on the table to ensure MACRA is implemented in a way that benefits patients and keeps providers particularly those in small practices in the Medicare program. US Rep. Phil Roe, MD, (R-Tennessee) April 10, 2017 Source: Your questions about the MACRA final rule answered. (n.d.). Retrieved April 11, 2017, from Slide 32 MACRA: Tracks & Scores Source: Medisolv, Inc. Follow. (2016, September 16). The Basics of MACRA and 2017 Reporting Options [SLIDESHOW]. Retrieved April 11, 2017, from Slide 33 MACRA: Reporting Timeline Performance: The first performance period opens January 1, 2017 and closes December 31, During 2017, record quality data and how you used technology to support your practice. Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, In order to earn the 5% incentive payment by significantly participating in an Advanced APM, just send quality data through your Advanced APM. Feedback: Medicare gives you feedback about your performance after you send your data. Payment: You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, If you participate in an Advanced APM in 2017, then you may earn a 5% incentive payment in 2019.

12 Slide 34 MACRA: Payment Adjustments Source: E. (2016, May 18). How MIPS, APMs Work Under MACRA to Improve Value-Based Care. Retrieved April 20, 2017, from Slide 35 MACRA: When to start? Expected outcomes? Anytime between January 1 and October 2, Whenever you choose to start, you'll need to send in your performance data by March 31, You can also begin participating in an Advanced APM. The first payment adjustments based on performance go into effect on January 1, Not participating in the Quality Payment Program: If you don t send in any 2017 data, then you receive a negative 4% payment adjustment in On choosing the MIPS path, you have three options. Test: If you submit a minimum amount of 2017 data to Medicare (for example, one quality measure or one improvement activity for any point in 2017), you can avoid a downward payment adjustment. Partial: If you submit 90 days of 2017 data to Medicare, you may earn a neutral or positive payment adjustment. Full: If you submit a full year of 2017 data to Medicare, you may earn a positive payment adjustment. Source: MACRA. (n.d.). Retrieved April 20, 2017, from Slide 36 Key Strategies How can I succeed, no matter what changes!

13 Slide 37 Adapt to New Market Realities Reduce cost structure Establish a consumer loyalty platform Establish sustainable Medicare risk strategy Elevate Physician network performance NOTE: The success of these four elements depend heavily on an appropriate and scalable Health IT platform Source: Webinar: What you need to know about the Post-AHCA. (n.d.). Retrieved April 11, 2017, from Slide 38 Your data is your best friend! Raw Data Clinical systems Billing/Claims Patient generated (e.g., wearables, portals) External data (e.g. social, financial) BI Capabilities Data acquisition, aggregation Coherent architecture Governance Tools, staff skills Culture, organizational data literacy Goal Optimization Clinical outcomes Patient experience Referral performance Financial efficiency Regulatory metrics Market share Cut down administrative costs Clinical Decision Support (Evidence based) Better Care Coordination Improved patient wellness Performance based referrals Eliminate Fraud and Abuse Risk Source: Top Ten Health IT Challenges for (n.d.). Retrieved April 11, 2017, from Slide 39 Success Story: Business Intelligence Who NorthShore University Health System Why Identify patients at risk for hypertension and control risk of health attack and stroke How Through a BI tool which: Linked practicing physicians with research and quality improvement- eliminate undiagnosed/at risk hypertension patients Flagged patients for additional follow up through algorithms Results Identified, tested and diagnosed more than 500 patients with previously undiagnosed hypertension Source: The Impact of Business Intelligence on Healthcare Delivery in the USA. (n.d.). Retrieved October 10,

14 Slide 40 Quality Assurance & Performance Improvement Define goals for yourself and your practice Collect performance standards relevant to the goals Perform a gap analysis between the existing performance with the goals/ benchmark with competitors Use basic lean six sigma principles, root cause analysis, and other similar methods to identify and reduce variation Establish a continuous quality assurance and performance improvement program to foster high quality in all areas of care and services Slide 41 Sample PI Tool: Readmissions Performance Tracking Slide 42 Success Story: Performance Improvement Who What Washington University Physicians at Barnes Percutaneous Intervention - Improving outcomes How Tailoring the following to patient needs: Equipment Access- Brachial vs Femoral Dosage of Contrast Media Anti-coagulant type- Bivalrudin vs Heparin ($547 vs <$ ) Results Impact seen on: Patient Safety & Outcomes Costs Readmissions Source: Sheikh IR, Ahmed S, Mori N, et al. Comparison of Safety and Efficacy of Bivalirudin Versus Unfractionated Heparin in Percutaneous Peripheral Intervention: A Single-Center Experience. J Am Coll Cardiol Intv.2009;2(9): doi: /j.jcin

15 Slide 43 Key Takeaways Do not wait for the legislative changes Focus of your strategy should be on accessibility, affordability and reliability Value based payment is here to stay! Plan NOW to win tomorrow Source: Webinar: What you need to know about the Post-AHCA. (n.d.). Retrieved April 11, 2017, from Slide 44 References QUIZ: How has Obamacare failed? (n.d.). Retrieved April 11, 2017, from Efforts to repeal the Patient Protection and Affordable Care Act. (2017, April 07). Retrieved April 11, 2017, from Bryan, B. (2017, March 29). House Republicans might take another swing at repealing Obamacare. Retrieved April 11, 2017, from Pass the American Health Care Act. (n.d.). Retrieved April 11, 2017, from American Health Care Act of (2017, April 07). Retrieved April 11, 2017, from American Health Care Act. (2017, March 23). Retrieved April 11, 2017, from Dinan, S. (2017, March 09). Ryan works to save GOP s Obamacare repeal. Retrieved April 11, 2017, from Geraghty, J. (2017, March 17). Tom Price: The Benchmark for Success Is Care, Not Coverage. Retrieved April 11, 2017, from Remarks by President Trump and Administrator Seema Verma in Women in Healthcare Panel Meeting. (2017, March 22). Retrieved April 11, 2017, from Slide 45 References DeBonis, M. (2017, March 27). Paul Ryan: House Republicans will continue their push for health-care reform this year. Retrieved April 11, 2017, from house-republicans-will-continue-their-push-for-health-care-reform-this-year/2017/03/27/8e331e86-130c- 11e7-833c-503e1f6394c9_story.html?utm_term=.8af16aabf415 Weigel, D. (2017, March 14). Sanders and Manchin, at opposite ends of Senate caucus, call ACA replacement immoral. Retrieved April 11, 2017, from Account, N. P. (2017, March 06). The GOP plan to #MakeAmericaSickAgain will do massive damage to millions. Retrieved April 11, 2017, from Carney, J. (2017, February 27). Schumer blasts leaked GOP ObamaCare repeal bill. Retrieved April 11, 2017, from Martin, K. L. (2017, March 16). Primary care physicians react to AHCA. Retrieved April 11, 2017, from Hansler, J. (n.d.). Democrats react to collapse of GOP health care bill: 'So much for "The Art of the Deal"' Retrieved April 11, 2017, from Lima, C., Pollack, H., Glasser, S. B., & Grunwald, M. (n.d.). Sanders: Public outcry helped derail GOP health care bill. Retrieved April 11, 2017, from

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