Kristina M. Young, MS Taught graduate courses in health care organization and health policy for students in the fields of public health, law and management for over 25 years Former Executive Director of the Western New York Public Health Alliance, Inc. President and Owner of Kristina M. Young and Associates, Inc. Former Vice President for Research and Development for a teaching hospital system and Executive Director of its health, education, and research foundation

Philip J. Kroth, MD, MS Associate Professor, the University of New Mexico School of Medicine Director of Biomedical Informatics Research, Training, and Scholarship unit at the UNM Health Sciences Library and Informatics Center Section Chief of Clinical Informatics in the UNM Department of Internal Medicine Directs a post-doctoral research fellowship in biomedical informatics and a new clinical informatics fellowship for physicians. Elected national chair of the American Medical Informatics Association Academic Forum for 2015

MACRA (2015) & ACA (2010): Separate, Complementary Laws ACA Major Features MACRA Major Features Promote value over volume-based care Expand coverage & control costs Insurance marketplaces Medicaid expansion Define baseline quality insurance Promote population health & prevention Incentivize care coordination Promote value over volume-based care: Merit-based Incentive Payment System (MIPS) Alternative Payments Models (APMs) Standardize quality reporting metrics Reauthorized CHIP through 2017 Shifts Medicare fee-for-service to APM incentive models by 2018

ACA Support & Opposition (Selected) Individual mandate 46 M+ uninsured Improves Medicare drug coverage Medicaid expansion Covers preventive care 100% Individual mandate Increases government role Too costly Increases Federal deficit No malpractice reform Employer mandate  job losses

MACRA Bipartisan Support (1) Pays for value, not volume – rewards cost savings and quality care Standardizes the quality reporting systems between existing programs Subsumes the Meaningful Use Program Physicians have two options: MIPS or APMs

MACRA Bipartisan Support (2) Repealed flawed Sustainable Growth Rate (SGR) formula for Medicare physician reimbursement with AMA & other physician groups’ support (“Doc-fix”) Republicans conceded $200 B cost offset with Medicare providers’ spending reductions & cost increases for high- earning Medicare recipients Democrats conceded 2 year (instead of 4-year) CHIP reauthorization

MACRA Selected Highlights (1) “Doc-fix” provides permanent, predictable physician Medicare reimbursement MIPS composite score reimbursement adjustments (upward, downward or none): Quality: 30% Resource Use: 30% Clinical Practice Improvement Activities: 15% Advancing care information: 25% (Formerly “Meaningful Use” Prgm) Adjustments are 2 years in arrears

MACRA Selected Highlights (2) APMs not subject to MIPS adjustments Annual lump sum payment based on 5% of previous year’s estimated aggregate expenditures according to fee schedule For individual physicians, working for APMs is easier than dealing with MIPS

ACA Executive Order (Limited to Federal Budget Taxes & Revenues) May eliminate: Individual mandate & penalty (tax) Employer mandate & tax penalty Premium tax credits & cost-sharing subsidies in marketplaces Medicaid eligibility expansion Prevention & Public Health Fund Federal revenues from, e.g. health insurers’ fees & medical device taxes

ACA Components Requiring Legislation to Change Family coverage for children up to 26 years Banning insurance denials for pre-existing conditions Changing baseline quality of insurance Reinstating annual dollar limits for covered benefits Reinstating co-pays for preventive services

ACA: Repeal, Replace, Repair? By 2018, Executive Order without changes in law may:* Destabilize insurance markets Drop 10 M people from non-employer market due to unaffordability Drop 5 M newly Medicaid insured Drop 3 M from employment-based coverage Initially increase non-employer-based premiums 20-25% with 50% increase after subsidies eliminated (Implementing changes requires significant time; requires adherence to “notice and comment rulemaking”) * Per Congressional Budget Office, January 2017 report

Teaching Resources for Instructors and Students The following provide continuous updates on the ACA and MACRA’s status with links to additional resources: ACA: http://www.khn.org http://commonwealthfund.org MACRA implementation updates: https://qpp.cms.gov/#scroll-content https://ehrintelligence.com/tag/macra http://healthaffairs.org/blog/2016/10/17/macra-final-rule-cms-strikes-a-balance- will-docs-hang-on/

Future Directions ACA: Highly interdependent economic & program components; major changes require tortuous deliberations with clarity of implications for population, industry, & market MACRA: Strong bipartisan support for continued push toward value & quality suggest survival in its substantially present form

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Thank you for participating! Sophie Teague steague@jblearning.com Recorded webinar will be posted on the LinkedIn Public Health Faculty Lounge: http://go.jblearning.com/PHLinkedIn