Intro to Health Policy Basics Jamie Dhaliwal, MD MPH EMRA Legislative Advisor @DenverDhali

Goals Define legislative and regulatory advocacy Understand the components of the SGR fix Understand the basics of King vs Burwell

The act or process of supporting a cause or proposal What is advocacy? The act or process of supporting a cause or proposal We typically think of legislative or grassroots advocacy when we think of this word.

How do we advocate? Legislative Advocacy Regulatory Advocacy Convince elected legislators to write, support and vote Target efforts in context of committee system and rules Regulatory Advocacy Regulations = How a bill gets put into practice Same opportunities for influence exist Example = Bill that is enacted into law in your state that says “You get a $5 tax refund for good behavior over the last year”. News story “Bill rewarding good behavior passed into law”. You think, oh cool, we’re rewarding good behavior. Whats unseen is that the bill also states that a committee will be formed that decides what good behavior is. Regulatory advocacy would come into play after the bills passage as different groups convince committee members to adopt a definition of good behavior they thought was best. We are now going to discuss two major issues, the SGR repeal and King vs Burwell. As we go through the bills, I want you to think about past and future opportunities for legislative and regulatory advocacy.

SGR repeal Medicare and CHIP Reauthorization Act (MACRA) Quick survey. Raise your hand if you know what SGR stands for. Keep it up if: You’ve seen the SGR equation You understand how the SGR worked Medicare and CHIP Reauthorization Act (MACRA)

SGR Basics Sustainable Growth Rate Balanced Budget Act of 1997 Tied aggregate Medicare spending to GDP growth 2002 – Physician reimbursement was threatened with large cuts Cost of permanent fix led to 17 short-term fixes To understand why MACRA is so important, lets review some basics of the SGR. 5 fixes in 2010 alone END WITH: How did this actually work?

Onward into the Weeds of Billing! Resource-based Relative Value Scale (RBRVS) Current Procedural Terminology (CPT) Relative Value Units (RVU) Geographic Pricing Cost Index (GPCI or “gypsy”) Medicare Correction Factor (CF) I’m gonna venture into the weeds a little bit and talk about billing – because understanding how the SGR works requires some basic knowledge of billing.

Billing Simplified….kind of Chart +ICD-9 CPT Code RVUs x Correction Factor Billable Amount 2015 Medicare Correction Factor With SGR = $28.22 After repeal = $35.74 SGR

Where did MACRA take us? SGR replaced with +0.5% 2015-2019, 0.0% for 2020-2025 Replaces PQRS, VBM and EHR MU with MIPS CHIP funding extended 2 years (9/30/17) Delayed phase-out of DSH payments by 1 year (20172018) Premium increase for wealthier Medicare beneficiaries Incentive for APMs - 5% increase if 25% of patients by 2019 Where did we go with MACRA? This bill was passed into law on April 16th, 2015 Medicare and CHIP Reauthorization Act APM = alternative payment model

Merit-based Incentive Payment System (MIPS) Replaces: Physician Quality Reporting System (PQRS) Value Based Modifier (VBM) Electronic Health Record Meaningful Use (EHR MU) Goal is to reward value instead of volume Shift from Medicare fee-for-service to value-based and APMs Performance in 4 Categories (1) Quality, (2) Resource Use, (3) Meaningful Use, (4) Clinical Practice Improvement Activities Composite score determines incentive/adjustment

MIPS Incentives Base PQRS VBM MIPS ‘15 ‘16 ‘17 ‘18 ‘19 ‘20 ‘21 ‘22 ‘23 ‘24 ‘25 ‘26+ Base 0.5% increase per year No base increase 0.25% PQRS -2% per year VBM -2% -4% MIPS +/- 4% +/- 5% +/- 7% +/- 9% NQS (National Quality Strategy Domains) – must report 9 measures across 3 domains including 1 cross-cutting domain for 50% of medicare Part B patients 1. Person and Caregiver-Centered Experience         2. Patient Safety         3. Communication and Care Coordination         4. Community and Population health         5. Efficiency and Cost Reduction         6. Effective Clinical Care What are the quality metrics?......to be determined

Opportunities for Advocacy Legislative CHIP Reauthorization in 2017 DSH phase-out (particularly in states without Medicaid expansion) Regulatory MIPS metrics Role of EM in Alternative Payment Models (eg ACOs, PCMH, etc) CPT codes, RVU assignment

King v burwell

King v Burwell Tax benefits (e.g. subsidies) should be granted for such individuals who purchase their insurance in exchanges “established by the State.” 

King v Burwell Not a constitutional question. Question of statutory interpretation. Does the language in the bill limit subsidies to states with state-run exchanges? SCOTUS must determine intent of writers Will not change Medicaid expansion. The medicaid ship has sailed. Transition: so what is at risk here? In the ACA there are 2 types of subsidies.

Review the ACA and “the sit(uation)” Individual mandate Expanded Medicaid to adults <65 and <133% of FPL ($15,521 in 2015) 2012: Nat’l Fed Independent Businesses v Sebelius Establish insurance exchanges to serve as insurance marketplace to individuals and families State-based, Federally-supported State-based, State partnership, Federally-facilitated Create premium and cost-sharing subsidies for people at 100%-400% of FPL ($11,343 - $45,372) Exemptions to individual mandate: financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples). State-based Marketplace: States running a State-based Marketplace are responsible for performing all Marketplace functions. Consumers in these states apply for and enroll in coverage through Marketplace websites established and maintained by the states. Federally-supported State-based Marketplace: States with this type of Marketplace are considered to have a State-based Marketplace, and are responsible for performing all Marketplace functions, except that the state will rely on the Federally-facilitated Marketplace IT platform. Consumers in these states apply for and enroll in coverage through heatlhcare.gov. State-Partnership Marketplace States entering into a Partnership Marketplace may administer in-person consumer assistance functions and HHS will perform the remaining Marketplace functions. Consumers in states with a Partnership Marketplace apply for and enroll in coverage through healthcare.gov. Federally-facilitated Marketplace: In a Federally-facilitated Marketplace, HHS performs all Marketplace functions. Consumers in states with a Federally-facilitated Marketplace apply for and enroll in coverage through healthcare.gov.

Subsidies for Exchange Plans Premium Tax Credit Cost-sharing Tax Credit

Premium Subsidies Sets cap on premiums as percentage of income Eligible if 100%-400% of FPL % of FPL Individual Family of 4 Premium Cap < 100% < $11,670 $23,850 No Cap 100-133% $11,670 – $15,521 $23,850 – $31,721 2.01% 133-150% $15,521 – $17,505 $31,721 – $35,775 3.02% – 4.02% 150-200% $17,505 – $23,340 $35,775 – $47,700 4.02% – 6.34% 200-250% $23,340 – $29,175 $47,700 – $59,625 6.34% – 8.1% 250-300% $29,175 – $35,010 $59,625 – $71,550 8.1% – 9.56% 300-400% $35,010 – $46,680 $71,550 – $95,400 9.56% In states that expanded Medicaid, subsidies are available for people 133-400% of FPL. In states without Medicaid expansion, subsidies are available for people 100-400% of FPL. In some states without Medicaid expansion and with Medicaid eligibility criteria below 100% FPL there are people who are too wealthy to get Medicaid but too poor to get subsidies --- Kaiser Fam Foundation estimates that 4.5 Million people fall into this category.

Cost-Sharing Subsidies Enrollees in Silver plans from 100%-250% of FPL Maximum out-of-pocket expense $6,600/$13,200 % of FPL Individual/Family of 4 Premium Cap OOP Max Indiv/Fam < 100% < $11,670 < $23,850 No Cap $6,600 / $13,200 100-150% $11,670 – 17,505 $23,850 – $35,775 $245 - $703 $479 - $1,438 $2,250 / $4,500 150-200% $17,505 – $23,340 $35,775 – $47,700 $703 - $1,480 $1,438 - $3,024 200-250% $23,340 – $29,175 $47,700 – $59,625 $1,479 - $2,363 $3,024 - $4,829 $5,200 / $10,400 250-400% $29,175 - $46,680 $59,625 - $95,400 $2,363 - $4,462 $4,829 – $9,120 Out of pocket costs

Medicaid Expansion States

Medicaid Eligibility = no MCD expansion X’s on states that didn’t expand medicaid and have eligibility criteria less than 100% FPL. The writers of the ACA stipulate that subsidies are available for people 100%-400% of FPL – there was an assumption that people below 100% of FPL would be enrolled in Medicaid. Because Medicaid expansion is now voluntary, you have 4.5 million people in the states with x’s that are “too poor” for subsidies but not poor enough to qualify for medicaid. AK, TN, WI, ME are states that didn’t expand medicaid but have eligibility >100% FPL = no MCD expansion

Exchanges = no MCD expansion 27 14 3 7 State-based Marketplace: States running a State-based Marketplace are responsible for performing all Marketplace functions. Consumers in these states apply for and enroll in coverage through Marketplace websites established and maintained by the states. Federally-supported State-based Marketplace: States with this type of Marketplace are considered to have a State-based Marketplace, and are responsible for performing all Marketplace functions, except that the state will rely on the Federally-facilitated Marketplace IT platform. Consumers in these states apply for and enroll in coverage through heatlhcare.gov. State-Partnership Marketplace States entering into a Partnership Marketplace may administer in-person consumer assistance functions and HHS will perform the remaining Marketplace functions. Consumers in states with a Partnership Marketplace apply for and enroll in coverage through healthcare.gov. Federally-facilitated Marketplace: In a Federally-facilitated Marketplace, HHS performs all Marketplace functions. Consumers in states with a Federally-facilitated Marketplace apply for and enroll in coverage through healthcare.gov. = no MCD expansion 27 14 3 7

Check Out North Carolina

If King is Victorious… - Loss of affordability - Loss of individual mandate - Insurance death spiral - Two-tiered system If King is Victorious… State-based Marketplace: States running a State-based Marketplace are responsible for performing all Marketplace functions. Consumers in these states apply for and enroll in coverage through Marketplace websites established and maintained by the states. Federally-supported State-based Marketplace: States with this type of Marketplace are considered to have a State-based Marketplace, and are responsible for performing all Marketplace functions, except that the state will rely on the Federally-facilitated Marketplace IT platform. Consumers in these states apply for and enroll in coverage through heatlhcare.gov. State-Partnership Marketplace States entering into a Partnership Marketplace may administer in-person consumer assistance functions and HHS will perform the remaining Marketplace functions. Consumers in states with a Partnership Marketplace apply for and enroll in coverage through healthcare.gov. Federally-facilitated Marketplace: In a Federally-facilitated Marketplace, HHS performs all Marketplace functions. Consumers in states with a Federally-facilitated Marketplace apply for and enroll in coverage through healthcare.gov. = no MCD expansion 27 14 3 7

Opportunities for Advocacy Legislative Lobby governors/legislators to establish state-run exchange Expand Medicaid to 138% of FPL (federal funding) Alternative short-term fix for EMTALA-related care?

Summary (in word salad format) SGR is gone MACRA is here MIPS is replacing PQRS, VBM and EHR MU King v Burwell is important for exchange subsidies If King wins:

What can you do? Learn at LAC Join the ACEP 911 Network at www.acepadvocacy.org Get involved with your state ACEP chapter Donate to NEMPAC Give-a-shift $120 for residents Join EMRA Health Policy Committee Follow the HPC on twitter at @EMadvocacy #EMRAadvocacy

Thank You! legislativeadvisor@emra.org Twitter: @DenverDhali