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

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

3. 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.

4. 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.

5. 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)

6. 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?

7. 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.

8. 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

9. Where did MACRA take us?
SGR replaced with +0.5% , 0.0% for
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

10. 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

11. 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

12. 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

13. King v burwell

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

15. 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.

16. 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.

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

18. 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 %
$11,670 – $15,521
$23,850 – $31,721
2.01% %
$15,521 – $17,505
$31,721 – $35,775
3.02% – 4.02% %
$17,505 – $23,340
$35,775 – $47,700
4.02% – 6.34% %
$23,340 – $29,175
$47,700 – $59,625
6.34% – 8.1% %
$29,175 – $35,010
$59,625 – $71,550
8.1% – 9.56% %
$35,010 – $46,680
$71,550 – $95,400
9.56%
In states that expanded Medicaid, subsidies are available for people % of FPL. In states without Medicaid expansion, subsidies are available for people % 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.

19. 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 %
$11,670 – 17,505
$23,850 – $35,775
$245 - $703
$479 - $1,438
$2,250 / $4,500 %
$17,505 – $23,340
$35,775 – $47,700
$703 - $1,480
$1,438 - $3,024 %
$23,340 – $29,175
$47,700 – $59,625
$1,479 - $2,363
$3,024 - $4,829
$5,200 / $10,400 %
$29,175 - $46,680
$59,625 - $95,400
$2,363 - $4,462
$4,829 – $9,120
Out of pocket costs

20. Medicaid Expansion States

21. 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

22. 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

23. Check Out North Carolina

24. 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

25. 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?

26. 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:

27. What can you do? Learn at LAC
Join the ACEP 911 Network at
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 #EMRAadvocacy

28. Thank You!