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The ACA’s Impact on Patient Populations

From volume to value-based care By Elizabeth Sidney

Welcoming the new era of population health management, which aims to bend the cost curve by shifting care away from fee-for-service, experts at a Chicago Medical Society symposium explained how their institutions are implementing the Affordable Care Act (ACA) on the public health frontlines. For safety net hospitals and federally qualified health centers, the ACA, while providing new financial lifeblood, also creates fresh challenges. For Blue Cross and Blue Shield of Illinois, the ACA opens up a new frontier, as the insurer expands into government programs and population health management.

Event moderator Peter Orris, MD, MPH, said he could safely predict one thing: some aspects of the law will fail and others will succeed. Dr. Orris is professor and chief of occupational and environmental medicine at the University of Illinois Hospital and Health Sciences System. His district co-hosted the event with the CMS Student Section on Feb. 8, at Rush University Medical Center.

Navigating the Marketplace

Illinois is among the states that rely on the federal health exchange for ACA-related coverage. And no insurer is closer than Blue Cross Blue Shield of Illinois (BCBSIL) to the fulcrum of activity in implementing the law, Dr. Orris said. As the national benchmark, the BlueAdvantage Entrepreneur small group PPO provides a baseline for services, covering 10 essential categories of care.

Opella Ernest, MD, chief medical officer for BCBSIL, gave highlights:

  • BCBSIL is one of six insurers participating on Illinois’ two public health exchanges, one serving individuals and the other employers with fewer than 50 workers.
  • The Small Business Health Options Program (SHOP) allows companies to define how much they want to contribute to their workers’ coverage.
  • Within each metallic plan level (platinum, gold, silver,
    and bronze), BCBSIL offers several tiers of coverage, with
    the exception of the platinum plan. There is only one
    platinum plan.
  • PPO gold plans are the most popular among individuals, followed by silver plans. Most individual and family plans are PPOs. Individuals can choose between a large and small PPO.
  • A short-term individual PPO health plan offers basic protection for those who are temporarily uninsured.
  • Under a three-year demonstration project, BCBSIL is contracted with the Centers for Medicare and Medicaid Services and state of Illinois to improve care for dual-eligibles. The program combines Medicare and Medicaid funding under a blended payment agreement.
  • BCBSIL will test population health innovations initially on dual-eligible and uninsured populations. As they are implemented, the innovations will be scaled to larger populations, including people covered by employer policies, Medicare, and commercial insurance.

[Update: At the end of February, more than 113,733 Illinoisans had enrolled in the exchange marketplace, a 28% increase over the previous month. This total included 28,000 people between ages 18 and 34, who are crucial to balancing out the market.]

Safety Net Hospitals

The ACA’s brave new world of Medicaid insurance is good for patients, the institutions that treat them and the state’s bottom line, panelist John Jay Shannon, MD, interim CEO of the Cook County Health and Hospitals System, said. (Dr. Shannon replaced Ramanthan Raju, MD, who returned to New York this year.)

County was able to jumpstart enrollment after obtaining a federal waiver to early enroll 115,000 uninsured adults before 2014. The federal Medicaid expansion pays the full cost for three to four years, and then slowly tapers off.

The funding flow reimburses County for patients already being cared for, while allowing the system to invest in the future. County is now able to hire more staff, modernize its technology, and concentrate on improving the patient experience.

CountyCare, the managed care program for adults, provides a medical home within a network of primary care providers, and access to comprehensive services. At least half of patients enrolled in CountyCare range in age from 50 to 64. They are among the most challenging and complex cases to manage, Dr. Shannon noted.

More than 200,000 had enrolled in the Medicaid expansion by late February. Officials predict another 100,000 before the end of 2014. The state has set a goal of moving half of Illinois’ Medicaid population into managed care by 2015. This intersection of Medicaid with managed care is new and confusing to patients, Dr. Shannon said.

Ironically, there is “some anxiety” at County because the newly insured will have the ability, eventually, to opt-out of CountyCare and go to other managed Medicaid programs, Dr. Shannon said. “However, this will force the system to become more patient-focused,” he continued. To offset the loss, County plans to begin accepting all types of insurance.

“County is evolving into a more complex organization, with layered strategic thinking on top of separate, distinct systems,” Dr. Shannon concluded. He foresees the increasing use of scaling and predictive modeling to identify people at higher risk of returning to the hospital, and applying this data across populations.

Community Care Clinics

Laboring on the frontlines, federally qualified health centers (FQHCs) are crucial to the implementation of the ACA. Chicago’s Access Community Health Network is one of many FQHCs enrolling the uninsured into Medicaid and other ACA-enabled health plans, panelist Tariq Butt, MD, said. Often these community organizations help those who are least able to navigate the system.

Dr. Butt is vice president of medical affairs and a founding member of Access.

Because FQHCs have extensive experience managing care for minorities, the poor, and the uninsured, population health isn’t a new concept for them, Dr. Butt said. FQHCs are used to high volumes of patients with chronic conditions, and Access links them to specialists within a large network. The organization has partnerships with local community hospitals and large academic centers.

Population-based medicine extends into every area of the patient’s life. Access helps resolve non-medical problems, such as writing a letter to get a patient’s electricity turned back on, Dr. Butt noted. “You have to know the details of your patients’ personal lives, which are socioeconomic in addition to medical,” Dr. Butt said. The job of obtaining this information falls mostly on care coordinators.

Even under the ACA, many people will not qualify for Medicaid or for the exchange plans. This group includes undocumented immigrants. Access will continue treating patients who lack coverage while absorbing many newly insured. To date, the network has assessed more than 45,000 uninsured patients for new health coverage opportunities.​

The ACA provides funding for the construction of new health centers, as well as the hiring of patient navigators to enroll people in health plans. Yet as well poised as FQHCs are to succeed under health reform, they face some challenges. For instance, FQHCs need to develop arrangements with health plans that participate in Medicaid and state exchanges. Other hurdles include clinical collaboration, analyzing patient data and connectivity issues.

To physicians who might shy away from working in a FQHC, Dr. Butt assures them that Access protects its doctors against lawsuits. “If a case ends up in federal court, it’s very hard to see the physician personally because they are never named in a lawsuit,” Dr. Butt explains. Malpractice insurance is covered under the Federal Tort Claims Act. “The FQHC sustains us,” he concluded.

Ongoing Concerns

Despite its promise, the long-term sustainability of the ACA model remains unclear. For patients, there is a steep learning curve and the early implementation was plagued by snafus and delays, panelist William A. McDade, MD, reported.

Dr. McDade is president-elect of the Illinois State Medical Society (ISMS), and an associate professor of anesthesiology and critical care at the University of Chicago. He is also deputy provost for research and minority affairs at the U of C, and a past president of the Chicago Medical Society.

Physicians should help their patients understand their new exchange policies since many of the newly insured won’t be familiar with the rules of insurance, Dr. McDade said. He cautioned his colleagues to expect more administrative hassles with confirming enrollments, calculating co-pays and deductibles.

Physician-members in independent practice have expressed various concerns to ISMS, which include:

Medicaid application bottlenecks in the federal enrollment system have led to processing delays. The state then indicated that affected patients would be covered retroactively for 90 days. As a result, medical offices have the burden of determining patient eligibility for care.

Patient sticker shock at the high deductibles and lack of education about the exchange plans.

Delayed premium payment deadlines. Under the three-month grace period, plans pay claims in the first month, but can hold claims submitted in months two and three, at which point the patient must either pay the physician directly for services, or else pay the premium.

Confusion over services provided incidental to preventive procedures, such as colonoscopy. Patients have received bills for medical supplies, anesthesia and facility fees, when they expected these procedures to be fully covered. Preventive care is supposed to be 100% covered, with no co-pays or deductibles.

Both patients and physicians find the narrow provider networks in some of the new plans to be quite troublesome.

Many experts consider the enrollment numbers to date as too low to sustain insurance company interest in offering exchange plans in the future.

The credit-rating agency Moody’s downgraded its 2014 outlook for health insurers based on the “unstable environment and the uncertainty over enrollment demographics.”

CMS and ISMS are working to reduce the physician’s burden of verifying enrollment for new ACA patients, and to provide access to information to help patients better understand the nature of insurance. We are closely monitoring the so-called “grace period” and collecting information from members about the integration of ACA patients into their practices, and the additional challenges this brings to members.

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