Brad Lucas, MD, MBA, FACOG
Chief Medical Officer
Buckeye Community Health Plan
Blucas@centene.com

Good things are happening and have been happening in health care.
We also have problems that have been developing for decades.
The Affordable Care Act has only partly been implemented—some funding for innovation—incorrect to blame long waits in a doctor’s office on “Obamacare”.

Health care is no longer just about the doctor’s office and the hospital.
Managed care fills in all of the other spaces. Airport analogy—no longer just airplane pilots flying wherever they feel like at the moment.
A good health plan knows where evidence based medicine can help its members.
-true example- 17P
A good health plan does not miss opportunities to help a member avoid sickness.
-True example- a prosthetic device is not fitting properly- listen, ask questions, get them to the doctor, and avoid the hospitalization for the abscess that develops from continued use of a problemed prosthetic that led to infection. The patient did see a doctor eventually and did ask for a referral to a different DME supplier who was more on the ball, but not until after the problem was severe. The health plan should have been in touch with the patient more often and more frequently to get her into the doctor’s office sooner and get a better prosthetic more quickly.

Nobody has all the health literacy they need at the time they need it most. Doctors need to put up the guardrails and inform them as best as possible. Doctors need to take the time to teach patients what they need to do when it does not include surgery or medications. Doctors may need to teach their patients … patience. There are numerous points of quality care that show a doctor is practicing high-quality medicine. These are not disputed. If doctors meet these quality points than hopefully they are delivering high quality care all around.
Health plans make sure that the best care is given at the right time. It is their business. If they cannot do this they fail.
Unmanaged care is sloppy, non-compassionate, dollars-first, shot-gun therapy medicine. There is not follow-up. There is no recognition of continuous quality improvement.

Without access to care we have no care.
Access problems come in many forms.
-transportation, transportation that is limited to certain dates and times, transportation that leaves if you are 10 min late, transportation that does not wait until the end of an appointment.
-a diabetes educator/clinic that is only located downtown and the patient lives 30 min out of town
-a doctor that does not return your calls
-lack of a specialist
-medical literature that cannot be read
-medical literature that can be read but really makes no sense to the reader
-an doctor that won’t see a patient because they are late or missed an appointment (without knowing anything about the patient’s circumstances)
-lack of insurance, not wanting to pay a co-pay, or cannot afford a prescription
-a patient just does not have a trusted, convenient doctor and does not know how to find one

Consumers are ignorant about the quality and cost of their care

Patient satisfaction surveys- $ 1 billion to be spent as mandated by ACA

We have not figured out how to properly measure patient satisfaction

Very difficult to qualify doctor performance

Doctors need to have intrinsic motivation not just P4P

Quality applies to all providers and payers

There is an analogy to groups of employees buying lottery tickets. Small cost- small chance of immeasurable benefit.

Fight for cost, quality, access

Taxes us to try and cover the gaps

Also paid for by Medicare cuts
-if there was $300 billion in Medicare cuts available why not look for it previously?
-steep cuts in DME from competitive bidding

$8 billion tax on insurers
8% cuts on fixed payments to insurers

Attempts to drive initiatives to improve our health care

Did not address inefficiencies in healthcare well enough -no pricing based on quality-no competitive pricing

Some employers will limit hiring. Others will reduce hours.

Some employers with just under 50 may stop purchasing health insurance if they were and let them access the individual exchanges.
-100-400% of poverty get tax - will get tax credits and cost sharing subsidies for using exchanges

Companies with a lot of part-time employees will carefully manage the part time hours so that all of their employees are not eligible for coverage. More often those who are in retail, hospitality, and food and beverage industries.

Individuals must get insurance or penalties.
The penalties are too low to influence most people who do not have insurance.
Low income in 2014 -$95 penalty that cannot realistically be collected

In 2014 citizens of states that opt to not expand Medicaid will not have to pay penalty if they would have newly qualified for Medicaid.

Insurers will no longer set premiums based on age and health

Health insurance will no longer be the business of insurance as time goes on

Incorrect to call Medicaid "health insurance". They are health plans

With essential benefits mandated and guaranteed issue businesses with younger, healthier employees will see premium increases- those with older will pay less

Individuals and small businesses will be able to purchase insurance from private insurers that is underwritten and rated based on rules written by the federal government.
Available for those at 100-400% of poverty (up to $49960 in single member home, $94200 in family of four)
States are tasked w/ administrating/implementing the expansion.
The states are behind—new rules, mandates, databases—it is falling onto the existing plans to build out an Exchange product
States are enforcing federal law and federal regulations.
Consumers begin enrolling in 10/1/13. Fully operational by 1/1/14.
Businesses w/ Hopefully lower cost, lower premiums than would have otherwise been available to early retirees and self-employed individuals. And more choices.

Falling behind schedule a bit. Hopefully one of the parts of ACA that really shines down the road.

Not just the next acronym in healthcare- there is some hope

Not the future of healthcare everywhere

Need to use evidence based medicine
Use the lowest acuity setting necessary
Need patient engagement and accountability

Medicare beneficiaries are entitled to a federal contribution to help purchase their healthcare through a health plan.

Example w/ Part D

Participate in Medicare D-choose drug coverage plan by private insurer
-a weighted average of each plan's cost is calculated
-gov helps w/coverage plan-if you want a higher cost plan than the benchmark you pay the additional cost

It is possible to give high tech care in lower cost venues

Consumers are ignorant about the quality and cost of their care

We need to make marketplace choices that show our true preferences - there is no marketplace force
-we choose our healthcare based on location, advertising, and word of mouth

More cost, less take home

Demoralized workforce

Doctors get paid based on quality of care not quantity. It has to be more important to deliver quality care.

Providers are paid for every service they deliver.

Fee-for-service plans have all of the traditional healthcare inefficiencies

Fills in the gaps in care
Reduces mistakes, error, and inefficiencies

There is still backlash from the 1990's HMO's

Kind of like "the world is flat thinkers"
-we were wrong- get over it