 Good afternoon. I'm Mark Smith. I'm the Chair of the Business Advocacy Advocacy That's hard to say committee for the Chamber of Commerce. I'd like to welcome you to our presentation today. Thank you for coming You started like to start out as we always do by recognizing our major sponsor Prevea Thank you Prevea for sponsoring our efforts today And thanks to the Elks Club for providing our fine feast again today. Thank you very much We also like to recognize our elected officials that are in the audience I saw Mayor Mike Vanderstien, Mayor Mike Senator Lemahue. Thank you both for coming I'm sure they would both love to talk to you after the presentation today Also, if you could please business advocacy members, please raise your hands For as far as the presentation goes today If you've enjoyed what you've heard if you'd like to hear more of the same if you'd like to hear other topics Please see any one of us who raised our hands after the presentation today The Business Advocacy Committee is the group that actually puts on these presentations every month. So we'd love to hear your ideas Positive negative ideas for improvement. Whatever you have We'd love to hear your ideas so that we can improve and keep these presentations going Before we get started with today's event. We have a special announcement Please Yeah, I'm a little short in that Not short just a little shorter than that Okay, well welcome everybody I just asked for a couple of minutes because I wanted to let all of you know and especially those in our audience who are in human resources We have a wonderful opportunity coming back coming up on August 16th and 17th It is a someplace better tour for HR folks and for realtors And this it has anybody gone on it. We had our pilot last year. Did anybody attend that? Well, the reviews from that were excellent and this year We're going to have a an evening reception on the 16th And that's going to be at spaceport and you'll have an opportunity to Interact with some of the people representing some of our assets in Sheboygan County And then the next day is a is a full-day tour And you're going to learn everything possible that you can put in your toolbox to help sell this county to potential Recruits who might be considering moving here And it's it's really put together. Well, you're going to have a great time. It's also a lot of fun We've even slipped in a little sales training as a part of it so that you can learn those techniques as well But please if you want more information on this, you can actually just go to our website You can email Tammy at sheboygan.org Or you can hopefully you're getting our Monday monitors And if you're not see me give me your card and we'll sign you up for that So but just a great opportunity. We didn't want you to miss it. If you haven't signed up yet There's still space So please just make it a priority if you're thinking and for other people on your staff as well So thanks. Thanks Mark. And thank you One other announcement I'd like to make before we get started with today's discussion is Next week's next month's first Friday forum will actually not be held on the first Friday Because that's going to be the Labor Day weekend So it will be on the second Friday. That's September 9th. The topic will be cyber security Fraud stories and how to protect yourself. I'll tell you that I've already heard this presentation and it will scare you But it will also give you some ideas some practical ideas you can take to help out yourself and your business So with no further ado today's presentation is on the affordable air cat affordable care act navigating the affordable air cat Navigating the affordable care act is the topic for today. Thank you very much and our panelists will be Andy Bagno He's from the St. Nicholas Hospital Terry Lovastand a shareholder and tax CPA from shank Julie Meyer an account executive from hub international and Kristen Stearns the executive director of the Lakeshore Community Health Center if you could please join us up here on the stage and One other announcement a little bit of housekeeping for us all while they're coming up on the stage There are cards on each one of your tables cards and pens if you wouldn't mind, please Write your questions down on these cards and we'll get them to our panelists And they would like to answer your questions at the end of the presentation. Well, thank you Hopefully nothing falls. I'm Terry Lovastand and I work at shank. I'm a shareholder in our tax department So the ACA and the impact that it has in my clients has been a pretty big deal for us the last several years Well, six years it's been around for six years So I just want to talk about a few things from a tax perspective in the business world really kind of focusing on the small employer Large employers if you if there are any that are out there you have some different issues You have the whole reporting requirement to 1095 C's you have potentially large employer penalties for failing to offer insurance or Affordable insurance, but small employers have Some additional things that I think hidden probably can potentially hit them pretty hard The first thing I want to talk about is reimbursement of employee individual policy premiums It's very common for small companies to not offer health insurance to their employees Instead what they do is they say employee if you have health insurance to go out and get your own policy And I'll reimburse some of your premiums. That is really common and I am convinced that is still happening today The tax world has not changed, but there is an interpretation of the ACA that the HHS and The IRS took that basically said if you as the employer reimburse individual premiums for your employees While that does not create a taxable income situation to your employees, which it never did You now as the employer are subject to an ACA violation penalty of a hundred dollars per day per incident until you stop doing this And there was some relief that went from 2015 from January through June in 2015 But that relief is no longer there so employers that are reimbursing individual premiums for your employees That's a problem that puts a hundred percent hundred dollar penalty per day for each of your employees that you're doing this for now one of the things that can be done is to You got to be careful that you don't tie this too much to the reimbursement But if you just give your employees additional compensation as Taxable wage they then have the ability to go out and buy and pay it for their own premiums It's not going to be tax-free to them because it can't be because you can't reimburse our premiums because you got this hundred percent hundred dollar penalty But if you do it as additional comp now they can afford their premium, so it's an unfortunate Situation right now there are bills in Congress that would allow small employers to reimburse Their employees for premiums and not be subject to the hundred dollar per day penalty So we'll have to monitor that But that is a really unfortunate thing that a lot of our smaller businesses are seeing Another another thing for the small business is the shop exchange So one of the one of the options for offering group insurance is to go to the shop exchange I don't even remember what it stands for since I can't there's an acronym I can't remember it stands for but really what the shop exchange is It's no different than the individual exchange or marketplace that individuals can go to on health care gov To purchase their health insurance, but the shop exchange is for small employers And it really allows them to provide group insurance to their employees, and it's it's actually I'm not going to get into the merits or pluses and minuses of the insurance that's offered there But it does administratively make it very easy for small employers because the shop exchange has do you have any idea? How many I don't know how many options there are there's probably what 40 different options Who knows what the number is but you as the employer do not have to determine? What plan and what's the benefits are the the individual employees go on to the shop exchange and they picked their own policy and You can pay for the employer pays for a portion of it the employee would pay for a portion of it just like group insurance and Just administratively the shop just offers you the insurance. It's kind of it would be an easy way The advantage of doing that is is there can there is a credit a tax credit for small employers? Who do pay for some of their employees health insurance for offering the shop exchange group insurance? tax exempt organizations qualify as do for-profit organizations You have to have a small number of employees under 25 and wages I think have to be under $50,000 on average and owners don't count in that so for some people the shop exchange may be a way To offer insurance on a relatively easy basis and also provide a tax credit One of the things in and some of you probably are so clearly a small employer for purposes of the tax things with the ACA But you always want to be aware of what the definition of small is Julie is going to talk about what a small group is for her health insurance purposes Which is a different measurement than what a small or large employer is for the ACA The IRS has very strict rules as to how you determine whether or not your small employer or large employer For purposes of whether or not you have a penalty So if you are getting borderline and you're looking at you're creeping up with the number of employees to me I always look at how many W2s that an employee an employer do That doesn't necessarily give you the answer whether or not you're small or large But if you only issue 20 W2s no way can you be large for purposes of the ACA and the employer penalty? But if you if you did 60 of them you might want to start looking at that So just be aware that that's done in an annual basis. You have to look at 2015 to determine whether or not you're large for 2016 Have any of you as the employer received a letter from HHS Telling you that you have employees that have enrolled in insurance on the exchange and qualified for subsidy Okay, so several you in some of though they still be could be coming out So what HHS is doing, which is where we go to the state of Wisconsin for the exchange? HHS is sending out letters to employers that are alerting them to the fact that they have employees That are on the exchange that qualified for subsidy and the letter is written in such a way that it actually says you as the employer Can appeal this subsidy? Okay, it's not your subsidy. You're appealing. It's your employee subsidy that you're appealing and that Makes me almost a little bit nervous because it's not your subsidy And that kind of puts you as the police for your employee and what they're doing on their individual return and what they're doing in their Individual life. There is no penalty for you as the employer to not respond to them And I've we've had a lot of debates within our firm And I've had other people that I've talked to about this and I've read a lot and I've talked to some attorneys And I've actually come to the conclusion that it may not be something that you want to do is to appeal it as the employer a Lot of the reasons that people give to appeal it is is that they say well HHS will notify the IRS So this would be if you're a large employer they'll notify the IRS to let you know that this person should not have had a subsidy And hopefully you won't have a penalty situation for that as a large employer We don't know what the process is going to be. We don't know that HHS will notify the IRS We don't know that the IRS will look at the information if HHS says this I'm of the opinion that I Don't know it's take is going to take time and effort to appeal and again It's not your subsidy. You're not fighting for your subsidy You're actually providing information to take away your employee subsidy potentially or confirm that there is that there should be one The other problem with that appeal is is that the subsidy is based on their household income and that is a number as an employer You do not know So I think that they're really just asking for information and they've worded it to be such that it's an appeal Because that makes it a little bit more scary for the employer Oh, I better appeal this or I have to do something but really they're asking for information for from you Which at this point you're not obligated to provide so You know that will be decision everybody has to make but I think if you are going to appeal them You need to appeal them uniformly so that your employees can say hey Why did you appeal his and not mine or vice versa versa because again? I think it's a little bit adversarial thing that's going on here with that appeal Okay, the other thing I just want to talk about I just want to remind people and Kristen will talk about this a little bit too is For those of you those of you who are on the exchange or those of you who have employees They are there are subsidies that are eligible if their income is built between 100 and 400 percent of the federal poverty level and for a family of four in 2016 that 400 percent is about $95,000 so a lot of people are really eligible for a subsidy in the state of Wisconsin just based on our standard of living in our cost of living in our wages here The only people that do qualify for a subsidy though are those that don't have any insurance offered to them at all Or if the employer provided insurance is unaffordable if someone does actually receive a subsidy though they have to go through a Process on their tax return by filling out a form to make sure that they're eligible for the subsidy And if they're not but they had an advanced subsidy that was issued to them each month They have to pay that back One of the arguments I heard going back to this exchange notification is one of the arguments to do this to appeal it is You may be watching out for the best interests of your employee if they're not really eligible for a subsidy And we'll have to pay it back if we can get that subsidy stopped sooner than later Maybe that's in the employee's best interest, but I don't know if we really know that or not so But the subsidies are very nice or very lucrative. It's based on a just-to-gross income of people's tax returns And so there can be some planning that can be done that if your income is just a little bit too high Something might be done and you might be able to get a nice subsidy out of that so That's I think all I have from kind of a business CPA tax perspective for small employers Thank You Terry and I'm Julie Meyer from hub international I'm an account executive and I work in the employee benefits area. So since 2010 have been working With my clients Around the Affordable Care Act. We do not give tax advice. We take a more strategic approach working with our clients to plan for the next three to five years and I've been asked to give again a small employer Perspective on offerings for health insurance and I'll probably deviate a little bit to larger employers towards the end of my conversation but Like Terry said, there are a lot of small employers who do not offer health insurance and and the reason they don't offer it is Because it's expensive There is some potential for getting tax credits I find in my practice that a lot of them employers simply aren't eligible for the tax credit or as Terry mentioned their family owned businesses So they themselves do not qualify for for the credit One of the reasons I am finding though that more small employers are offering coverage because they're not required to Under the Affordable Care Act They're not subject to the penalty if they have less than 50 employees But I'm finding some companies are starting to offer health insurance where they hadn't before because of the whole idea of Tracting and retaining employees. That's a very important Part of hiring and we were talking earlier in our conversation. You know when I got my first job I didn't know anything about the health insurance because it didn't cost anything and I had a hundred dollar deductible I have kids now that are under 25 years old and The they're very aware Because once they come off of our policy where they have free insurance when they turn 26 They'll have to pay for their own insurance that job and how that job pays is going to be Very much effective by the cost of their health insurance a couple hundred dollars a month taken off their Paycheck or more plus they'll have these substantial deductibles. So from an attract and retain perspective I mean, they're looking for positions where they'll have health insurance offered or available to them Qualifying for a subsidy and buying coverage on the exchange Of course is also an option and that really was a goal of the Affordable Care Act to get more people covered But that that will also be an option to them But what's more appealing is having an employer that offers health insurance So we're finding more small employers actually inquiring at least or asking about offering health insurance than they did in the past I am going to spend a little bit of time talking about this idea of community rating and like Terry mentioned earlier penalties for Employees with 50 or more employees The way that the count happens is different than 50 or more employees for community rating. So what community rating is is that Everybody pays the same rate every group pays the same rate regardless of health conditions So if you're if you were an older and or unhealthy group You probably moved to a community rated policy and those policies can be purchased on or off the exchange so Those were the groups that moved to these community rated policies the younger healthier groups are still in transitional relief And this is under 50 employees They're still staying where they're at in that transitional relief actually has been delayed I think three times ends on January 1 2018 as things are currently written So what you can imagine is that you know these younger healthier groups who had transitional relief the old like year-old plan You can keep your old plan They're still paying I mean they're not getting substantial price increases, but these Plans that move to community rated plans They're they tend to be somewhat unhealthy and a little bit older And and they are getting some significant price increases as are the individual products, which I think Christine will be talking about later This transitional relief and compute in community rating and how we count for community rating is 50 or more employees average count on your payroll so you could have six full-time employees and 60 part-time employees and still be community rated like a landscape or a big landscaper might be an example where They have you know 60 people on their payroll only six full-time employees well, they could get themselves out of community rating because They have more than 50 employees on their payroll average and again that can be favorable for some companies You know if they're young and healthy they get themselves out of community rating that can be favorable It cannot be favorable if they're older or unhealthy because again those community rates are very very high So just something to think about it. It'll be interesting to see what happens when the community rating applies to Everyone on what happens with with those rates The other thing I wanted to touch on with small employers is some carriers are offering what they call a level funded product Basically, it's a hybrid self-funded product So what you're doing is you're buying a stop-loss deductible a high deductible on each of your individuals in the plan and then hiring insurance company To administer those claims There's a maximum exposure that set that set on those plans, but it's self-funded So community rating doesn't apply to those plans. So again if you're a younger healthier group You might want to consider self-funding. I had one group that was community rated I still can't figure out for the life of me why I had taken them over there a small contractor and They went to self-funding and were able to you know, even on their maximum exposure safe Significance amounts of money So that's something to take a look at but take a look at carefully because if you need to exit that self-funded plan You need to have a plan that gives you a good way a good way to exit that plan and most of the Carriers that are offering these smaller self-funded plans do have provisions in the policy for doing that So that that's one strategy Something that larger companies are doing to reduce their costs and again 50 or more. They're rated based on their experience So a healthier 50 year older group is going to get more competitive rates and an unhealthy 50 or over I'm finding that the carriers have been Competitive with these 50-plus groups because they can still underwrite. They're looking at them very closely When we're looking at a three to five year plan We don't like to you know put our employees in a situation where they have to get a different insurance company every year So, you know, we're putting plans out to bed But we really don't want to have people always having to change their insurance carriers change their cards change their providers So just as a side note with my larger employers and hub international happens to have a separate data analytics department Where they'll take a look at the carriers rate offers prior claims experience demographics and you know say yes That was a good rate or or no, it's not Unfortunately, we're still working situations. So where we have to do RFPs almost annually You know to work with the carriers to get the best possible available rates The danger in doing that though is in the bad year comes and then you get this huge rate increase And then you have to communicate to that to your employees as well And that's another thing that I wanted to touch on is plan communication These benefits again are very very important to your employees So how those benefits are communicated at all is also very important Christine mentioned at lunch, you know, do people understand that they have preventative coverage on their plan that preventative coverage is There is covered a hundred percent Do they really even you know know actually what their benefits are Do they understand that if you're not offering health insurance That they can't just get health insurance whenever they want they have to wait for the open enrollment All those things I think are important to communicate to your employees And the other thing I like to talk about is you know, it doesn't probably matter so much with community rating But it really does for all of us as a whole is that claims costs are really what drives premiums I mean, there's when there's higher claims that premiums get higher that's for all of us on a community rated plan or on a on an individually rated group plan so wellness is really the key I think for At least leveling out the increase in plan costs going forward For larger groups, you know, they can chase net networks try to get the best networks from the providers There's all sorts of things that larger employers can do, but I think the really Where it's at in Messaging is is doing everything that you can to keep your employees healthy and again that goes back to communications With the large groups many offer on-site near-site clinics health reimbursement arrangements Wellness programs, but the carriers to the insured carriers check with your carrier to see what? Wellness offerings they have many of them have Wellness programs built into their their insurance plans that your employees can access So again to conclude really I think it's communication to your employees What are you communicating? How you how how are you communicating and how is? Your health insurance and benefits plan utilized to work with your hiring and attracting and retaining employees process Hello, my name is Andy Bagnell and I serve as the president and CEO of St. Nicholas Hospital and I Want to go at this a little different more from the provider Hospital perspective of the ACA and how that's impacted us and how we look different today Then where we were at five ten two three years ago I would say in the health care industry. We're going through perhaps the most rapid pace of change that we've ever seen So there's a lot of complexity to what you've already heard today and what you will hear from myself as well Going back several years or it's really three things that the Affordable Care Act sought out to address number one cost the trajectory that we were on as a country was unattainable in terms of the cost structure for Medicare and the cost of health care services number two to address quality Back in 1999. I believe there was a report that came out that we were One of the highest leading causes of death in the United States hospitals were providers were that's not a good thing so We needed to do something to improve quality across this country and number three to address the coverage issue the lack of the uninsured population so those are the three basic Premises around the Affordable Care Act. I just want to make sure we're all grounded in that The other piece and I and I think right now we're we are We're correcting or we're we are healing a fractured health care system in this country essentially and there were issues and Things that this really sought up to address number one a siloed and misaligned Payments system or mechanism how we pay for health care services Number two the lack of health care coordinate care coordination and transition management So coordination between providers hospitals post-acute care providers, etc number three addressing the growing uninsured population and Reinforced by risk selection Number number four there are uneven outcomes across the country some are doing it really well Some not so well and how do we even that out and improve that and then finally, you know as I mentioned before unsustainable cost increases without improvement in out outcomes So really three major goals as I mentioned coverage payment financing And you know from a hospital's perspective, you know, where we stand today and where we're headed We're really moving we've had a foot and two canoes so to speak from a provider's perspective for many years And and the foot in the canoe is really transitioning over more towards value from volume As a provider, you know when I say we're a provider We are no longer just a hospital taking care of patients coming into, you know, St. Nicholas Hospital We are also a physician Group we have Prevea as part of our group and I know Aurora in town has a medical group as well but we're also an insurer now and So it's really we go at this as we're really a three-legged stool is what we say In coordinating care the best way we can for the population that we serve to provide value so When we look at our risk for payment We're looking at about a quarter or more of our payment and really it's our operate operational operations margin is now at risk for Whether that be through the insurance side that we're taking on risk or value-based purchasing from the federal government and so Each year we are getting paid more and more to take on more risk. So For better outcomes better payment Not good outcomes no payment or even actually a reduction in payment and so I'm going to walk through some of those things that that That that are addressed by that but also the implications On this mark on market reform or the Affordable Care Act the first one and I think Is a real important one is a hospital Is really partnering with your medical staff and your physicians and making sure that we can coordinate care the best way we possibly can This really as I mentioned before really kind of segues our volume to value equation and looking at how we can better work Coordinate care closer with our medical staff providers and make sure that we're going at the care process as one care team no longer providing care as a pilot and so Or care in a silo and this really addresses The triple aim which is better care for patients better health for populations and lower costs so when we look at this at least for for our Hospital and our hospital system We look at as a care integration strategy. So so really there's there's four Four layers that we looked at number one is the physician slash provider alignment Making sure that we are engaging our medical staff in a plan jointly as I mentioned before and also establishing a clinical integrated Delivery network. So we're working hand-in-hand with our providers to make sure we're improving quality and cost and and also number two performance alignment with our physician partners, so Making sure that we have a common approach relative to quality Efficiency and care management. So making sure that those processes are clinically integrated Number three ensuring that we have a strategy for payment reform. Obviously, we are well on our way for payment reform We're in the middle of that right now, but making sure that we are aligning in a way with our provider payer payers as well Things are looking so much different today than than where they were from the perspective of you come to a provider or a hospital You might have a doctor blur copay To meet and we just get paid for you know the volume And volume only well today. We're entering into unique payment relationships such as bundled payment System so if you look at getting a hip or knee replacement It's an episode of care that we're getting paid for today So we're not just looking at okay, you come to the hospital We get paid this and the physician gets paid this and then the skilled nursing gets paid this We're entering into pilots now where we're looking at the whole episode of care so Several days prior to admission your whole admission process as well as 30 days post-acute Getting paid one payment for that entire episode So much different than what we had before now that's on one extreme the others are of quality measures So patient experience Our quality outcomes so an example of this is patient gets readmitted to the hospital No longer will we get paid for that readmission for certain categories diagnosis? You have low patient experience Scores or low Satisfaction with the care being provided Portion of that payment will be is at risk Now so a lot of different things and then finally taking on that financial risk Which is what we're saying the value base, you know We're taking on a hundred percent risk now being the fact that we're all we're now an insurance Product, you know, we purveyor 360 happens to be our insurance plan that we own It is a narrow network product and the reason why that's narrow And for those of you that don't understand what that that means narrow It's really a coordinated network of limited provider panels. So it's our system of care We can guarantee our cost and our quality structure, but it's really limited to our providers in our hospitals So basically probably the best way to put this is that We're putting our money where our mouth is we can control our costs. We can control our quality We can control what we do from an outcome perspective as an insurer in partnership with the hospitals the physicians and then we're taking full risk for that so That's population health, you know, obviously, you know to the other extreme in terms of Where we're headed with this from a provider perspective Now one of the things that Isn't isn't talked about much and I know the the community rating was talked a little bit about From from from Julie and this doesn't really have an impact on community rating But it is very similar to that from a health care provider perspective whereby we're also measured by Efficiency how efficient are you as I mentioned before The bundled payment system. We're you know in some cases we're now being paid as bundled So you're responsible for the whole episode of care, but Medicare is now looking at the Medicare beneficiary spending per beneficiary and the amount that is being Outlaid for that for each community hospital, etc And so what what they're looking at is Medicare claim data to look at the whole episode of care Not just at the hospital, but they're basically saying, you know hospital. You're you're now responsible for that whole care episode So, you know, that's different for us. Obviously as we look at we're not in the skilled nursing business now We do have home health care Services which is put which is post-acute and other related services, but it's really Forcing us and this is a good thing To partner with our area skilled nursing facilities to ensure that we're preventing unnecessary readmissions Preventing other things to come back in the hospital reducing reducing costs. So there's a lot of Partnership and relationships that are happening even though on the sign of some of these buildings They may not say Aurora or St. Nix or whatever There's a lot of care coordination that's happening behind the scenes, especially with the post-acute care providers And and we're getting measured. It's it's on a it's basically a one-point scale And the federal government is hold withholding some payment to hospitals now saying You know, you need to be at a certain rate. So it's like I think it's point nine five And I think the state averages point nine four last I checked You know in terms of a cost structure of that entire episode of care and if you're over that They're saying, you know, we're gonna withhold dollars Now if you're below that we're gonna reward you provider in that and we might actually even pay you more so Some different things happening there but as you can you can see a lot of Coordination has to happen behind the scenes to make that happen and the best way to describe that and coordinating care is to make Sure you have clinically integrated information systems to make that happen. So both Praveya and St. Nix we've invested in epic as our clinically integrated solution for that And then Aurora did almost at the same time as us, which is really very helpful And so both hospitals in in Sheboygan now have you know grant each other access to care What we call care everywhere so if someone goes to one hospital or the other now We can access medical records to ensure that that care is being coordinated across the system Even though we're not part of the same system It might be you know, even with the skilled nursing facilities We provide them access to certain level of data so that we can coordinate that care back and forth Five six years ago guys that was not happening at all. We weren't talking to one another in that way So the care coordination has really drastically improved. So I would say from an affordable care act perspective It's accomplished some things in this in in this community and across the country The I'm just gonna throw another loop in this presentation here because this is relatively new information I mean not not to the panelists likely but The physician payment Mechanism has also been in question and up in the air for for quite some time the federal government Really kind of kicked the can down the road for many many years relative to medicare payment cuts for physician For physicians and what ended up happening is over the years that that deficit kept increasing Every year to the point where you know if they would if they would have reduced the payments the physicians We would have had a pretty catastrophic issue on our hands With respect to access and providers So that was called the sustainable growth rate formula that the government came up with a fix This past this past year and it basically creates And and basically what is called what they came up as a fix is a called the medicare access and chip reauthorization act of 2015 an acronym within an acronym because it's called MACRA so Again very complex But I will just just share with you some of the things that are occurring with that it essentially creates incentives to move physician payment To risk-based models much like I shared with you on the hospital side Payment for value quality experience efficiency those kinds of things and so there's deaf There's there's essentially a couple different tracks that are coming down the line for physicians number one is called MIPS And MIPS stands for merit-based incentive payment program. The second is APM, which is an alternative payment models and CMS which makes us more complicated CMS is still writing the regulations so details emerge every day But it but essentially applies to all medicare part B provider payments and it really locks in part B reimbursement rates at Near zero growth rate annually or less so What they're doing is are basically physicians will Need to be in one of those alternative payment delivery models or both But I think it's 2019 and so a significant portion of physician payment is also going to be at risk in the near future and already is beginning to I will skip some of this because I know it was mentioned earlier, but You know this whole acceleration from volume to value What how we got there is really it's a fundamental shift from On it from a risk perspective from the employers Consumers health plans and government payers to providers medical groups hospitals, etc I talked a little bit about population management from the perspective that we are now taking on full risk As an insurer as well But that we're managing the health of the population Not just as it from an insurer perspective, but also provider We can see the actual claims and coordinate that care appropriately talked about bundled payments So that really addresses some of the care coordination that's necessary From from where we're going From a cost structure a number of things and I can probably speak on this for about three hours Although I will make it 30 seconds I will just say that from a healthcare provider perspective. We have really had to become Much more lean and efficient in our operations Hsh stands for hospital sisters health system We have a 14 hospital system across Illinois and Wisconsin And I about six seven years ago We really operated more as a holding company for 14 separate hospitals actually 13 at the time Now we're operating as a health system leveraging the resources and the relationships and the contractual contracts, etc Operating as one system of care in a coordinated way Again that that's what you're seeing in some of the alignment structures that are taking place many independent hospitals Are joining health systems? So you're seeing a lot of that consolidation occurring as well across the country And before I pass the microphone because I'm sure I'm well over my time right now Is just some considerations I I was on vacation last week So I was doing a little makeup reading in my office this morning And I opened the the Milwaukee business journal from last week. How many of you read that? Last week, it's okay if you didn't Because I I will point it to you and if you haven't I would encourage you to go Online or or if you still have in your office take a look and read it because I think it has some really good points In there there's about a two or three page article For employers as considerations In navigating the affordable care act how timely I read it this morning at about nine o'clock So I just want to highlight the five points that they made number one Explore plan design and find options. There's a lot out there And depending on where you're at and I know it was discussed earlier There's a lot of implications for each of those But there's also things that you can do to reduce your spend and reduce your cost Number two consider on-site and also near-site clinic solutions and partner with health care providers to help coordinate improve prevent hospitalization etc Number three anticipate change in how providers are paid Our world is already different, but anticipate it number three Welcome market disruption And we're seeing it around us health systems are consolidating with other health systems Um, clinically a great grid health networks are forming Um, a lot of things are happening in in health care number five There's a continual and will be a continual downward pressure An impact of government reimbursement payment systems, etc So with that I will pass the mic to Kristen Hi everyone. I'm Kristen Stearns and I just want to ask you how much time do I truly have? It's one o'clock right now Perfect. Okay. I just want to make sure I get everybody out of here I respect your time. Um, so I I run Lakeshore community health center for those of you that don't know We are a federally qualified health care center in Shwig and Manitwakonis. We Became a federally qualified health center in june of 2012 so Many of you may not know us. Um, we really are here as a safety net provider To provide a system of care. We work with our partner agencies St. Nick, purveyor and rora To provide care and especially to those that are uninsured and underinsured So today I'm going to talk a little bit about how uh, how the aca affects us as well as To give you I'm a stats person and I've got the stats on where our state is today So I'd like to just talk a little bit about What we where we've been and how how far we've actually come in ensuring our our population here in Wisconsin um, so just so you know um As of february 22nd Which is really the end of open enrollment for the aca marketplace There were over 200,000 Consumers that were either either selected or were re-enrolled automatically in with this state of wisconsin So we have 200,000 people who are who are now receiving aca insurance, which is really exciting nationwide It's about 11.7 million. So if you think about how how we play into that um with that 89 of of our wisconsin consumers Have been signed up Have qualified for an average tax credit of $315 Per month on the marketplace. So those are those subsidies that uh, I think terry and julie we're talking about 50 percent of of our wisconsin market played Place enrollees were able to get covered for $100 or less So their payment in was $100 or less and there's plans. So if you've never gone on healthcare.gov I suggest you do especially if you're a small employer and you're trying to figure out what's going on And what your employees are talking about There's different types of plans of brands silver gold and platinum. They all have different values and have different Subsidies that go with them different costs and different deductibles. So so there's a lot to choose from Wisconsin Out of those 200,000 that Consumers that are on aca I just want to let you know that uh, 26 percent of them are between the age of 18 and 34 years of age So we're covering a large group of that young population That that in the past, uh, may not have been covered. So it's really interesting In the there was a gallup survey that recently went out that said the uninsured rate in wisconsin In uh, 2014 was 8.4 percent That's down from 11.7 percent in 2013 So we're definitely making an impact on getting people insured which helps all of us I am sure andy would say that we would rather have people insured than Then uninsured it, uh, even with high deductibles. It's cheaper for us overall as as health health systems to to really have those those insured individuals We can do a lot more with them and there's a there's a lot that that is able to be covered Um, and I think julie talked about that there's a lot that's able to be colored. It's covered. So those hr You hr people out there talk about it talk about because they everyone is covered the same way especially with preventative visit There's no cost to your employers or to anybody who's insured on services such as a blood pressure checks diabetes and cholesterol tests Many cancer screenings are included in our insurance. So colonoscopies and mammograms. That's covered at 100% No copay no cost again when we talk about making sure that wellness. We're pushing wellness Having these preventative services done early on helps overall costs to to the health care systems Um counseling uh smoking cessation counseling, right? We want people to quit smoking. That's really important losing weight eating healthy treating depression and Reduction of alcohol these are all services that potentially are covered at 100% through through All of our health care providers. So again, we need to to educate our our employees on what is what is covered Regular well, baby visits You know different things like that vaccines a lot of the vaccines are covered at 100% So no know what's covered. Um, it's really really important to tell your employees that we we talk about it all the time We get a lot of individuals who have never been insured before coming to our clinic. They have no idea how to actually Use their insurance card What it is how to understand it and what's really covered and not covered as a cost So just make sure that you're doing that this year Hot off the press I will say like two days ago Um, we got to see what uh the increased rate on our aca marketplace plans are going to be so for those of individuals who You're working with who are Taking aca plans that are not subsidized. They're looking at a 12 to 36 percent increase in In the cost of care now if they get the subsidies that's taken on by the subsidies, but Overall if you don't have the subsidy, that's what they're looking at So those that are over that 400 percent of the fpl That are that are doing that. That's who's going to get hit. So everybody realizes that I just want to talk a little bit about what services we provide and how we can assist you So we have a onsite uh outreach and enrollment specialist. She's a certified application counselor We are the only people in the community. I believe at this point in time that has that that's available to anyone So anybody off the street can come in meet with our certified application counselor jennifer schmidt Go through the marketplace get assistance And then usually we hand them off To julie's cohort Barb if they if they really want to dig deep into into the insurance piece But we also enroll people in badger care Which is the other part of Of the aca is that any Any single childless adult now who's under at or below 100 percent of the federal poverty level can be insured Through state medicator badger care And and so this includes ssi ssi related things map which is I'm going to get this wrong. Uh it's I don't know it's it has to do with high intense Stuff elderly and disabled coverage Well women if so child if any parent if anybody becomes pregnant Medicaid can kick in again And so that's up to 100 percent of the federal poverty level and just so you know where our numbers are in 2013 About 4,444 individuals were covered In 2015 at year end it was 51,000. So we're not seeing a huge increase But again, it is almost a thousand people that are now covered And that changes every day people go on and off badger care based on their on their income So again, we're available Jenny's available to come out. I said we were talking I said, you know if you need posters about Open enrollment like it's open enrollment time on the aca We've got some of those Open enrollment this year is November 1st through January 31st So just like your open enrollment if you're a big employer or you under there's only a small limited time frame for you to get enrolled So talk to your employees about it Anyone who's uninsured let them know this is the time to get to get enrolled You need to be enrolled by December 15th to have coverage on January 1st So that's a good thing to to know And I'll I'll be done. I'm almost 10 minutes So All right, so you want me to read them to you you guys want to pick who wants them Um So this is ideas on communication overload about wellness What if employee numbers change on a regular basis? Maybe you can do that Yeah, you can do that one Okay, I just gave terry the what if your employee numbers change on a regular basis I'll let her answer the pay or play penalty count I'll answer community rating community rating Basically, all you're doing is totaling the number of your employees on your last Four quarterly wage and taxes and dividing by four and that's your total number of employees For determining whether or not your community rated and generally The carriers will do it prior to your renewal. They'll ask you so that's how they that's how they count It's pretty simple your last four quarters total divided by four doesn't matter if they're full time part time Whatever they're on your payroll they count to determine whether or not your community rated Yeah, so what julius talked about was for the insurance and whether you're a small group or a large group For purposes of the aca and whether you're a large employee or a small employer for determining whether or not You have a 1095c filing requirement or if you have potentially the employer penalty That's very very strict rules as to how this is computed So for 2016 you determine whether or not you're large by looking at 2015 calendar year It doesn't matter what your health plan year is It's all calendar year basis and you look month by month and each month So in january you look to see how many employees do I have in the month of january that work more than 100 130 hours or more And they're one person if they work 200 hours are still one person You don't get to ever be more than one point. You're always one full-time equivalent. You're never more than one Then you look at all of your people that worked under 130 hours divided by 120 long story And that's your full-time equivalency add those together. That's your number of full-time equivalents for january You do that each month and then you look at it for all of 15 take the average of each month That's how you determine it. It's very very strict rules There's no deviation from that and if you're at 49.9. You are under 50 So But yes, it's always a look back to the prior year to determine so for 17 you would use 2016 Every calendar month and that determines whether or not you're large for 17 Now it probably makes sense why I had Terry answer that question I don't want to answer it We also have calculators in our office as I'm sure does shank does too if you're on the edge That you can use to help make that calculation. Hopefully a little bit easier Yeah, and most payroll software will do it too The question I had is and ideas on communications overload how to avoid so people get engaged in wellness and getting people engaged in wellness That's a really big huge question that I'm sure There's a lot of different answers to but you know, the bottom line is that it does work I have one employer who actually has And and and and other people do too. They have you know Dietitians that come in and talk they have You know people who do exercise programs come in and talk and sometimes it feels like nobody shows up and you know Nobody comes or nobody's really paying attention They will pay attention if you reward them for participating or if you put punish them for not participating And we have numbers in our office that you know kind of indicate how high or low that reward has to be in order to get People to participate But my experience is they do work and I understand you know A lot of people feel like they just keep pushing this stuff pushing this stuff pushing this stuff at me And I really don't want to do it, but I always say too. I don't think that most people who are Working want to be unwell. I mean, I think most people like Achieve to be well and to live healthy lifestyles. Um, and I think More and more employees are appreciating um employers who are for wellness programs You know, I do get the I just started this job and you know where I work before Um, they had um, they paid they reimbursed my gym membership or they had exercise programs They had people come on site and this place doesn't have it. What can I what what can I do? You know, and if you're a small employer, it's hard To put the resources into building and creating a wellness program And that's where I go back to um relying on you know prevea 360 the health plans the insurers Looking what they have available prevea 360 actually has a very strong Well-built program that's geared towards small employers as do some of the other carriers But again, I understand the feeling of overload, but I also have a A strong opinion that people themselves want to be well and they do appreciate their employers wellness programs You know, just a couple comments I would just say, you know, keep it as simple as possible And then I would say integrate it with your plan design So there's some incentive and ownership on the employee to participate in those programs So have some dollars at risk for the employees for that Thank you And thank you again to the panel. Enjoyed the discussion today. Just two quick reminders Remember that august 16th and 17th some taste bitter tour that betsy spoke about earlier And also remember next month. It's september 9th. This is second friday next month. So we'll see you here. Thank you You