Florida Blue Market President Penny Shaffer discusses the challenges and opportunities presented by the Affordable Care Act (ACA)
How has the ACA impacted the relationship between health care providers and insurance companies?
ACA focuses mostly on access and does not mandate enough changes on the delivery side, yet the only way to provide affordable access is to have the right payment model in place and share accountability among all the players. Rather than maintain the current fee-for-service model, we need to strive for better health outcomes. Florida Blue has established over seventeen Accountable Care Organizations (ACOs) across the state and 2,500 patient-centered medical homes, with over 4,500 physicians participating. These arrangements allow physicians and insurance companies to share analytics regarding a set of patients. Doctors are rewarded for their patients meeting certain health standards. keeping the focus on wellness more than illness.
How has the implementation of ACA created challenges for businesses in South Florida?
It makes affordability a challenge, particularly in South Florida. We are a community of small businesses. Today these businesses are trying to figure out where to go from here as a result of the law. Do they offer insurance or do they let employees go to the individual market where they could get a subsidy? Miami is arguably the most expensive setting for health care in the U.S. This is primarily due to our large aging population. This market has a high concentration of medical specialties, with fewer primary care providers. Moreover, Miami has one of the highest concentrations of Medicare fraud, which further drives up the cost of health care. Finally, we have a large uninsured population, which is in large part comprised of immigrants from countries with socialized medicine, and are therefore unaccustomed to having to procure insurance for themselves or their employees.
How would Medicaid expansion affect South Florida?
Nearly 700,000 people in Florida are in the coverage gap, meaning that they make too much for the state’s current implementation of Medicaid and too little to qualify for subsidies on the exchanges. The majority resides in South Florida, and inevitably we have to fix this gap.
At the state level, what policy developments will have the greatest bearing on health care in the near term?
New legislation would expand the availability of telehealth services, which would provide more convenient access to health care services, particularly to Floridians in rural areas or areas with physician shortages. Proposals to modify prior authorization rules and step therapy protocols must strike a balance between the management of medical costs and the treatment needs of the patient along nationally-recognized guidelines. Covering more South Floridians should result in lower health care costs as uncompensated care is decreased.