1. "Market Disruption: Can the ACA's
Insurance Reforms Support Primary
Care?"

2. Disruption
• AAFP policy: Healthcare for All …. Everyone in
the United States will have health care
coverage - here’s our opportunity!
• Harvard Business School professor’s theory;
disruptive innovation helps create a new
market, and eventually goes on to disrupt an
existing one, displacing an earlier version.

3. Setting the Bar for Innovation
“Health insurance exchanges must require that
participating plans provide access to team-
based, coordinated primary health care if they
are to successfully improve outcomes, address
health care disparities and bend the cost
curve.”
– Lori Heim, MD, 2009 President
American Academy of Family Physicians

4. AAFP weighs in on developing exchanges
1. Fair Representation of Stakeholders
2. Payment for PCMH & Enhanced Access
3. Standardized Contracting
4. Set Primary Care Targets
5. Require Robust Primary Care-Based
Essential Benefits
6. Presume Eligibility
7. Reward Quality
8. Protect Consumers & Physicians

5. How will Family Medicine make a difference?
• On Oct. 6th, IOM’s report “Essential Health
Benefits: Balancing Coverage and Cost
emphasized finding the right balance between
making a breadth of coverage available for
individuals at a cost they could afford
• As HHS defines this package of essential
health benefits, let’s remind them:
primary care physicians =
lower cost and higher quality

6. National Academy for State Health Policy
“No wrong door” - ACA’s simplified enrollment
vision: integrated and seamless eligibility
systems, electronic data sharing and minimum
documentation burdens.
Some call it radical simplification
*Paving an Enrollment Superhighway: Bridging State Gaps Between
2014 and Today – March 2011

7. How will exchanges work with Medicaid?
• coordinate with state Medicaid and CHIP
agencies to develop specific transition
procedures, particularly for enrollee
populations with significant health care
needs
• develop procedures for coordinating plan
payments in the event that changes in
individual or family income result in a
change in eligibility for Medicaid during an
enrollment period

8. Other Factors in Seamless Coverage
• Continuity of care will depend on what is
designated as a qualified health plan (QHP)
• Providers will have to be accepting of all the
QHPs AND Medicaid
• Challenge will be to elevate the stature of
Medicaid in order to coordinate better with
health plans

9. Who’s impacted in Illinois?
• Currently, 700,000 individuals without health
insurance will have coverage by 2014
• By 2020, a projected 1.4 million Illinoisans will
get coverage through the insurance exchange
• The percentage of Illinois residents without
health insurance will decrease from 12%
currently to a projected 7% in 2020 (the
remaining uninsured will be primarily those
who do not seek coverage or are
undocumented)

10. What does IL AFP want?
We want the exchange to have the
mandate and the power to ensure that
consumers get the best possible rates for
good insurance. Period.
Here’s how we’re involved to make it
happen …..

11. Engaged in the Dialogue
IL AFP shared its views with:
• The health advocates coalition
• IL Dept. of Insurance
• IL Attorney General
• IL General Assembly members
• A Legislative Study Task Force appointed by
the IL Commission on Government Forecasting
and Accountability (COGFA)

12. What did we say?
• Shared a customized version of AAFP’s Principles
with all stakeholders
• Submitted written testimony and provided written
comments to the Study Committee’s report
• Stated that Illinois should have the power to expand
the requirements for plans participating in the
Exchange beyond the minimum federal requirements

13. NO assessment on providers
• Budget-strapped states, such as Illinois, should:
• optimize the flow of federal funds coming into the
state.
• leverage its Medicaid program to finance the
Exchange administration– so by including Medicaid
plans and providers, the state would be bringing in
more federal dollars to support the Health Benefits
Exchange.
• levying an assessment on providers where Medicaid
provider rates are low is NOT an option.

14. Will exchanges make life better or worse ?
• As small business owners:
– many family physicians will shop the exchange for their
practice
– potential to increase a practice’s bottom line
• As clinicians:
– those purchasing coverage are likely to be relatively
older, less educated, and more racially diverse and report
to have poorer health, but have fewer diagnosed
conditions than those who currently have private
insurance

15. Aligning Goals
Family Medicine HHS’ Triple Aim
• Improving quality of • Improving care
care
• Requiring primary care- • Promoting health
based essential benefits
• Primary care = lower • Reducing overall system
costs costs

16. How to engage and prepare
• This “market disruption” will create an array
of new insurance products.
• Consumers will have “navigators” helping
them, but who’ll be the docs’ navigator?
• Here are some important considerations and
questions …..

17. First ask, What’s YOUR chapter’s role
in YOUR state’s insurance exchange?
• How do family physicians view exchanges as small
business owners?
• How will continuity of care look and work?
• Will the plans in the exchange have to participate
in Medicaid?
• Ethically, will the providers in the exchange have
to accept Medicaid?

18. Questions for me?
Gordana Krkic, CAE
Deputy Executive Vice President
of External Affairs
Illinois Academy of Family Physicians
gkrkic@iafp.com
THANK YOU!