Care

09th Aug
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3 Important Statistics About Provider Referrals

improve patient experiences

Referral management is an increasingly important part of managing the patient experience and coordinating care within a clinically integrated network (CIN). Yet, often times, referral workflows and trends are poorly documented and misunderstood. Our organization, Fibroblast, a patient referral management solution company, conducted a survey of over one hundred physicians across thirty specialties to quantify how their referral processes work and how they affect providing care. Our data revealed three major conclusions:

Patients do not follow-up

Our data revealed that approximately 33% of patients do not follow-up with the specialist to whom they are referred. That’s worse than the adherence rate for most prescription medications![i] Put another way, only two out of every three patients actually receive the care that they need when a referral is made. This gap in adherence results in higher acuity cases, poor patient outcomes, and millions of dollars of cost to healthcare organizations annually. In an increasingly risk-based environment, providers cannot afford this gap in care.

 

Read More Here!

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01th Jul
Posted By

Three Steps to Immediately Improve Patient Referral Management

Here are three tactical ways primary care practices can improve the patient referral processes and see immediate improvements in patient followthrough with referral appointments.

1. Dedicate staff members to actively manage referrals

Designate members of the front desk or administrative team as the practice’s referral coordinators. The referral coordinators orchestrate the referral process and track the progress and outcomes of each patient referral. Referral coordinators should be good communicators who work well with patients and providers, both inside and outside the practice. Referral coordinators should also be highly organized, familiar with the practice’s information systems and time expectations for various referrals, and be willing to take persistent action to facilitate and track referrals.

2. Create scalable, repeatable referral workflows to ensure the referral loop gets closed

To the greatest extent possible, the practice should create standardized referral workflows that are scalable, repeatable, and transparent. Too often, referrals are handled ad hoc by multiple members of the staff, using faxes and phone calls to transit patient information and track referrals. That system is inefficient and opaque—patients are lost and potentially catastrophic outcomes can ensue. Rather, all referrals should be routed through the referral coordinators so that the referrals can be tracked. Ideally, the referral coordinators would utilized an automated, end to end referral management solution like Fibroblast, which guides patient referrals to the most appropriate network provider, ensures the timely two-way flow of information between providers needed to complete the referral process, and tracks referrals in real time. After all, the referral doesn’t actually happen until the patient receives the care or services the patient needs; the referral loop isn’t closed until the referring provider receives information back from the consulting provider about the patient’s care.

3. Engage the patient with referral-related messages

The most important and most overlooked stakeholder in the entire referral process is the patient. The most common reasons why patients do not follow up on referrals for care are confusion by the process and frustration over scheduling an appointment. What is more, recent research indicates that 72% of patients would like to communicate with their medical providers over email and 63% would like to communicate by text message. The practice should adopt an automated patient messaging application, like the one offered by Fibroblast. By sending patients automated, preference-sensitive messages about their referrals, the practice keeps patients informed and engaged, greatly increasing appointment attendance rates and promoting better patient outcomes.

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19th Jan
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Missed Connections

By Miranda Crowell

While social media may have all but erased the missed connections portion of the newspaper, the idea still exists. Two people meet and are unfortunately unable to communicate potentially useful information to each other. Healthcare providers are far too familiar with missed connections. But this isn’t the sappy kind you see in the movies. It’s the worst type of missed connection – the kind where despite each party involved doing his or her job diligently and correctly, a bad experience and a negative health outcome for the patient still ruin the climax of the story.

This is precisely the type of missed connection recently experienced by one gastroenterologist, Dr. Raye (as we will call him). Dr. Raye met with a 70-year-old patient with normal mental status named Ellen (as we will call her) and delivered to her a diagnosis of cancer. After some brief in-office education, Ellen was sent home with explicit directions to obtain follow-up tests and receive further care from several recommended specialists. Time passed. But when Ellen returned for her next appointment with Dr. Raye, Ellen was completely stunned by Dr. Raye’s request as to the whereabouts of her lab results. It was as if she hadn’t been present for the initial diagnosis and the discussion of plans for her future treatment and care. . .

This type of missed connection is not only predictable; it’s preventable. This isn’t a personal failure on the part of the doctor, the patient, or her family. It’s a systemic problem. While the industry may be loosening its reliance on old payment models in order to take advantage of the much-anticipated benefits promulgated under the Affordable Care Act, a fee-for-value system does not do enough to unbreak the patient referral process. A scribbled prescription pad or a computer printout instructing a patient to receive further care depends on the patient to proactively and diligently follow up for his or her treatment and care to proceed as was prescribed. This heavy reliance on patient self-management, however, allows some patients to all too easily fall through the cracks of the healthcare system.

There is however a solution to this problem and tools to help. Electronic referral systems are one such tool. They come with many benefits including analytic capabilities and perhaps most importantly an opening of the line of communication among providers, care coordinators, and patients, thus connecting the dots in patients’ care. An open line of communication and closed information sharing loop among Ellen, Dr. Raye, and her oncology specialists could have led to a better experience and improved health outcome for Ellen. Fibroblast is a referral management tool committed to promoting better patient outcomes, improving patient health, and ensuring that patients like Ellen never fall through the cracks of the healthcare system.

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23th Jul
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Patient Leakage: Acknowledging the Rusty Pipes

By Miranda Crowell

 

If you’re involved in any aspect of a patient referral, patient leakage is a problem which cannot be ignored. Like water dripping from a pipe, patient leakage leads to lost revenue and increased costs. And if money is not enough to perk your ears, patient leakage can also lead to negative clinical outcomes and a poor patient experience.

Patient leakage occurs when a patient’s business leaks out of the system because either (i) the patient failed to make or attend a follow-up/referral visit or (ii) the patient took his or her business to a competitor. While not an exhaustive list, below are four key reasons why patient leakage happens in the first place.

Old Habits Die Hard: Providers and Staff Revert to Past Trends

Like any business, patient referrals can be all about who ya know. When doctors create a relationship and a belief that the other performs satisfactory work, a tendency to refer to that person may form. It can be difficult for new players to enter into this system of trust, even when the new provider is in-network. Without taking advantage of ways to put a medical service in plain sight for other doctors to see, referring doctors and staff may not have knowledge of all the options. Lastly, some staff may have a “We have always done it this way” attitude, but it is this approach that could be costing your business money.

Patient’s Beliefs

Even if your business has made a strong effort to refer in-network, patient leakage can still occur when the patient subjectively believes that one provider outperforms another. Word of mouth is a powerful tool, so businesses should use this tool to their advantage by capitalizing on in-network referrals when they can and educating patients on the benefits of staying in-network when they cannot. Poor past experiences also motivate a patient to go outside of a network, so businesses should not shy away from the tough conversations.

Convenience

Sometimes a patient’s lack of follow-up or missed referral has a simple root cause: lack of convenience. A patient may fail to follow-up because (i) the consulting or referred-to doctor took too long to respond to the patient, (ii) the doctor’s office is too far or other access to care issues exist, or (iii) the consulting doctor is not accepting patients (among others). Recently, price has become a part of the convenience discussion. As discussed in a previous blog post, retail healthcare offices are far superior than traditional providers when it comes to price transparency. But even if your office is not ready to post the price for routine services on your website, cost is becoming increasingly important to the consumer. Providing cost transparency for services, such as colonoscopies, mammograms, X-rays, and vaccinations, may poise your business to reduce patient leakage.

A Broken Referral System – Still Largely a Paper-Based System

If the state of the art referral is made on a one-fourth sized sheet of paper or a computer printout, it is no surprise that patient leakage exists. A patient will feel little commitment to follow through with instructions for future action. Conversely, appointments for follow-ups made on-site are an obligation; the appointment is already scheduled into the patient’s life. Moreover, most physicians do not share an IT platform, so there is little way to follow the patient through their course of treatment. This could lead to potential poor outcomes, medical malpractice risks, and poor patient experiences. (You can read more about medical malpractice risks involved in a patient referral here.)
In short, patient leakage is a preventable problem. Unless the rusty pipes are acknowledged, patient leakage could be bleeding your business of downstream revenue. With a few minor changes and some clever tools, such as Fibroblast’s referral platform, the problem of patient leakage can be a problem no more.

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03th Jun
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Clinically Integrated But Not Necessarily Aligned: Who’s to blame for patient leakage in Clinically Integrated Networks?

Patients are falling through cracks in our healthcare system, leading to poor patient outcomes and hundreds of millions of dollars in lost revenue opportunities per healthcare system. This problem is intensified by declining fee for service reimbursements and the financial risks of value-base payment models.

Why does out-of-network patient leakage occur, who is to blame, and what can be done about it?

On June 24 at 12 PM CDT, Fibroblast, in collaboration with Matter and EDLoop, is hosting a one hour webinar discussion of how and why out-of-network patient leakage occurs in a Clinically Integrated Network from the perspectives of an independent private practicing physician, an employed physician, and former ACO executive.

Click on the flier below or this link to register.

Fibroblast Webinar

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21th May
Posted By

Presence Health and Fibroblast Partner to Improve Quality, Control Costs, and Improve Care Coordination for Millions of Illinois Patients

 

FOR IMMEDIATE RELEASE

Chicago, IL.  One of the ways leading health systems improve quality, control costs and improve care coordination is by leveraging emerging technology. Presence Health and Fibroblast jointly announce a new partnership for innovative referral management technology that will reduce fragmentation and streamline navigation as patients move between providers and services while receiving medical care. The contract was inked in March 2015.

“Adoption of this technology will be a huge benefit to the patients and enrollees in the Presence Health network, and to physicians as well. Presence is transforming its own infrastructure at startup speed, which is both rare and refreshing to see for a system of this size and complexity,” said Scott Vold, CEO and co-founder of Fibroblast.

The adoption of this new technology aligns with Presence Health’s Vision to lead the transformation of health care. The partnership with Fibroblast is mutually beneficial as it allows Presence to leverage technology in a new way and Fibroblast to catalyze the development of this tool across one of the largest health systems in Illinois.

“Presence Health is committed to giving patients our best by continuously improving how we do things, which in this case, means moving to a physician referral process that is more responsive and able to meet the needs of our physicians and our consumers. After serious study, we believe Fibroblast’s platform of tools addresses what has been lacking in referral management processes across the country, and we’re thrilled to be an early adopter of this exciting technology,” said Amy Dirks Stevens, President, Presence Health Partners, Presence Health’s clinically-integrated accountable care organization.

The secure, HIPAA compliant software is flexible and easy to deploy. Because Fibroblast is web-based, Presence Health’s independent physicians can use the software with their existing internet connections and computer or mobile devices. For Presence Health’s employed physicians, Fibroblast can integrate with the electronic health record and practice management system.

Millions of times each year, patients have medical needs that require expertise from different providers in different places. In order to involve others in diagnosis and treatment of illness, physicians “refer” patients to other physicians or services (from primary care to specialist, from specialist to diagnostic procedure, from emergency room to primary care, to name just a few examples). By definition, the referral process contains a bewildering number of transitions and handoffs.

Despite its complexity, too often the management of referrals still depends on time-consuming and error-prone manual/paper processes. Many office staff use one-way communication tools such as FAX machines to send and receive referrals. Doctors search for each other by phone or pager. Records and notes from the receiver to the sender have to manually route back to the patient’s chart. Tools to comprehensively understand and visualize key clinical data elements in real time are limited. Despite best efforts, administrative inefficiencies remain commonplace, wasting time, complicating the patient’s experience, fragmenting care, increasing medical system costs, and producing limited business intelligence.

Efficient, effective referral management is therefore a key linchpin in improving care and lowering costs as the market platform for health care delivery moves providers from volume to value based reimbursement structures.

Fibroblast automates and improves the physician referral process from beginning to end and everywhere in between, resulting in:

  • Increased patient satisfaction, including peace of mind that comes from knowing referrals are made with the patient’s personal insurance and network in mind, preventing financial harm to families that can accompany out-of-network referrals.
  • Increased physician and staff satisfaction by mapping referrals in real-time and closing the referral loop.
  • Improved patient outcomes through better access to care and care results.
  • Concentrated and focused care inside accountable care organizations, and reduced leakage from networks that are financially rewarded or penalized based on patient outcomes (rather than diffusing and fragmenting care by ad hoc referrals outside those accountability safeguards).
  • Assurance that referrals flow to high quality, low cost providers.
  • Increased drive toward top-line revenues.

About Fibroblast

Fibroblast is a Chicago-based health technology company on a mission to fix the broken referral process to ensure that no patient falls through a crack in the healthcare system and misses out on potentially lifesaving care. Fibroblast automates the physician referral process and reduces patient leakage from provider networks, increasing revenue and mapping referral patterns in real-time. In the fee-for-service context, Fibroblast closes the referral loop to drive top-line revenues, increase patient satisfaction, and improve patient outcomes through better access to care. In the fee-for-value context, Fibroblast’s automated referral platform reduces risk by driving referrals to the highest quality, lowest cost providers, improving profitability, patient outcomes, and population health.  Fibroblast is venture-funded, an alum of Excelerate Labs/TechStars and 1871, and a founding member of Matter, a community of healthcare entrepreneurs and industry leaders working together in a shared space to individually and collectively fuel the future of healthcare innovation.

About Presence Health

Presence Health is the largest Catholic health system based in Illinois, created in November 2011 through the merger of Provena Health and Resurrection Health Care. With more than 150 sites of care, including 12 hospitals, Presence Health has more than 20,000 employees, 4,000 medical professionals and a revenue base of $2.7 billion.

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28th Apr
Posted By

Health-software startup Fibroblast gets a leg up

Fibroblast is in the news! Check out this article by John Pletz of Crain’s Chicago Business.

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21th Apr
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The Shift (Part 1) – Dispelling the Shroud of Complexity: HHS’s Plan to Shift Medicare Payments from Volume to Value

By Miranda Crowell

 

Every so often, an industry will undergo a core-shaking and fundamental transformation; an absolute overhaul. The transformation can permeate throughout the industry. As you know, the healthcare industry has been riding a roller-coaster since the announcement of the Affordable Care Act. But the ride is far from over, and the Department of Health and Human Services (HHS) has built yet another addition to the coaster’s track.

Before the healthcare market was pulled kicking and screaming into compliance with massive Affordable Care Act (ACA) legislation, it was generally accepted that the United States had one of the most expensive health care systems in the world. And this lofty price tag did not exactly correlate with health outcomes: consumers paid more for healthcare that was arguably inferior to the services that could be obtained in other countries for less cost. (For a 2014 study on the matter, check out The Commonwealth Fund’s Study here.) This problem needed to be addressed. Boiling down the hundreds of pages of the Affordable Care Act, there are three goals at the heart of the ACA: (1) Coverage: to expand access to health insurance, (2) Costs: to protect consumers from the arbitrary actions of insurance providers, and (3) Care: to reduce costs of care and to protect the autonomy of consumer choices. In early 2015, HHS announced goals and timelines to change payment models for Medicare from quantity-based to quality-based payments. This announcement fits nicely within the goals of the Affordable Care Act. As Secretary of HHS Sylvia Burwell said in a press release on the matter, “it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.” Value-based payments strive to provide healthcare providers with a financial incentive to coordinate care for their patients and to move away from delivering care in chunks of tests and waives of treatments.

The Announcement

According to the HHS announcement, this shift is the first time that “HHS has set explicit goals for alternative payment models and value-based payments” in the history of the Medicare program. By the end of 2016, HHS intends to tie 30% of Medicare payments to quality or value through alternative payment models, such as Affordable Care Organizations or bundled payment arrangements, and plans to increase this number to 50% by the end of 2018. Additionally, HHS intends to tie 85% of all traditional Medicare payments to quality or value by 2016, and 90% by 2018, through programs such as the Hospital Readmissions Reductions Programs and Hospital Value Based Purchasing.

“What does all that mean,” you ask?

Don’t worry, we will walk you through it.

The Explanation

Many of the value-based payment puzzle pieces were envisioned in the ACA, and this announcement promulgates a timeline for implementation. As mentioned, an important piece of the HHS announcement is the healthcare provider’s participation in an Accountable Care Organization (ACO). According to the Centers for Medicare and Medicaid Services, ACOs are “groups of doctors, hospitals, and other health care providers, who come together voluntarily and give coordinated high quality care to their Medicare patients.” The main perk of participating in an ACO is that the participants share in the savings achieved for the Medicare program when the ACO is successful in lowering costs and giving high-quality care simultaneously. There are a few types of ACO programs. First, the Medicare Shared Savings Program helps Fee-for-Service providers become an ACO. Second, the Advance Payment ACO Model is an additional incentive program for select participants participating in the Shared Savings Program. Lastly, there is the Pioneer ACO Model; however, if you are not already enrolled in this model, you have missed the boat, as this program was designed for early adopters and is no longer accepting applications.

The Hospital Readmissions Reductions Program is, at the very least, well-named. In short, parts of the ACA amended the Social Security Act to establish this program. It requires CMS to reduce payments to certain hospitals that have excess readmission. Those certain hospitals use what is called an inpatient prospective payment system; a system whereby hospitals treating inpatient Medicare Part A patients are paid based on the weight assigned to a specific diagnosis-related group. It sounds complicated, but the short of it is, certain hospitals will be receiving reduced payments from CMS when excessive readmissions occur. Additionally, Congress authorized Hospital Value-Based Purchasing via the ACA. Hospitals participating in hospital value-based purchasing are paid for the inpatient acute-care services they provide based on the quality, not the quantity, of the services they provide. This program takes advantage of the hospital quality data-reporting infrastructure developed for the Hospital Inpatient Quality Reporting Program.

The HHS announcement specifically set measurable goals pertaining to the Medicare program, but HHS does not intend to limit the shift to just Medicare payments. In order to encourage and assist the entire market to jump on the value-based-payment bandwagon, Secretary Burwell also announced the creation of the Health Care Payment Learning and Action Network. This network was “established to provide a forum for public-private partnerships to help the U.S. health care payment system meet or exceed recently established Medicare goals for value-based payments and alternative payment models.” (For more information on the network, click here.) This network is an open-invite style party for all “payers, providers, employers, purchasers, states, consumer groups, individual consumers, and others.” Other tools are also available. For example,  Health Care Transformation Task Force is an industry consortium that brings together private and public sector efforts to align with HHS’s value-based payment goals. This task force has many players ranging from patients to payers and strives to achieve 75% of their businesses operating under value-based payment arrangements by 2020.

Undoubtedly, the shift in Medicare payment styles will set the tone for the rest of the industry. This brief explanation of HHS’s plan to convert Medicare payments to a value-based system is Part 1 of a three-part series aimed at dispelling (or at the very least, diluting) the shroud of complexity surrounding the HHS announcement. In Part 2, we will explore various opinions about the shift in Medicare payment styles, and outline the obstacles that must be overcome in order to comply with HHS’s plan. And finally, Part 3 will discuss how the announcement will impact persons working with, but not necessarily within, the healthcare industry. Be sure to check out https://fibroblast.com/blog/ for the series as it is released.

 

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25th Mar
Posted By

Bread, Milk, Eggs, and . . . Healthcare? The Advantages and Limitations of Retail-Based Health Care Clinics

By Miranda Crowell

 

It’s not groundbreaking news that retailers such as Walgreens, CVS Health, and Walmart offer medical care to consumers “on the go.” But in the words of Emeril Lagasse, some of the retail clinic providers have really “kicked it up a notch.” From an expanded scope of services to a heavy use of technology, retail clinic providers continue to shake up and successfully compete in the healthcare market.

Here are just a few examples:

CVS Health removed all tobacco products from its shelves in September 2014, a month ahead of schedule, added the word “Health” to its corporate name, and racked up over 900 locations of Minute Clinic across 31 states and the District of Columbia. CVS Health’s website touts that the Minute Clinics have clocked over 24 million patient visits with a 95% satisfaction rating. Even more interesting is the fact that CVS/Minute Clinic has received accreditations from the The Joint Commission (the national evaluation and certifying agency for health-care organizations and programs in the United States) on more than one occasion.

Walgreens has formed partnerships with WebMD to give Walgreens customers access to “virtual wellness-coaching programs.” Furthermore, Walgreens uses the Balance Rewards program to reward their customers for exercising, for tracking their blood glucose levels, and for accomplishing fitness goals. For instance, a customer can get 20 points for jogging a mile. The Walgreens Healthcare Clinics are integrated into Walgreens stores, and a customer can schedule an appointment online. I downloaded the Walgreens app and checked out a few of the clinic’s features online. Some of the features I found most impressive were the complete cash price list for customers who will not be using insurance for their visit and the ability to securely chat with a member of a pharmacy team through the app. Additionally, scheduling an appointment was a breeze on the company’s app, and I could easily see if Walgreens accepted my insurance on their website.

Walmart has taken their services a step further. While most retail clinic providers offer medical care for non-urgent matters such as sore throats, physicals, and basic testing for things like blood glucose and strep throat, Walmart claims to be different. And to prove it, Walmart states that its “expanded scope of services enables [it] to be [the customer’s] primary medical provider.” (emphasis added).

For purposes of this discussion, if one defines the healthcare consumer as a person in need of basic medical care, then the benefits of choosing a retail clinic over other medical  providers are clear: scheduling convenience (including convenient locations, extended hours, and online scheduling tools), price transparency, and timeliness. In 2014, The Advisory Board Company asked almost 4,000 consumers what they preferred in a health care clinic treating low acuity illnesses like sore throats. With little surprise, convenience holds the key: walking into a clinic without an appointment and being seen within half an hour was ranked first out of 56 variables. Traditional primary care delivery models are not ignoring the shift either. For example, Novant Health has partnered with Target in select locations to open walk-in clinics, and Temple University Health Systems operates ReadyCare clinics in Philadelphia. But what happens when what the customer thinks is a simple sore throat turns out to be something more troublesome?

While transparency through websites, apps, press releases, etc., of retail clinics is seemingly high, one area is lacking: information on patient referrals. Retail clinics are positioned to refer patients should their case become complex, but with many retail clinics offering chronic disease management, some cases that would usually be involved in referral process can be kept within the clinic doors. As Ronald L. Hammerle, President of Health Resources, stated, “The sophisticated player recognizes that whoever controls point of entry [to health services] manages the downstream revenue.” In other words, clinics with broad services, such as chronic disease management, can grow their business (leading to increased revenue) and partner with surrounding hospitals and doctor’s groups to gain new customers. But if a referral is needed, it is unclear from the retail clinics’ websites and apps how the referral will take place. Walmart’s website at least acknowledges that they can and “will be glad to” refer out a patient should the need arise. So, I took to the street to find out.

Stopping by a Chicago location of a Walgreens Healthcare Clinic, I asked the nurse practitioner how she refers patients to other doctors and specialists should the need arise. A little hesitant, she referred me with a smile to their national patient support center. (I also tweeted Walgreens the questions; I was referred to the same number). While listening to the automated voice serving to filter my call, I was informed that Walgreens Healthcare Clinics can send a summary of the visit to the patient’s primary doctor, although it does not specify how this sharing will occur. Once speaking with a representative, I was told the referral process all depends on the nurse practitioner on duty at a particular clinic and on the patient’s specific needs. In short, it is up to the nurse practitioner’s discretion as to how a patient referral is made.

The referral process from healthcare clinics to primary care doctors or specialists raises some eyebrows. On a previous Fibroblast Blog post, I posited that there are ways to mitigate medical malpractice in the patient referral process. The same concerns apply when the referring clinic is a retailer. Those medical malpractice concerns can be addressed by, inter alia, (1) referring a patient in certain situations, (2) clearly communicating patient education points, (3) securely transmitting patient health information, (4) utilizing a patient referral coordinator, and (5) clearly severing the patient/doctor (or in this instance, nurse practitioner) relationship. But when little is known about the referral process, a nurse practitioner may remain exposed to liability because it is unclear who is actually responsible for the particular patient’s care. Without more specifics on the procedure of a patient referral from a retail health clinic to a traditional doctor’s office, it seems that patient referrals may be the one limitation to retail health clinics. Moving forward, communication of a clear referral process could assist the patient in making an educated decision as to whether or not they should visit a particular health clinic. But in the present, your next health visit could be just a few clicks away.

 

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17th Mar
Posted By

A Brief “Exchange” on the Matter of King v. Burwell

 

By Miranda Crowell

 

In what some legal scholars are calling a “sleeper” case, the next challenge to the Affordable Care Act (ACA) was argued before the Supreme Court on March 4, 2015. King v. Burwell has likely been flying under the radar because of its über technical questions of standing, administrative law, and statutory interpretation, leaving the non-lawyer (and even most lawyers) scratching their heads.

Here is the skinny on this not so small case. In short, Petitioners, financed by the Competitive Enterprise Institute, are Virginia residents who did not want to purchase comprehensive health insurance. The Petitioners brought an action to challenge the Internal Revenue Service’s final rule which implemented a premium tax credit provision of the ACA. This final rule interprets the ACA as authorizing the IRS to grant tax credits to persons who buy health insurance on both federally- and state- facilitated “exchanges.” The Petitioners, making a textual argument, insist that tax credits can only be authorized for individuals who purchase insurance on state-ran exchanges. On the other hand, the government’s position is that tax credits can be authorized for persons who purchased insurance in both federally- and state- facilitated exchanges. Thirty-four states have federally-ran exchanges; thirteen states and the District of Columbia operate their own exchanges. Three states operate as a federal-state hybrid. As complex as the issues are in this case, the Justices will be asked to interpret and provide a final ruling on these four words: Exchange established by the State. But as we all know, a plain reading of the words in isolation is not the end of the road; even the capital letter “E” provides clues that will help the Justices make this gargantuan decision.

It is important to know that predicting the outcome of a case based on oral argument outcomes is a dangerous rabbit hole, but oral arguments can be helpful in convincing any Justices sitting on the fence of an issue. Without sending our readers into a never-ending saga on whether or not §1311 is properly deemed a “definition” or that misnomer is more properly characterized as a requirement, we do know a few things after oral argument. First, the theme of King v Burwell is undoubtedly federalism, and the Solicitor General did lean in on this theme. Second, while the Court did raise some questions on the issue of standing, it does not seem that standing or mootness will impede the Court in reaching the merits of the case. Third, Mr. Carvin, arguing for the Petitioners, raises a reasonable and fair argument (through the slightly comical overuse of the word “scintilla”)  that a plain language reading of the statute will operate in favor of petitioners. And for anyone who follows the highest Court, you already know that Justice Scalia consistently supports a textual interpretation. Lastly, Justice Kagan received a host of laughter with an analogy about a memo assigned to her clerks, and she noted that, surely, Congress did not intend what she classified as a “Draconian choice” for the states. (And as an aside, Twitter user @SCOTUSHUMOR tallies Kagan as the true winner of SCOTUS laughs in Burwell.)

According to Reuters, 7.5 million people in at least the 34 states operating federally-ran insurance exchanges will lose subsidies if the Petitioners prevail. These subsidies assist low- and moderate-income people in affording insurance. If the Petitioners prevail, it is safe to say that the individual insurance market will be disrupted in a big way. But on the other hand a Government win will set precedent for great levels of deference to agencies. President Obama thinks this is a pretty straightforward case in favor of the Respondents (the Government), but legal scholars such as Jonathan Adler side in favor of the Petitioners. No matter which side of the issue you fall on, King v. Burwell will play a key role in the ACA moving forward.

 

 

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