Transcript Prostate Cancer Symposium Chicago

Annual Prostate Cancer Forum
October 27, 2012 • NYU Kimmel Center • New York, NY
Robert Schermer, MUP
Strategic Innovation Management, LLC
Annual Prostate Cancer Forum
October 27, 2012 • NYU Kimmel Center • New York, NY
Getting the Care You Need:
Understanding the Affordable
Care Act
Robert Schermer, MUP
Strategic Innovation Management, LLC
Annual Prostate Cancer Forum
October 27, 2012 • NYU Kimmel Center • New York, NY
Patient Protection and
Affordable Care Act
A Presentation by
Bob Schermer
Morris Regional Public Health Partnership,
Inc. ©
Why?
• Increasing and aging population is accelerating health services
demand;
• Health services demand increase after 50 years of age
• Increasing numbers of uninsured persons=reduced access to
services;
• Health care costs increasing faster than those of other
economic sectors
• Large portion of health services paid for by government
• Public & private insurance waste, fraud and discrimination
• Fragmented industry with inefficiencies and waste
• U.S. Population is increasingly unhealthy
Institutional Focus On Cost Savings Has Led To:
Institutional focus on cost savings has led to:
 Competition among charitable organizations and
curtailment of their services and service quality;
Incentives for insurance companies to restrict benefits paid
for with premiums;
Incentives for physicians to specialize in order to increase
revenues; and consequently,
A need for more primary care physicians.
There is no national system for preventive services;
our system primarily addresses acute emergent
problems.
Some Problems in New Jersey
Commonwealth Fund ranks NJ nationally:
•27th for access to services – 47th for Children
•21st for prevention – 41st for children requiring mental health
care,
•37th for children with a medical home
•48th for potentially avoidable use of hospitals and costs of care
•50th for Medicare reimbursements per enrollee
•46th for long term care residents with a hospital admission
•45th in breast cancer deaths per 100,000 female population
•29th for children’s obesity
Is the law a
band aid?
Or is it a
monster?
Major Purposes: Improve Patient Care and
Services and Reduce Costs.
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Reform wasteful practices with better
management, evaluation and quality
improvement;
Initiate new practices and service models
(including some experimentation);
Provide a strong emphasis on prevention;
Improve transparency of operations;
Integrate health services to improve access and
continuity of care and control costs.
Some Controversies
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Is this socialism?
Are there “Death Panels”?
Are $716 billion being cut from Medicare?
Just what does the law require you to do if
you have to buy health insurance?
A Whole New World
The Way It Works
• The Law is Passed – 2010
• National Regulations, Policies and Guidelines Follow:
 Definitions & Intended Funding are Stated
 Oversight Organizations Created: Commissions and Task
Forces
 Calendar of Implementation Including Demonstration
Projects Declared: 2010-2018
 Immediate Federal Implementation Commences for Some
Programs, Studies and Demonstration Projects.
State’s Activities
• Follows Federal Policies and Organizes to
Address Requirements of the Law
• State Passes Required Legislation and Regulations
 Initiates Prevention, Chronic, and Public Health
Programs
 Creates Insurance Exchanges
 Modifies Medicaid Regulations and Waivers
 Passes Accountable Care Law
• INFORMATION HARD TO GET
The ACA Has Nine Titles
• I- Quality, Affordable Care for all Americans
– (Primarily Reforms to Insurance and Licensed Facilities)
• II- Public Programs
– (Medicaid and Related Services)
• III- Improving the Quality and Efficiency of
Health Care
– (Evaluation, Oversight, Reporting, Quality Improvement, and
Other Contemporary Management Techniques.)
• IV- Prevention of Chronic Disease and
Improving Public Health
– (Private and Publicly Provided Services)
)
Titles V-IX
• V- Health Care Workforce
• (Support existing & increase supply with appropriate skills)
• VI- Transparency and Program Integrity
– (Require reports by providers on their measured results, and make
resulting information public)
• VII- Improving Access To Innovative Therapies
• VIII- CLASS ACT- Now rescinded
– Provides for voluntary insurance in community living settings, and during
emergencies.
• IX- Revenue Provisions
Title I – Quality, Affordable Health Care
For All Americans
Primarily addresses insurance reforms:
•Creates Insurance Exchanges and provides for consumer
information
•Specifies Insurance Policy Requirements (Guaranteed
Coverage Availability, Quality of Care, Prohibition of
Discriminations, Mandated Dependent Coverage, etc.)
•States Employer Requirements and Tax Credits
•Makes Individual Requirements and Mandates
•Requires reporting of coverage benefits leading to
improved outcomes, reduced readmissions, patient
education, improved patient safety, wellness and health
promotion activities.
Let’s Look at the Mandate
• By 2014. Most people in the United States will
be required to purchase health insurance. No
criminal enforcement is intended, but persons
not purchasing could lose their tax credit and
will be required to pay certain penalties if they
are of a certain income.
• Please see the handout.
Title II – Primarily Medicaid
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Medicaid for Population up to 133% of Poverty Income
Premium Assistance for Employer Based Insurance
Additional Support for Children (NJ Family Care)
Hospitals may exercise Medicaid presumptive eligibility
Coverage for freestanding birth centers
Home and Community Services Support and Barrier Reduction
(Includes development of formal evaluation and data
collection)
• State eligibility for family planning services
• Increased Support for aging and disabled
• Long Term Care Improvements for home and community
services
A Note About Medicare
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The purpose of the Medicare program is to provide healthcare services to fixed income
elderly persons who generally do not have large incomes.
Benefits are safe. There is nothing in the law that talks to eliminating existing benefits.
People will be able to keep their own physician.
At this time the law adds preventive screenings for disease to the Medicare package at no
cost outlay to the person receiving that service.
Prescription drugs cost less as the famous ”doughnut hole” shrinks and is eliminated.
The AARP reports that Medicare beneficiaries will save $4181 over the next 10 years under
the new law.
People who are high level drug users are expected to save $16,000 during the same period.
Regulations and payment incentives will be initiated in 2013 to prevent readmissions to
hospitals; a current major problem. Hospitals will be penalized financially if their readmission
rates are too high. To assist prevention of readmissions more home service benefits will be
provided to Medicare recipients.
Major effort will be made to pay physicians and hospitals on the basis of successful
outcomes, and not just for the number of services provided.
High income Medicare beneficiaries will make increased payments for part B and part D
benefits.
• Prescription Drugs Rebates, Discounts, and Elimination of
Exclusions
• Hospital Disproportionate Share Review and Adjustments
• Integration and Management Of Medicaid And Medicare Dual
Eligible Beneficiaries
• Hospital Disproportionate Share Funding Adjustments
• Development of Adult Health Quality Measures
• Payment Adjustment For Health Care Acquired Conditions
• Personal Responsibility and Education
• Health Homes for Low Income People with Chronic Conditions
(State Option)
• Grants for Early Childhood Visitation Programs to include maternal and
prenatal health, parenting, infant and child health development, school
readiness and reduction in child abuse, neglect and injuries.
• Research and services for postpartum depression.
• Personal responsibility education for adolescents (teen pregnancy).
• DEMONSTRATION PROJECTS
• Integrated Care among Hospitals and Community Settings
• Medicaid Global Payment System (from fee for service to capitated
payment
• Pediatric Accountable Care
• Medical Emergency Psychiatric
Title III – Improving the Quality and
Efficiency of Health Care
Created a National Strategy for Quality
Improvement in Healthcare and an Interagency
Working Group on Health Care Quality
 Establishes, among other subjects, national priorities, and measures for
services, health plans, patient functional status outcomes, population health,
management and coordination of services, transitions across providers.
Enforcement will affect most health services. Measures and reports to be
made public.
 State and federal activities to be coordinated
•Linked to payment for services
 Includes incentives and penalties for hospital and licensed facility
performance based on performance standards and measures;
 An initial focus on hospital re-admissions, infections, cardiac diagnoses,
pneumonia, surgeries
Title III – Quality and Efficiency
• Strategic Priorities
 Improve health services outcomes and efficiency
 Identify system elements that are likely to achieve
rapid improvement
 Address gaps in quality, efficiency, health outcome
information and data aggregation
 Link federal payments to quality and efficiency
 Enhance healthcare data for quality improvements
 Improve Quality Improvement Research
 Reduce disparities
 Reduce medical errors and re-admissions
Title III – Quality and Efficiency
• Physicians required to make quality reports of
their services and outcomes - to be made public
based on measured performance
 Use of electronic health records
 Will produce a database of comparative physician
experience and use of resources
• Quality measures developed and to be reported
will also apply to long term care, rehabilitation
hospitals, hospice, skilled nursing, and home
health.
Title III – Quality and Efficiency
• Intends the creation of new patient payment
and service delivery models with incentives
for their achievement, i.e.
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Medical Homes
Community Based Care
Post acute hospital coordinated care
Linking evidence based cancer care to patient
incentives
Title III – Quality and Efficiency
• Medicare Shared Services Program
 Accountable Care Organizations
 Savings obtained from providing services at
lower than historical costs are shared with
efficient and innovative providers
Title III – Quality and Efficiency
• Integrated Care and Payment Bundling
• Payment for combined inpatient and outpatient
services on the basis of episode groups
• Demonstration Programs to pave the way
• Community Based Care Transition Program
 For high risk Medicare patients to receive healthcare services at home
to prevent their readmissions
• Healthcare Systems Research
• Medicare Advisory Board created to advise
Medicare policy and budget
Title III – Quality and Efficiency
• Establish Community Health Teams to Support
the Patient-Centered Medical Home
 Create Interdisciplinary teams of health care
providers (which are the medical home)
 Purpose: care management, education and
prevention initiatives
 Uses continuous quality improvement techniques
 “Home” paid for on capitated basis
Title IV- Prevention of Chronic
Disease and Improving Public Health
• Created National Prevention, Health
Promotion and Public Health Council
• Developing a National Strategy for Health
Promotion, Prevention, Public Health and
Integrative Care to Improve the Health of
Americans and Reduce the Incidence of
Preventable Illness and Disability
Prevention, Chronic and Public Health
• Identifies Tobacco Use, Sedentary Behavior
and Poor Nutrition as the subject of Wellness,
Health Promotion and Public Health Goals
– Now being implemented in New Jersey (!!!)
– Creates a Prevention and Public Health Fund to
provide an expanded and sustained national
investment in prevention and public health
programs.
Prevention, Chronic and Public Health
• Creates the Community Transformation Program and
the Education and Outreach Campaign for Preventive
Benefits, and Immunization Programs
• Creates the Preventive Services Task Force
– Produces a Guide to Clinical Preventive Services
for science and evidence based best practices
• Creates an independent Community Preventive
Services Task Force
– Produces a Guide to Community Preventive
Services
Prevention, Chronic and Public Health
• Initiates the Education and Outreach
Campaign Regarding Preventive Benefits
– A public/private partnership for prevention and
health promotion, outreach and education.
– Promotes use of preventive services
recommended by the U.S. Preventive Services
Task Force and the Community Preventive
Services Task Force
Prevention, Chronic and Public Health
• Creates the School Based Health Centers
– Physical and Mental Health
– Comprehensive provision of health services
– Focus on areas of special need
Prevention, Chronic and Public Health
• Creates the Oral Healthcare Prevention
Program
– Education program
• Creates the Medicare Annual Wellness
Visit
– Results in a personalized prevention plan
based on a persons risk profile.
Prevention, Chronic and Public Health
• Removes barriers to preventive services in
Medicare
• Improves access to preventive services for
eligible adults in Medicaid
• Provides tobacco cessation services for
pregnant women
• Provides incentives for prevention of chronic
diseases in Medicaid
Prevention, Chronic and Public Health
• Creates Community Transformation Grants
– Dissemination of evidence based community
preventive health activities to:
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Reduce chronic disease
Prevent development of secondary conditions
Address health disparities
Develop a stronger evidence base of effective
prevention programming
– Being Implemented now in New Jersey (NJPN)
Prevention, Chronic and Public Health
• Create Healthy Aging, Living Well Program
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Directed to people 55-64 years of age
Improve nutrition
Increase physical activity
Reduce tobacco and substance abuse
Improve mental health
Promote healthy lifestyles
Conduct screenings
Prevention, Chronic and Public Health
• Public Health Intervention Program
- Grants for working with community health
centers, rural health clinics, and mental health and
substance abuse service providers to assist
referrals of at risk patients.
• Removing Barriers and Improving Access to
Wellness for Individuals with Disabilities
Prevention, Chronic and Public Health
• Immunization
– Demonstration program to improve immunization
coverage
• Nutrition Labeling of Standard Menu Items at
Chain Restaurants
• Demonstration Project Concerning
Individualized Wellness Plans
Prevention, Chronic and Public Health
• Research on Optimizing the Delivery of Public
Health Services.
- Evidence based prevention
- Identifying strategies for organizing, financing and
delivering public health services in real world
community settings.
• Data Collection, Analysis and Quality
Prevention, Chronic and Public Health
• CDC Employer Wellness Programs
– Provides employers with technical
assistance for wellness programs
• Prevention, Chronic and Public Health
• Childhood Obesity Demonstration
project
Title V – Health Care Workforce
• Establish National Health Care Workforce
Commission
• Assess national need for healthcare workforce
• Increase supply of qualified workforce to improve
access
• Enhance workforce training and education
• Provide assistance to existing workforce
• Promote positive health behaviors and outcomes
Title VI – Transparency and Program
Integrity
• Elder Justice
• Create Elder Justice Coordinating Council
– Studies elder abuse, neglect and exploitation, and
other crimes against elders.
– Makes short and long-term multi-disciplinary
strategic plans for the development of the field of
elder justice.
– Provides grants to State Adult Protective Services
Title VI – Transparency and Program
Integrity
• Makes publication requirements reporting
payment transactions between physicians and
manufacturers
• Includes reporting of drug sample practices by
pharmaceutical firms and pharmacists
Title VII – Improving Access to
Alternative Medical Therapies
• Will consider creating standards for and safety
of biological products intended to be used as
alternatives to currently approved products.
Title VIII – CLASS ACT - CANCELLED
• Community Living Assistance Services and
Support
• Establish a national voluntary insurance
program for purchasing community living
assistance services and supports:
– To promote independence of individuals with
functional limitations.
– The CLASS program is designed to expand options
– for people who become functionally disabled and
require long-term services and supports.
Title IX – Revenue Provisions
• Hospital Community Assessment Requirement
• Miscellaneous fee requirements and
eliminations
Had Enough? . . .One More Thing
Sources of Information
• Robert Wood Johnson Foundation [www.rwj.org] (general
information)
– RWJF News Digests [[email protected]]
– RWJF Publications [[email protected]]
• Status of the law (general information)
– www.healthcare.gov
• U.S. Department of Human Services – (general information)
• www.hhs.gov
• Commonwealth Fund (general information)
– http://www.commonwealthfund.org/
Shaping New Jersey (general information)
[email protected]
NJ Healthy Aging (general information)
[email protected]
Sources Of Information
• The Full Affordable Care Act (the law)
– www.scribd.com/doc/30194273/hr-3590
• Community Catalyst (advocate)
– http://www.communitycatalyst.org/resources/
• The Heritage Foundation (opposes the law)
– http://www.heritage.org/
• USEconomyAbout.com (economic information)
• Healthcarefinancenews.com