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Patient Protection and Affordable Care Act (ACA). Individual mandate (2014) State insurance exchanges Expansion of Medicaid program Changes to private insurance Employer requirements mandates Medicare changes. Untruthful Assertions. Cuts Medicare by $1000 per person
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Patient Protection and Affordable Care Act (ACA) • Individual mandate (2014) • State insurance exchanges • Expansion of Medicaid program • Changes to private insurance • Employer requirements mandates • Medicare changes
Untruthful Assertions • Cuts Medicare by $1000 per person • Both ACA and the Ryan plan reduce increases in spending in the future by over $700 billion over 10 years • Establishes death panels • Payment to physicians for holding advance care planning discussions was cut from the Act
U.S. spending much more for older ages Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009.
Medicare • Reduce payments to Medicare Advantage • MA plans were paid 113% of FFS • Some bonuses for high quality programs • Balance payments to high/low areas • Establishes an “Independent Payment Advisory Board” • Early donut hole relief – eventual elimination • Coverage for prevention services
Independent Payment Advisory Board • Recommend cost savings • Produce public reports – access, quality, costs • Make recommendations to President and Congress • Prohibited from “rationing” or “changing benefits or eligibility” or “Medicare premiums” • Hospitals and hospices not subject to recommendations until 2019
Donut Hole Relief 2011 • $250 rebate • 255, 996 FL seniors received the rebate • Total amount to FL seniors - $63,999,000 • Part D coverage gap discounts • 252,989 • Ave. per senior - $600 • Total amount - $151, 807,700 Kff.org, 1/7/13
Prevention & Wellness in FL • Free preventive services • 1,662,014 FL seniors received free services • 70% of FL Part B enrollees (65.5% US) • Annual wellness visit • 151,133 FL seniors had an annual wellness visit • 6.9% of FL Part B enrollees (5.4% US) Kff.org, 1/7/13
Older Adult Workforce • Funds Geriatric Education Centers • Expand Geriatric Academic Career Award to other disciplines (nursing, pharmacy, etc.) • New Geriatrics Career Incentive Award • Advanced training opportunities • Professionals • Direct care workers
Elder Justice • Create an Elder Justice Coordinating Council • Report published in May 2013 • http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/Meetings/docs/2013_05_13_EJCC-Proposals.pdf • $400 million for Adult Protective Services • $100 million for state demonstration grants • $26 million to create Elder Abuse, Neglect and Exploitation Forensic Centers
New Models of Care • Innovation Center at CMS • Foster patient-centered care & coordination • Models • Accountable Care Organizations • Bundled payments • Medicare Coordinated Care • Partnerships for patients • Comprehensive Primary Care
Problems with Medical Payments • Fee-for-service • Provider (not the consumer) decides what is needed • Insurance (not the consumer) pays the fees • Provider is incentivized to do more • Capitation (“by the head”) • Insurer decides what is needed • Insurer pays provider regardless of use • Provider is incentivized to do less
Accountable Care Organizations (ACO) • An organization of physicians and hospitals that agree to cost and quality targets • Strong primary care base • Payment is linked to quality (instead of volume) • Savings are achieved through improvements in care • Savings are shared between providers and CMS
Bundled Payments • “Bundling” expenses that used to be separate • Hospital admission and after care • Surgery and a “warranty” • Considerations • Hard to predict costs • Difficult cases may be avoided • Doesn’t discourage unnecessary care
Medicare Coordinated Care • Funds coordinated care for people with chronic conditions • 15 programs • Face-to-face meetings with client • Helped with medications • Facilitated communications (“hub”) • Helped with transitions • 8%-33% reduction in hospitalizations • Cost neutral
Comprehensive Primary Care • 4 states (OR, CO, AK, NY) • Components • Risk adjustment • Access and continuity • Non-visit services & fees • Planned care for chronic conditions • Patient and caregiver engagement • Coordination od care
Partnerships for Patients • Reduce hospital-acquired conditions and readmissions • Elements • Hospital Engagement Networks (TMH) • Care Transitions (5 sites in FL) • Patient and family engagement • Provides resources to health care providers to better educate staff and patients/families
Elephant in the Room - LTC • Nursing homes - $100,000/year • Many become impoverished and go on Medicaid • Low satisfaction • CLASS act – (part of ACA) – would have established a national LTC insurance • Dropped by Democrats • Are some interesting new models • Eden Alternative, Greenhouse Model
4 2 3 1 5 1 – Affordability & Access - 35 4 – Support of family caregivers - 40 2 – Choice of setting & provider - 41 5 – Effective transitions - 14 3 – Quality of life & quality of care - 43 State Scorecard on LTSS Commonwealth/AARP 2014
Few Good Things in LTSS in ACA • National panel of LTC experts • Report issued Sept. 2013 • Funding for LTC Ombudsman Program • Funding for LTC training and recruitment • Nursing home transparency • Some financing options • Money follows the person • Home health and HCBS
Nursing Home Transparency • Disclose ownership, financers, etc. • Take steps to reduce violations • Establish quality assurance programs • Provide dementia care training • Data collection requirements • Pilot program – extend to all states a national criminal background check system
Good Resources • Kaiser Family Foundation • http://kff.org • CMS Innovation Center • http://innovation.cms.gov/initiatives/#views=models • Eden Alternative • http://www.edenalt.org • Greenhouse Project • http://thegreenhouseproject.org • Autumn Blossoms • http://autumnblossoms.org