Academic Issues in the Affordable Care Act and the Future

1. Academic Issues in the Affordable Care Actand the Future Texas Family Medicine Leadership Conference Hope R. Wittenberg Director, Government Relations Council of Academic Family Medicine February 17, 2011

2. ACA and the Future ACA provisions of interest to academic family medicine Advocacy for the future: Environment today Specific legislation/issues Family Medicine Congressional Conference Advocacy Training

3. The Affordable Care Act of 2010 Organized Family Medicine’s approach to health care reform: Support specific issues relating to academic family medicine Foundational Principle: Move the U.S. Health care system to one where its characteristics are associated with improved outcomes and decreased cost

4. Programs for which we advocated strongly Goal: Aim to increase the primary care workforce and accessibility to high quality care for all Enhanced health professions primary care training grant funding (Title VII) Technical changes to Medicare GME non-hospital training (Volunteer Preceptor Changes) Medicare GME slot re-distribution Rural Physician Training Program Primary Care Extension Service Teaching Health Centers National Workforce Commission

5. What Did We Get?

6. Title VII: Primary Care Cluster Reauthorized at $125M 5 year Grants Dentistry removed PAs get 15% Includes Research in AAU and fac dev grants 9 New priorities Grant announcement Withdrawn; reissued 5 pts for each priority Awards process late Larger awards to cover 5 yrs

7. ACA: Primary Care Residency Expansion Surprise Initiative – Not specifically Included in ACA Creative Use of Prevention Trust Fund - $250 M Expansion of Residency Positions – 82 residents $80,000 Direct GME ONLY Controversial Program

8. ACA: Primary Care Residency Expansion TOTAL: $7.7 m

9. Title VII – Rural Physician Training Grants Not in the primary care cluster New provision establishes a grant program to help medical schools recruit students most likely to practice medicine in underserved rural communities, provide rural-focused training and experience, and increase the number of medical graduates who practice in underserved rural communities. Authorized at $4 M Program won’t be implemented unless funding is appropriated for FY2011, even though program authorized for FY2010 Secretary will need to define “underserved rural area” students must come from underserved rural areas AND wish to practice in same areas Interim final rule published in July, 2010 No changes suggested unless program is funded

10. GME Nonhospital Training: Effective July 1, 2010Volunteer Preceptor Win!! Modifies DGME and IME funding to count costs incurred at nonhospital settings Volunteer Preceptor Fix Removes 90% requirement “All or substantially all” defined as resident stipends and benefits Will still need written agreement Hospital sharing of resident time: hospital that pays can claim Didactic Time Vacation, Sick or Approved Leave Implementation August 3, CMS published proposed rule implementing GME regulations November 24, Final GME Rule Published.

11. Effective, July 1, 2010

12. GME Slot Redistribution: Effective July 1, 2011 Reduce resident cap level by 65% of the difference between cap and actual resident FTE count. Exception: rural hospital with < 250 beds Hospitals that receive new slots – five year maintenance of effort maintaining average number of primary care positions for last 3 recent cost reporting periods At least 75% of new slots for primary care or general surgery IME update factor remains the same as other GME positions January 21, Deadline for applications for new slots

13. Real World – Who gets the slots?Not Texas! Eligibility Criterion: Demonstrate Likelihood of Filling If meet this criterion, can go forward

16. Real World – Who gets the slots?Not Texas! Montana, Idaho, Alaska, Wyoming, Nevada, South Dakota, North Dakota, Mississippi, Florida, Puerto Rico, Indiana, Arizona and Georgia Louisiana, Mississippi, Puerto Rico, New Mexico, South Dakota, District of Columbia, Montana, North Dakota, Wyoming and Alabama 70 % to 13 states- R to P ratio 30% to 10 states - HPSA If all slots are not spoken for, hospitals in rural areas are next in priority

17. Teaching Health CentersEffective Date; July 1, 2010 Development Grants: Allows the Secretary to award grants (under Title VII) to THCs to establish new accredited or expanded primary care residency programs. These would be considered planning grants. Authorized funds equal $25 million for FY 2010 and $50 million for FY 2011-12. THCs defined as community based ambulatory patient care center that operates a primary care residency program; listed as FQHC, rural health clinic, community mental health center, health center operated by Indian Health Service, or a center receiving Title X grants

18. Teaching Health CentersEffective Date; July 1, 2010 Operating Funds: Operating funds for direct and indirect costs would be established through a mandatory appropriations trust fund equal to $230 million over five years. Payment is only for expansion -- funding for residents above a base level -- or establishment of new programs. Funding is only to programs where the teaching health center is the institutional sponsor of the residency program. Allows up to 50% fulfillment of NHSC service obligation time through clinical teaching at Teaching Health Centers

19. Teaching Health CentersEffective Date; July 1, 2010 Direct GME: Established by formula Indirect GME: Methodology to be determined by Secretary – how this is done will be key $150,000 per resident (DME and IME) 1st year interim payments; future years dependent upon data collected from awardees Notice of Proposed Rulemaking to come

20. 2011 Awards

21. Primary Care Extension ProgramEffective Date, FY2011 Establishes a Primary Care Extension program Purpose: support and assist primary care providers with the incorporation of techniques to improve community health. State Hubs and local extension programs may be created. $120 million is authorized for FY 2011 and FY 2012 and as much as necessary in FY 2013 and FY 2014.

22. AHRQ’s General Spending Authority NEW Grant Announcement: Deadline February 15: Infrastructure for Maintaining Primary Care Transformation (IMPaCT) – Support for Models of Multi-sector, State-level Excellence (U18) 3 Awards – total $1.5 million in FY2011 No grant over $500,000 per year or $1,000,000 over two years

23. National Healthcare Workforce Commission National Commission Independent like MedPAC Appointed by Comptroller General Conduct studies and make recommendations to Congress Consult with HRSA and State workforce grant program Receive and Assess reports from the National Center for Health Workforce Analysis Majority of members NOT directly involved in health professions education or practice 15 members Only 1 Family Physician Appointed

24. State Healthcare Workforce Commission State Health Care Workforce development grants Grants to states Administered by HRSA Planning grants (1 yr) Implementation (2-3 yrs)

25. National Center for Health Workforce Analysis National Center for Health Care Workforce Analysis $12 million FY2010 Coordinate with Nat’l Commission Develop national workforce data Establish performance measures and benchmarks for Title VII programs Annually Evaluate Title VII programs Establish nat’l registry of Title VII grants and database to collect data from longitudinal evaluations

26. Longitudinal Evaluations Advisory Committees to establish guidelines Funded as supplements to Title VII grants

27. Age of Aquarius: Are We There Yet? Harmony and understandingSympathy and trust aboundingNo more falsehoods or derisionsGolden living dreams of visionsMystic crystal revelationAnd the mind's true liberationAquarius!Aquarius!

28. Election Impact Key Republican Goals Deficit Reduction Spending Cuts Grow the Economy Repeal Health Care Reform Key Democratic Goals Deficit Reduction Freeze on Domestic Spending Grow the Economy Preserve Health Care Reform

29. Reality Check New Congress – New Culture • Three Goals of Republicans • Get the Government Out • Deficit Reduction • Defeat President Obama • Three Goals of the Democratic • Government Serve the People • Deficit Reduction • Don’t lose the White House or the Senate

30. Get the Government Out Attempts to Roll Back Health Care Reform • Full Repeal – Only successful in the House • No funding for new programs included in the ACA • Possible De-funding of mandatory appropriations or repeal of specific programs included in ACA

31. Deficit Reduction • H.R. 1 – Continuing Resolution Introduced February 11 March 4 Deadline for current CR Over $100 billion in cuts Title VII and VIII brought to FY2008 levels – a 29% cut • GME is on the table for cuts and transformation (Heritage Foundation, President’s Deficit Reduction Commission) • Use health care reform funding to pay for other cost items (eg. Repeal of 1099 form; malpractice, SGR) • Debt Ceiling Vote

32. Defeat President Obama "But the fact is, if our primary legislative goals are to repeal and replace the health spending bill, to end the bailouts, cut spending and shrink the size and scope of government, the only way to do all these things is to put someone in the White House who won’t veto any of these things," Senator Mitch McConnell, Minority Leader of the Senate at a Heritage Foundation Function

33. Why All the Discord? From Brigette Jordan, Birth in Four Cultures, 4th Ed., p152, by way of Jerry Kruse’s Plenary address at the 2011 Medical Student Education Conference Authoritative Knowledge: “To legitimize one way of knowing as authoritative, adherents devalue and often totally dismiss all other ways of knowing. Those who espouse other systems are seen as backward, ignorant, or naïve trouble makers…”

34. Our Environment Michael Kinsley (political pundit, writer, liberal former half of Cross-fire): The only thing supporters of Obama's health care plan have going for them is the truth. Paul Ryan (R-WI) Chair of House Budget Committee: Health care spending is driving the explosive growth of our debt. And the President’s law is accelerating our country toward bankruptcy.

35. Now What? • CAFM Agenda • Status of Key Issues/Goals • COGME 20th Report • Specific Issue “Asks” • Advocacy, Advocacy, Advocacy

36. CAFM Agenda Title VII funding – keep what we have, increase funding GME – Maintain Funding GME Modernization Pilot Workforce Development Research – explore funding stream for primary care research Support AAFP efforts on physician payment, PCMH, ACOs….

37. Issue Status • Title VII Funding • Continuing Resolution • President’s FY2012 Budget • Grant cycle • Other Discretionary Spending • National Health Service Corps • AHECs • NIH • Community Health Centers • AHRQ

40. COGME 20th ReportAdvancing Primary Care Authorized by Congress to provide ongoing assessment of physician workforce trends, training issues and financing policies. Primary Care’s Workforce Bible: “There is compelling evidence that health care outcomes and costs in the United States are strongly linked to the availability of primary care physicians.” http://cogme.gov/20thReport/cogme20threport.pdf

41. COGME’s 20th Report Number of Primary Care Physicians – At least 40% Physician Payment and Practice Transformation Pre-medical and Medical School Environment Graduate medical education payment and accreditation policies AND a significant increase in Title VII should support the 40% goal Geographic and Socioeconomic Maldistribution of Physicians

42. COGME 20th Report, cont. The Number of Primary Care Physicians: At least 40% of all physicians (measured once in practice) Physician Payment and Practice Transformation To achieve the desired ratio of practicing primary care physicians, the average incomes must achieve at least 70% of the median income of all other physicians. Financial rewards for care coordination, improvements in performance measures, PCMH, bundling payment models for ACOs

43. COGME 20th Report, cont. Premedical and Medical School Environment Resources should be allocated to increase involvement of primary care physicians through all levels of medical training Support student primary care interest groups Recruit and develop community physician faculty Require student participation in rural, underserved, and/or global health experiences Expand Class size strategically Reform admission processes, And more….

44. COGME 20th Report, cont. Graduate medical education payment and accreditation policies AND a significant increase in Title VII should support the 40% goal. Support more training in outpatient settings and practice models Strategically increase the number of new primary care GME positions and programs to accommodate production of graduates to meet 40% goal Increase training in ambulatory, community and medically underserved sites – reallocation of existing funding, new funding not calculated by Medicare bed-days, expansion of Title VII, directly provide GME funding to primary care residency programs…and on…

45. COGME 20th Report, cont. Geographic and Socioeconomic Maldistribution of Physicians Support and expand programs that have proven effective in addressing maldistribution, such as National Health Service Corps, Title VII, Section 747, AHRQ funding for community-based research, community health centers that teach students and residents, and AHECs

46. GME Modernization Pilot Modernize Medicare GME for Primary Care Training Family Medicine’s Ask: Introduce legislation to establish a pilot to test new models of financing graduate medical education for primary care production

49. What would the pilot look like? Budget neutral; five years At least 4 organizational models tested (2 of each) Robust payment amounts to accommodate: High cost of training in the community; money would follow the resident Provide incentives: - to medical students who choose a primary care - for training in underserved areas, - to increase participation by underrepresented minorities, and to support hospitals in their staffing needs. Provide accountability for the Medicare GME dollars

50. What would the pilot look like?, cont. Funding, decision-making, control, and flexibility will be placed with the organization whose sole mission is training primary care physicians Pilot would test funding mechanism and outcomes of primary care production and accountability to the community Pilot programs would be able to increase their complement of residents by up to 50%