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California State Rural Health Association Health Care Reform: Past, Present and Future Danny Fernandez National Rural He

California State Rural Health Association Health Care Reform: Past, Present and Future Danny Fernandez National Rural Health Association. Health Reform: One Year Ago. This time last year… Health reform still up in the air… NRHA Grassroots Efforts How to bring rural “voice” to process?

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California State Rural Health Association Health Care Reform: Past, Present and Future Danny Fernandez National Rural He

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  1. California State Rural Health Association Health Care Reform: Past, Present and Future Danny Fernandez National Rural Health Association

  2. Health Reform: One Year Ago This time last year… • Health reform still up in the air… NRHA Grassroots Efforts • How to bring rural “voice” to process? • NO P.A.C., NRHA’s small staff, etc… • Answer: Huge network of members, partners and advocates • Weekly Webinars/Updates • Daily emails • Capitol Hill days • Letters to the Editor • HUGELY SUCCESSFUL

  3. “Health Reform” “Health INSURANCE Reform” NRHA’s Overall Message: COVERAGE ≠ ACCESS!!!

  4. House Passes Health Reform • House passes Senate bill in exact form (219-212) (34 Ds Vote No) Public Law 111-148 • House then passes Reconciliation Package (“corrections” bill) (220-211) (33 Ds Vote No) Public Law 111-152 • Both health reform bills signed by President and become law. (March 21 and March 30) • Together, referred to as: The Affordable Care Act (ACA)

  5. California by the Numbers • Rural Health Clinics: 264 • Federally Qualified Health Centers: 114 • Average per-capita income • all California: $41,805 • Rural: $31,386 • Poverty Rates • Urban: 13.2 % • Rural: 15.5 %

  6. California by the Numbers Critical Access Hospitals: 30

  7. The ACA and Rural

  8. The ACA and Rural Insurance Coverage • Coverage for Pre-Existing Conditions • Insurance Mandate • Insurance Exchanges for Uninsured • State Run, with opt-out provision (Senate version) • Premium subsidies for families between 100 and 400% FPL • CO-OPs (Consumer Operated and Oriented Plans) • Replaced Public Option • Tax Credits to small employers • Up to 50 employees, though tiered • Small businesses carved out of many coverage requirements

  9. The ACA and Rural Medicare • 10 Percent Bonus to Primary Care Physicians • 10 Percent Bonus to General Surgeons Performing Major Surgeries in HPSAs (2011 until 2016) • One-Year 5 Percent Bonus to Mental Health Physicians • Geographic Practice Cost Index (GPCI) Adjustment • Originally Sen. Grassley’s provision, but Reconciliation bill improved it (See OPPS Proposed Rule Below) • Center for Medicare and Medicaid Innovation (CMI) • Independent Payment Advisory Board (IPAB) • Rural Medicare “Extenders” • Previously expired Medicare programs (See list below)

  10. The ACA and Rural Medicaid • 133 percent of FPL (Currently $29,000 for family of four) • States must expand Medicaid to include childless adults starting in 2014 • Federal Government pays 100 % of costs for covering newly eligible Medicaid recipients for 2014 through 2016. (recent bill passed to fund this) • Medicaid payment rates to primary care physicians providing primary care services no less than 100% of Medicare payment rates in 2013 and 2014.

  11. The ACA and Rural Workforce • National Health Service Corps (NHSC) • Workforce Commission • State health workforce development grants • Administered by HRSA • $8 million authorized • Medicare bonuses to primary care, general surgery and mental health physicians • Rural physician training grants • Primary care training grants • Teaching health center grants • AHEC expansion • Nursing student loan program • Public health workforce loan repayment program • Geriatric education and training improvements

  12. The ACA and Rural Hospitals Critical Access Hospitals • CAH Technical Correction for Method II Payments • Allows 101 percent reimbursement for qualified services regardless of billing method • Extension of Medicare Rural Hospital Flex Program • Quality Incentives/Bonuses PPS Hospitals • Bonus to hospitals in low-spending counties ($400 million over two years) • Low-Volume bonus adjustment • Sliding scale based on total discharges (up to 1600)

  13. The ACA and Rural Improving Quality

  14. The ACA and Rural Improving Quality • Value Based Purchasing • Pilot Project for CAHs • Accountable Care Organizations • Minimum of 5000 Medicare Part A or B patients • May be difficult for widespread rural reach • Payment Bundling Program • Specific to PPS Hospitals

  15. Prescription Drugs 340B expansion Expanded program availability to Critical Access Hospitals, Sole Community Hospitals, Rural Referral Centers Originally expanded to inpatient but Reconciliation changed availability to outpatient drugs only. Orphan drugs excluded Part D donut hole The ACA and Rural

  16. The ACA and Rural New Boards/Commissions/Offices • Independent Payment Advisory Board (IPAB) • Center for Medicare and Medicaid Innovation • Workforce Commission • HPSA/MUA Negotiated Rulemaking Committee • NRHA on Committee • Currently Under-Way • Many others Rural representation!

  17. The ACA and Rural Tax Provisions • Health insurance sector fees • Pharmaceutical sector manufacturing fees • Medical device “industry fees” • Excise tax on “Cadillac Plans” (2018) • High-cost plans offered to high earning employees • Medicare payroll tax on investment income • 10 Percent tax on indoor tanning

  18. Well, Now What?

  19. Health Reform Timeline

  20. Front-loaded with “popular” provisions High risk pools (3 months); $5 billion funded Dependent Coverage for children up to 26 Children with pre-existing conditions (6 months) Caps on coverage eliminated Preventive care benefits (6 months) $250 for seniors in prescription “donut hole.” 5% Bonus for mental health physicians GPCI Adjustments (Practice Component) Center for Medicare and Medicaid Innovation Dual-Eligibles Rural Medicare extenders (Includes GPCI Work Component) Timeline - 2010

  21. Timeline - 2010 2010 Workforce Provisions • Establish Workforce Advisory Committee • Develop “National Workforce Strategy” • Increase workforce supply and training of other health professionals through new scholarships and loans • Establish Teaching Health Centers

  22. Timeline – 2011, 1012 2011 • 10 % bonus Medicare payments to primary care docs • Reduce annual market basket updates (See IPPS hospital proposed rule below) • Medicare bonus to low-spending counties 2012 • Hospital VBP Program • Bonus payments to high-quality MA Plans • Reduce MA rebates • HHS Secretary recommendations on bundling program for CAHs and small rural hospitals

  23. Timeline – 2013 2013 • CO-Ops • Payment bundling program • Increase Medicaid payments to primary care doctors • 2013 and 2014 (100 percent federal) • Increase Medicare Part A tax • Individuals earning $200,000 • married couples earning $250,000 • Medical device excise tax imposed • 2.3 percent

  24. Timeline – 2014 2014 • Insurance Mandate • Taxes imposed on employers not offering coverage • State-Based Health Benefit Exchanges and Small Business Health Options Program (SHOP) • Reduce out-of-pocket limits on individuals with up to 400 percent of FPL (tiered) • Limit waiting periods for coverage to 90 days • IPAB Initial Report • Reduction of Medicare and Medicaid DSH payments (in coordination with insurance coverage increases) • Medicaid Expansion • Medicaid adjustments for hospital acquired conditions

  25. Timeline – 2015 and beyond 2015 • CHIP federal match increase 2016 • Health care choice compacts • Allows states to form compacts and allow inter-state insurance policies 2018 • - “Cadillac” insurance taxes

  26. NRHA HCR Summaries Implementation Timeline Independent Payment Advisory Board (Medicare Commission) Research Requirements Medicare Medicaid Workforce Commission Workforce Components Hospitals CHCs RHCs Disparities/Minority Pharmacy HIT Mental Health Preventive Care Ambulance/EMT Frontier Oral Health Coverage Components Grants Quality

  27. The politics…

  28. The results are in… Republican Controlled House • Republicans 239, Democrats 187 • R’s gain 60 seats • What’s it mean for rural? • 37 members of House Rural Health Coalition lose • Including current Chair, strong rural advocate Earl Pomeroy (ND) • Over half of House Blue Dog Coalition (27 members) lose • Key rural advocates during health reform • However, many new/existing D’s/R’s in rural districts • Similar, bi-partisan goals • New/existing relationships

  29. Dems keep the Senate Democrats 53, Republicans 46 What’s it mean for rural? Blanche Lincoln (AR) loses – long-time rural champion Jerry Moran (KS) – Current House Rural Health Coalition Republican chair Moves from House to Senate One last race…Lisa Mur-kow-ski (AK) Unprecedented write-in candidacy??? “Write in,” 41% Joe Miller, 34% Scott McAdams, 24% The results are in…

  30. Now What..2010? Lame Duck 2010 Sustainable Growth Rate (Doc-Fix) • Temporary “band-aid” passed earlier this year • Not before CMS reduced claims to physicians, 21 percent reimbursement cut • First time ever since SGR became an issue • Cut could take place in December if Congress doesn’t intervene • Other possibilities for attached legislation???

  31. Moving Forward:What was left out? • CAH health IT fix (ARRA) • 340B for RHCs • 340B expansion to inpatient drugs • Reinstate “Necessary Provider” for CAH status • CAH bed flexibility

  32. Moving Forward:What was left out? • RHC Payment Cap Increase • Ensure Rural Access to Anesthesia Services • Eliminate CAH "Isolation Test" for Ambulance Reimbursement • Ensure Rural Representation on MedPAC and newly created similar Commissions (IPAB, Health IT, Workforce, etc.)

  33. Regulations • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…” • “Secretary Shall…”

  34. The Secretary Shall… EHR/Meaningful Use First stage incentives • Improved regulations compared to original • Computerized Physician Order Entry requirements loosened • CAHs now eligible for Medicaid incentives • Still, much work to do! • NRHA achievability survey of CAHs • Only half of all CAHs will qualify for stage 1 incentives

  35. The Secretary Shall… • CMS Hospital Inpatient Prospective Payment System (IPPS) final rule • Provider Tax Issue • Potentially huge impact on CAHs and small rural hospitals • CMS Outpatient (OPPS) Proposed/Final Rule • Physician Supervision • Huge impact on CAHs and small rural hospitals • FINAL RULE UPDATE: CMS will delay enforcement for CAHs until 2012. • New quality measure for hospital emergency department transfers • Very important for rural quality measure development

  36. CMS Physician Fee Schedule Changes for 2011 Implementing many ACA requirements 10 percent primary care bonus 10 percent general surgery (HPSA) bonus Geographic Practice Cost Index (GPCI) provision Graduate Medical Education (GME) The Secretary Shall…

  37. Moving Forward • No legislation is perfect • Health Reform included… • Still, it contains important building blocks to help resolve the access to care crisis in rural America.

  38. Continue Strong Grassroots Message • Health Reform Monthly calls • regulatory process critical • Appointments for Workforce Advisory Committee currently in process • Appointments for IPAB • Grant opportunities • Provider shortage opportunities • Fight for what’s left out! • Specialized task forces • Our grassroots efforts must continue!

  39. Continue Strong Grassroots Message Sign up for monthly grassroots calls: • Please join the NRHA rapid response grassroots team by sending a blank e-mail to: join-grassroots@lists.wisc.edu. • You will then receive an activation e-mail. Encourage others to join as well!

  40. THANK YOU! Danny Fernandez Manager, Government Affairs and Public Policy National Rural Health Association 1108 K St. NW, 2nd Floor Washington DC 20005 fernandez@nrharural.org 202-639-0550

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