Advancing Health Care Reform: The ACA and Medicare

1. Advancing Health Care Reform: The ACA and Medicare Aging Advocacy Summit Presented by Joyce Dubow Augusta, ME November 14, 2012

2. Presentation overview • How consumers can engage in the “3 aims” and help to reform health care • Approaches to quality improvement and delivery in health reform legislation (ACA) • ACA and Medicare • Future of Medicare • Implications of sequestration

3. The Three Aims (DHHS) • Better healthcare: • Improve individual patient experiences of care along the Institute of Medicine’s six domains of quality: Safety, Effectiveness, Patient-centeredness, Timeliness, Efficiency, and Equity. • Better health: • Encourage better health for entire populations by addressing underlying causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventive care and poor nutrition. • Reduced costs: • Lower the total cost of care resulting in reduced monthly expenditures for each Medicare, Medicaid or CHIP beneficiary by improving care.

4. Patient/Person Centeredness/Engagement

5. Patient Engagement: 2 pathways • (1)Engagement in one’s own health and health care; and • Center for Advancing Health- “actions individuals must take to obtain the greatest benefit from the health care services available to them” (Jessie Gruman, et al., 2010) • Judy Hibbard- Consumers taking on new roles and behaviors, such as choosing high performing providers; selecting evidence-based treatments; collaborating with their providers; taking preventive actions; self-management; being vigilant to prevent errors • (2) Engagement in policy development and governance to ensure patient perspectives are addressed

6. Why Patient Engagement Now? • Greater sense of urgency due to fiscal constraints of federal and state budgets and the unwillingness of purchasers to contribute to a system that doesn’t produce good results • HIT, and the need to tie clinical and patient decisions to evidence • A demand for greater accountability through measurement and public reporting

7. How will we know success? • Health care that gives each individual and family an active role in their care; • Care that adapts readily to individual circumstances as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds; • Sees a person as a multi-faceted • Requires a partnership between the provider and the patient with shared power and responsibility • Gives the patient access to understandable information and decision support tools • Determines whether patients achieve their desired outcomes. • (AHRQ Report to Congress, 3/2011)

8. Problem drivers • Scientific uncertainty • Perverse economic and practice incentives • System fragmentation • Opacity to cost and quality • Changes in health status • Lack of patient involvement

9. We get what we pay for, but not what we want • Incentives for high volume and intensity • Inadvertent reward for poor care (e.g., payment for readmissions, correction of mistakes) • Procedures paid more than primary care • No incentive to integrate care • Payment does not differentiate between good/poor performance (no reward for high quality, no penalty for poor care)

10. Where we need to go Current system IOM Aims for improvement Safe Effective Patient-centered Timely Efficient Equitable • (Too) often, unsafe • Fragmented, uncoordinated, unnecessary care • Provider-focused • Timely (?), rushed • Inefficient, wasteful • Disparate (geography, gender, age, race, ethnicity) • Costly, >unaffordable

11. How we get there… IOM, the Healthcare Imperative, 2010 • Payment redesign to focus on results and value • Quality and consistency in treatment • Timely evidence that is independent, and understandable • Clinical records that are reliable, shareable, and secure • Transparency requirements on cost, quality, including outcomes

12. Health Care Reform: The ACA

13. Infrastructure to support quality goals • Evidence base • Performance measures • Health Information Technology • Robust workforce

14. ACA quality provisions that relate to delivery reform • Infrastructure: develop evidence, measures, HIT; test new ideas; certify shared-decision making tools • New models of care: Shared Savings Program (ACOs); medical/health homes • Accountability: transparency/public reporting • Financial incentives/payment reform • Workforce reform/strengthen primary care • Wellness and health promotion • *(HITECH provisions in ARRA “meaningful use” of HIT have significant implications for quality)

15. Infrastructure National Strategy for Quality Strategy Improvement in Health Care (NQS) • Make care safer by reducing harm caused in the delivery of care. • Ensure that each person and family is engaged as partners in their care • Promote effective communication and coordination of care • Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Work with communities to promote wide use of best practices to enable healthy living • Make quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

16. ACA: evidence for clinical and patient decisions: PCORI • Patient-Centered Outcomes Research Institute,a private, not-for-profit entity to: • identify research priorities and a research agenda • conduct research, with priority to AHRQ, NIH • release and disseminate findings (which many not be used in making Medicare coverage determinations, or for reimbursement or incentive programs.)

17. Patient-Centered Outcomes Research Institute (PCORI) • PCORIdoesn’t actually define patient engagement or patient-centeredness, but rather incorporates these concepts in its approach to research • Researchfocuses on outcomes that people notice and care about: survival, function, symptoms, and health-related quality of life • PCORI poses the following questions • : • “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?” • “What are my options and what are the benefits and harms of those options?” • “What can I do to improve the outcomes that are most important to me?” and • “How can the health care system improve my chances of achieving the outcomes I prefer?” • PCORI models another aspect of patient engagement—inclusion of patients at the governance level

18. Infrastructure: measure development and reporting ACA : quality infrastructure: capacity to measure performance • Performance measurement to improve quality, safety and efficiency, promote accountability, payment, and delivery reform • HHS will: • develop and implement a national strategy (3-21-11) • identify and fund gaps in measures • oversee a process for collecting and aggregating data • develop a framework for public reporting • engage in a consultative process with stakeholders on selection of national priorities and quality measure (5-11)

19. Infrastructure ACA: CMMI to test new ideas • The Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models that enhance quality of care provided to Medicare and Medicaid beneficiaries; implement innovations as they are ready for prime time • Examples of initiatives: ACOs, bundled payments, Primary Care Initiative, FHQC Advanced Medical Homes, Medicaid Incentives for the Prevention of Chronic Diseases http://www.innovations.cms.gov/

20. ACA: advance accountability, reward good quality, greater efficiency • Physicians rewarded for P4R through 2014, then those who fail to report lose $ • Physicians participating in MOC eligible for bonuses • HHS to provide physicians with information on their resource use • In 2013, public reporting on Physician Compare • “Value-modifier” to reward physicians who deliver better care, lower costs

21. Delivery reform ACA: new delivery models • Medicare Shared Savings Program (ACOs) • Medical Homes pilot (Health Homes in Medicaid) • Medicare Community-based Care Transitions program • Independence-at-home demonstration

22. ACOs in the traditional Medicare program (MSSP) • Governance • Process to promote patient-centeredness, patient engagement, use of evidence • Quality measurement and reporting • Beneficiary notices • Data sharing • Risk sharing

23. ACO: whole-person orientation • Seamless, coordinated, integrated care, available 24/7 • Responsive, respectful, care that recognizes patients as equal partners in care decisions and delivery • Ongoing efforts to examine care to improve performance, eliminate disparities

24. Patient engagement in ACOs • ACO functions to demonstrate patient engagement: • Patient involvement in governance • Use of a patient experience survey • Process for evaluating and addressing needs of population served • Systems to identify high-risk individuals • Mechanisms in place to coordinate care via enabling technologies • Written standards for beneficiary access and communication • Process to allow for shared decision making • Communicating clinical knowledge in a way that is understandable to patients

25. Financial incentives ACA: accountability, incent better care, lower costs • Hospital readmission reduction program • Reduced payment for “excess” readmissions for 3 high cost/high volume procedures (acute MI, HF, Pneu) • Public reports of readmission rates on Hospital Compare • Assistance for hospitals with high rates of readmission • Reduced payment for hospital/healthcare acquired conditions (e.g., bedsores, complications from extended use of catheters, injuries caused by falls) in the 25 percent of hospitals with highest rates)

26. Payment reform Payment to incent improvement • Bundled payments encourage individual and shared accountability for entire episodes of care (including acute and post-acute care) or for a bundle of services • Reimbursement for all the services needed by a patient for a treatment or condition across multiple providers or settings

27. Delivery reform ACA: strengthen primary care • Increase payment to primary care providers (Medicare bonuses, Medicare rates for Medicaid providers) • Establishing community health teams to support PCMH (grants, contracts) • Support for training clinicians in primary care • Community-based collaborative care networks (with FHQCs) to serve low-income individuals • ACOs, PCMH pilots

28. ACA: advance accountability, reward good quality, greater efficiency Accountability/transparency/public reporting • Physicians rewarded for P4R through 2014, then those who fail to report lose $ • Physicians participating in MOC eligible for bonuses • HHS to provide physicians with information on their resource use • In 2013, public reporting on Physician Compare • “Value-modifier” to reward physicians who deliver better care, lower costs

29. HITECH “Meaningful use” • “Meaningful Use” Use of technology to achieve significant improvement in care • Financial incentives ties payment specifically to the achievement of advances in health care processes and outcomes • Stage 1 identifies core objectives • basic functions to enable an EHR to support care improvement (vital signs, demographics, medications, allergies, problem list, smoking status) • Provide patients with electronic versions of their health information

30. Summary of ACA steps to improve quality:an advocacy agenda • Build the evidence base: comparative effectiveness research • Incent HIT and data exchange • Promote accountability through transparency/public reporting • Align payment with performance • Bundled, episode-based payments • Penalties for preventable re-hospitalizations • MA bonuses for attainment/improvement in quality • Improve health service delivery • Primary care; Medical homes; ACOs • Care coordination • Promote wellness and prevention • Adopt enhanced role for patients through shared decision making and greater engagement through self-efficacy • Appropriations

31. Public Policies to Support Patient Engagement • Provider payment to incent patient-centered delivery of care • Publication of patient experience and patient-reported outcomes • Shared decision making grounded in evidence • Value-based benefit design to encourage better patient choices • Encourage patient-centered delivery Investment in and support of EHR adoption to facilitate patient access to their health information; enhance communication with clinicians; and enhance care coordination • Encourage patient-centered deliverymodels through support of primary care, shared savings, etc.

32. Potential Saved if USA “bends the curve” of Health Care Spending Potential Savings NHE in trillions We are here Yellow line = CBO Estimated savings achieved by ACA Total National Health Expenditures, 2009–2020, Current Projection and Alternative Scenario

33. Will all these ideas work?

34. QUALITY • Getting the right care • Coordinated care • Safe care • Patient-centered care ACCESS • Universal participation • Affordable • Equitable Core Goals and Priorities for Health System Performance Improvement LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENCY SYSTEM CAPACITY TO IMPROVE Source: Commonwealth Fund Commission on a High Performance Health System.

35. Medicare Reform Switching gears to

36. MEDICARE IS A TARGET IN BUDGET DEBATE Current Financing Unsustainable in Long-Term • ACA Improved Short Term Outlook (10 yrs) • Medicare’s share of GDP: Long Term Outlook (20 yrs+) • 3.7 % GDP in 2011 • 4.2 % GDP by 2022 • 6% GDP by 2040 • Cost Growth in Medicare caused by: – Health care cost growth – Aging of the population

37. System-wide and Medicarecost containment one and the same

38. Medicare Savings from the ACA 2013–2022 (billions) ***Other provisions include increases in Medicare payments to Disproportionate Share Hospitals that serve many low-income uninsured persons, effect on federal spending for prescription drugs and biologics (including savings from eliminating the provisions that close the donut hole), and repeal of IPAB. 

39. Deficit Reduction Proposals (Round I) Source: Commonwealth Fund

40. Major Health Policies Proposed inDeficit Reduction Proposals (Round II) SOURCE: Committee for a Responsible Federal Budget, Summary Table of Fiscal Plans, April 2011, available at http://crfb.org/sites/default/files/CRFB_Fiscal_Plans_Summary_Table.pdf

42. Characteristics of the Medicare Population Percent of total Medicare population: Income <200% FPL ($21,660 in 2010) 3+ Chronic Conditions Cognitive/Mental Impairment Fair/Poor Health Under-65 Disabled 2+ ADL Limitations Age 85+ Long-term Care Facility Resident NOTE: ADL is activity of daily living. SOURCE: Income data for 2009 from U.S. Census Bureau, Current Population Survey, 2009 Annual Social and Economic Supplement. All other data from Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2008 Access to Care file.

43. Sequestration Switching gears to

44. Sequestration: percentage reductions for FY 2013 by category of spending • Non-exempt defense discretionary 9.4 • Non-exempt nondefense discretionary (after-school programs, special ed, reduced FBI, border security, reductions in oversight of air traffic control, food inspection, water, air protection, NIH research, FEMA, 8.2 • Medicare 2.0 • Nonexempt defense mandatory 7.6 • Nonexempt nondefense mandatory 10.0

45. Impact of Sequestration on Older Adults (NCOA) $54.5 billion in non-defense discretionary cuts in FY13 • 17 million fewer congregate and home-delivered meals for seniors • 1.9 million fewer senior transportation rides to medical appointments, grocery shopping, and other needs • 1.5 million fewer people receiving personal care services, such as in-home help with bathing and dressing • 290,000 senior households losing their heat due to a $285 million cut in the Low-Income Home Energy Assistance Program • 6,400 fewer unemployed low-income older adults getting hired and paid because of cuts to the Senior Community Service Employment Program

46. Conclusion: Consumer have a horse in the race!