LEADERSHIP IN MEDICINE: Positioning THE NCMS for the Future of Health Care

1. LEADERSHIP IN MEDICINE:Positioning THE NCMS for the Future of Health Care Government Affairs and Health Policy, North Carolina Medical Society

2. CATALYSTS FOR CHANGE • Unsustainable increases in health care costs • Increased numbers of uninsured • Premium increases that are more than 5x the rate of inflation and wage growth • Future viability of Medicare and other public programs

3. CATALYSTS FOR CHANGE • Both sides of the aisle agree that change to our health care delivery system is needed (even though there is a lack of consensus on specific reforms) • Private sector, including health care providers, health plans, employers, and consumers all recognize the need for change • Increased emphasis on quality, safety, and accountability • Patient Protection and Affordable Care Act (“The Act”) is a reality and unlikely to be changed significantly

4. MAJOR THEMES OF “THE ACT” • Insurance reforms • Access to care / workforce • Payment reforms • Quality / health information technology

5. INSURANCE REFORMS • Insurers cannot rescind coverage of enrollees; deny coverage to kids with pre-existing conditions; place lifetime caps on coverage (all 2010) • New private plans must cover preventive services without cost-sharing (2010) • Insurers must offer COBRA dependent coverage to cover children up to age 26 (2010) • State Insurance Exchange to sell “qualified health plans” to individuals and small businesses (by 2014, or else feds will do it) • Individual and employer mandate takes effect (2014)

6. MEDICAID • Eligibility expanded to all people under age 65 with incomes up to 133% FPL – FMAP available only for newly eligible (2014)  • States must reimburse PCPs at 100% Medicare (2013-14)

7. ACCESS TO CARE / WORKFORCE • Increase in the number of insured / covered persons • More health care providers, especially in primary care, will be needed • More medical school and residency slots • More limited scope practitioners • Increase pressure to expand scope and recognize new classes of providers • Autonomy and fragmentation are contrary to the general direction of and consensus on health care reform

8. PAYMENT REFORMS • Medicare Shared Savings Program utilizing Accountable Care Organization (ACO) model—interim step using fee for service as foundation • Increase focus on quality, care coordination, efficiency, and accountability • Numerous pilots, demos, boards, commissions, grants • What is clear: • Feds are moving away from passive, volume-based, purchaser (FFS) to a move active, results-oriented, value-based purchaser • Feds don’t have the answer yet--hence the # of demos, pilots, boards, grants, etc…

9. QUALITY AND HEALTH INFO TECH • Process and outcomes measures • Data collection • Meaningful use • Patient and caregiver engagement • Patient-centeredness • Coordination of care • Safety • Accountability • Prevention and wellness • Health disparities

10. HANDOUTS • At least 33 new boards, commissions or task forces established • At least 62 new grant programs • At least 35 pilot programs and demonstration projects created

11. LESSER-KNOWN PROVISIONS • Medical loss ratio minimums established (80% individual, 85% large group); state can increase: 2010 -2013 (s.1001) • Secretary and States to review “unreasonable premium increases” and require explanation: 2010 (s.1003) • Those in the NC high risk pool will be excluded from all coverage for 6 mos prior to enrollment in federal HRP: 2010 (s.1101) • A qualified health plan may K with provider only if the provider implements mechanisms to improve quality: 2015 (s.1311)

12. LESSER-KNOWN PROVISIONS • PQRI extended through 2014, with penalties after 2015; meaningful use measures to be incorporated by 2012; Sec shall provide timely feedback re satisfactorily reporting; new informal appeals process added (s. 3002) • Confidential reports to physicians measuring resources used to furnish care. 2012 (s. 3003) • Value-based payment modifier (based on risk adjusted health outcomes) for physician fee schedule ;Jan 2015 – implement for selected physicians (TBD); Jan 2017 – implement for all physicians (s. 3007)

13. LESSER-KNOWN PROVISIONS • Payment adjustments for hospital-acquired conditions - 2015 (s. 3008) and excess readmissions 10/1/12 (s. 3025)– expand concept to other settings, including clinics (p.258) • National strategy for quality improvement – Jan 2011. (s.3011) • Data collection and public reporting (via website) of aggregated performance data on quality measures: 2010-2014 (s. 3015) • Center for Medicare & Medicaid Innovation (CMI) established to develop and test innovative payment and service delivery models to reduce expenditures: 2011 (s.3021) • Shared Savings Program (ACO) to be implemented: 2012 (s. 3022)

14. LESSER-KNOWN PROVISIONS • Secretary to periodically review “misvalued” codes in Physician Fee Schedule (s.3134) • Modification of equipment utilization factor for advanced imaging services (expects to save $3 b from 2010-19) (s. 3135) • Independent Physician Advisory Board established to reduce Medicare per capita growth; Sec shall implement recommendations; however, Congress can supersede by enacting legislation: created 2010/ reports and proposals 2014 (s. 3403) • Grant money available to professional societies if they have demonstrated expertise in QI support and assistance (s.934)

15. LESSER-KNOWN PROVISIONS • Community health team grants for programs to provide capitated payments to be made to primary care practices (s. 3502) • Accessibility standards to be promulgated for physician offices with diagnostic equipment: 2012 (s.4208) • Data collection re race, ethnicity, sex, primary language, disability; provided practicable and funded (s. 4203) • Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services: 2010 (s. 6003)

16. LESSER-KNOWN PROVISIONS • National Health Care Workforce Commission will recommend (to Congress) changes to meet medical workforce needs: Sept 2010 (s. 5101) • $240 million over 6 years to be spent on increased fraud & abuse and program integrity efforts (s.10606) • Expansion of the RAC program to state Medicaid: Dec 31, 2010 (s. 6411) • Medical Reimbursement Data Centers: physician rates posted on internet (related to medical-loss ratio prv.)

17. STATE LEGISLATIVE AND REGULATORY ISSUES • Individual Mandate (opposition and support) • Insurance Regulation (massive) • Medical Loss Ratio Adjustment • High Risk Pool • Health Insurance Exchange • Medicaid Program Expansion (500K lives est.)

18. STATE LEGISLATIVE AND REGULATORY ISSUES • State Option - Medicaid Health Homes • State Option - Community First Choice • Scope of Practice & Professional Regulation • Medical Schools, Health Workforce Funding • Medical Facilities Planning • Alternatives to Medical Tort Litigation Demonstration Project (NCMS, NCHA & others are looking at this) • Adapt Laws to New Corporate Forms

19. BURNING QUESTION • How can NCMS help our members adapt to the changes? • Current strengths: state lobbying; health policy; legal analysis; private sector (health plan) advocacy • New areas of increased focus: • Regular updates on health system reform activity • Education & training availability re: quality improvement & measurement • Access to effective & affordable health information technology • Federal level advocacy • Strategic partnerships • Facilitation in development of physician-led ACOs