Janet R. Kahn, Ph.D., NCTMB University of Vermont. Dept. of Psychiatry

1. Changes in our Healthcare System:Thoughts for Complementary and Integrative Health Care (CIHC)American Public Health Association 140th Annual Meeting & Exposition October 30, 2012 – San Francisco Janet R. Kahn, Ph.D., NCTMB University of Vermont. Dept. of Psychiatry Member, Advisory Group on Prevention, Health Promotion and Integrative and Public Health

2. DONNA M. FEELEY, MPH, RN, CMT, NCTMB

3. Affordable Care Act 101 • Imperfectly…yet to an unprecedented degree, this law: • Offers some opportunities for CIHC • Reflects the values of CIHC • Like many laws, the ACA is subject to interpretation, thus • the key to our opportunities lies in rulemaking/implementation and our involvement in that

4. Overview • Public Health reframed through the National Prevention, Health Promotion and Public Health Council + Fund + Advisory Group + Community Transformation Grants • Other elements of ACA with potential for CIHC practices • Current Status • Opportunities

5. Thinking Differently About Health • National Prevention, Health Promotion and Public Health Council • Advisory Group on Prevention, Health Promotion and Integrative and Public Health • Prevention and Public Health Fund

6. INTENTIONS • Shift from sickness care to health & wellness as primary focus • Salutogenesis – how is health created? Not by attacking one disease at a time. • Search for structural rather than biomedical solutions to our nation’s health problems • Coordination between clinical and community/environmental aspects of health promotion

7. National Prevention Council: Setting a Larger Table -- Policy Matters

8. National Prevention Strategy • Vision: Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness. • Extensive stakeholder and public input • Aligns and focuses prevention and health promotion efforts with existing evidence base

10. Empowered People • People are empowered when they have the knowledge, resources, ability, and motivation to identify and make healthy choices • When people are empowered, they are able to take an active role in improving their health, supporting their families and friends in making healthy choices, and leading community change

11. Improving Population Health Outcomes Depends on Transforming the Health System to Coordinate and Integrate Primary Care, Public Health and Community Prevention Efforts Health Care System/Primary Care • Incentives for providers to achieve pop. health out-comes and improve quality • Incentives for plans/ACOs to address population health outcomes • Funding mechanisms that enable braiding of financing streams • Primary care & team based care • Patient assessments include personal data and SDOH regarding patients’ homes and communities • Quality improvement • Leveraging, linkages and referrals to community resources • Data collection & EHRs contribute to community health data base • Coordination with community health outreach workers • Chronic disease mgmt Community Prevention/Social Determinants of Health (SDOH) Payers, Insurers, and ACOs • Interventions at the intersectionof primary care, public health and the social • determinants of health • require: • Common agendas and goals • Shared responsibility • A compelling story • Partnerships and collaboration • Leadership and Integrators • Data • Financing systems • Accountability mechanisms Interventions At The Intersection Public Health • Social and support services • Disease prevention and management programs • Outreach and referral to clinicians • Education, including health education • Coalitions and advocacy to address SDOH • Community engagement Public policy is a critical lever to support all of these activities • Policy leadership on programs and policies that improve community health • Community health assessments • Educating policymakers, agencies, and stakeholders regarding pop. health • Population health data tracking and analytic tools Improved Population Health, Health Outcomes, and Lower Costs (Triple Aim)

12. Role of Advisory Group • Advise • Hold accountable • Develop a broader constituency • Preventive services • Integrative health • Resilience • Outreach • New focus: education, community development

13. Affordable Care Act Other elements with CIHC potential:Current Status, Opportunities

14. SEC. 5101. NATIONAL HEALTH CARE WORKFORCE COMMISSION. • (i) Definitions- In this section: • (1) HEALTH CARE WORKFORCE- The term 'health care workforce' includes all health care providers with direct patient care and support responsibilities, such as physicians, nurses, nurse practitioners, primary care providers, preventive medicine physicians, optometrists, ophthalmologists, physician assistants, pharmacists, dentists, dental hygienists, and other oral healthcare professionals, allied health professionals, doctors of chiropractic, community health workers, health care paraprofessionals, direct care workers, psychologists and other behavioral and mental health professionals (including substance abuse prevention and treatment providers), social workers, physical and occupational therapists, certified nurse midwives, podiatrists, the EMS workforce (including professional and volunteer ambulance personnel and firefighters who perform emergency medical services), licensed complementary and alternative medicine providers, integrative health practitioners, public health professionals, and any other health professional that the Comptroller General of the United States determines appropriate.

15. Current Status • The law did not mandate funding for the National Healthcare Workforce Commission – commissioners were duly appointed but having no budget for staff, travel or even phone calls, have never met. • Definition was intended for that section of the law, but with many other mentions of CAM/IHC in the law, this is being used as a talking point with policymakers in HRSA, DOL and other agencies.

16. SEC. 2301: COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES. (C) A State shall provide separate payments to providers administering prenatal labor and delivery or postpartum care in a freestanding birth center (as defined in subparagraph (B)), such as nurse midwives and other providers of services such as birth attendants recognized under State law, as determined appropriate by the Secretary. For purposes of the preceding sentence, the term `birth attendant' means an individual who is recognized or registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law(or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a birth attendant.'...

17. Current Status • Mandates reimbursement for both facility fees and provider fees for freestanding birthing centers. • Pace of implementation varies from state to state; overseen by regional Medicaid offices

18. PCORI Patient-Centered Outcomes Research Institute Sec 6301 – “(c) PURPOSE…to assist patients, clinicians, purchasers, and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through research and evidence synthesis that considers variations in patient subpopulations, and the dissemination of research findings with respect to the relative health outcomes, clinical effectiveness, and appropriateness of the medical treatments, services, and items described in subsection (a)(2)(B).

19. Patient-Centered Outcomes Research Trust Fund (PCORTF) Mandated appropriations of • For FY 2010, $10 million • For FY 2011, $50 million • For FY 2012, $150 million • For FY 2013, $150 million from the general + an annual $1 fee per individual assessed on Medicare and private health insurance and self-insured plans. Combined estimated total is $320 million. • For FYs 2014-2019, $150 million from the genera + an annual $2 fee per individual assessed on Medicare and private health insurance and self-insured plans and an adjustment for increase in healthcare spending. The combined estimated total averages $650 million per year.

20. Status Accomplishments • Governing board appointed • PCOR defined • Research Priorities set w/selection process described • Methodology Committee issued report Much potential w/caveat: • Neither PCORI, nor NCCAM, can fund research for which they have not received a qualified proposal

21. Action Alert! 3 key provisions are being determined at the state level * Section 2706 Non-Discrimination * Section 3502 PCMH support teams * Section 2303 Essential Benefits

22. SEC. 2706: NON-DISCRIMINATION IN HEALTH CARE: (a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

23. SEC. 3502. ESTABLISHING COMMUNITY HEALTH TEAMS TO SUPPORT THE PATIENT-CENTERED MEDICAL HOME (a) IN GENERAL.—The Secretary of Health and Human Services (referred to in this section as the ‘‘Secretary’’) shall establish a program to provide grants to or enter into contracts with eligible entities to establish community-based interdisciplinary, inter-professional teams (referred to in this section as ‘‘health teams’’) to support primary care practices,including obstetrics and gynecology practices, within the hospital service areas served by the eligible entities.

24. SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS (1) IN GENERAL.—Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories: (A) Ambulatory patient services. (B) Emergency services. (C) Hospitalization. (D) Maternity and newborn care. (E) Mental health and substance use disorder services, including behavioral health treatment. (F) Prescription drugs. (G) Rehabilitative and habilitative services and devices. (H) Laboratory services. (I) Preventive and wellness services and chronic disease management. (J) Pediatric services, including oral and vision care.

25. What can you do? • Get to know and be known by your insurance commissioner • Find out where your state is re EHB • What are the implications for your practice site of the planned EHBs? • Are your state’s EHB’s compatible with • Your patients’ best interests/health? • Integrative healthcare? • Non-discrimination section 2706?

26. Timing? • Now! • Section 2706 becomes effective 1/1/2014 • EHB’s being determined now for launch of Insurance Exchanges in 2014 • PCMH demos underway already