THE CHANGING FACE OF HEALTH CARE AND ITS IMPACT ON OUR PATIENTS

1. THE CHANGING FACE OF HEALTH CARE AND ITS IMPACT ON OUR PATIENTS Lisa M. Palacios RN, MSN Clinical Nurse Liaison Liaison Manager Boston Home Infusion September 10, 2013

2. Objectives • Identify the contributing factors that are influencing change in the health care industry. • Describe 3 constructive pathways or means to manage the proposed and expected changes in health and home care as we go forward.

3. “Change is the law of life. And those who look only to the past or present are certain to miss the future.” ~JFK

4. The Alphabet Soup of Health Care • ACA • CBO • ACO • CMS • CBA • OMG!!

5. ACA  Affordable Care Act. The Patient Protection and Affordable Care Act (PPACA) commonly called Obamacare or the Affordable Care Act (ACA), is a United States federal statute signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act, it represents the most significant government expansion and regulatory overhaul of the country's healthcare system since the passage of Medicare and Medicaid in 1965.

6. CBO Congressional Budget Office The Congressional Budget Office (CBO) is a federal agency within the legislative branch of the United States government that provides economic data to Congress. The CBO was created as a nonpartisan agency by the Congressional Budget and Impoundment Control Act of 1974.

7. ACO Accountable Care Organization An Accountable Care Organization (ACO) is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. A group of coordinated health care providers forms an ACO, which then provides care to a defined group of patients. The ACO may use a range of payment models (capitation, fee-for­ service with asymmetric or symmetric shared savings, etc.). The ACO is accountable to the patients and the third-party payer for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services (CMS) an ACO is "an organization of health care providers that agrees to be accountable for the quality, cost and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it."

8. CMS Center Medicare Services The Centers for Medicare & Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP) and health insurance portability standards. In addition to these programs, CMS has other responsibilities, including the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA), quality standards in long­ term care facilities (more commonly referred to as nursing homes) through its survey and certification process and clinical laboratory quality standards under the Clinical Laboratory Improvement Amendments.

9. CBA Competitive Bidding Area The service area that a provider who won the competitive bid must provide products and services to regardless of their physical location.

10. Friend or Enemy? • AFFORDABLE CARE ACT • ACCOUNTABLE CARE ORGANIZATIONS • COMPETITIVE BIDDING

11. HEALTH CARE REFORM Aka THE PATIENT PROTECTION AFFORDABLE CARE ACT

12. The Affordable Care Act provides Americans with better health security by putting in place comprehensive health insurance reforms that will: • Expand coverage. • Hold insurance companies accountable. • Lower health care costs. • Guarantee more choice. • Enhance the quality of care for all Americans.

13. The Affordable Care Act • The Patient Protection and Affordable Care Act • The Health Care and Education Reconciliation Act of 2010

14. Eligibility • The Affordable Care Act fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country. • Beginning in January 2014, individuals under 65 years of age with income below 133 % of the federal poverty level (FPL) will be eligible for Medicaid. • Low-income adults without children will be guaranteed coverage through Medicaid in every state without need for a waiver. • Parents of children will be eligible at a uniform income level across all states. Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment will be much simpler and will be coordinated with the newly created Affordable Insurance Exchanges.

15. Financing • Coverage for the newly eligible adults will be fully funded by the federal government for three years, beginning in 2014, phasing down to 90% by 2020. • Authorization for the Children's Health Insurance Program (CHIP) is extended through 2019 and funding is currently authorized through 2015. • Additional federal funding for state Medicaid programs is also available for primary care, preventive care, community based long-term services and supports and new demonstrations to improve quality and re-engineer delivery systems.

16. Information Technology Systems & Data • CMS developed and codified a policy and financing structure to provide states with tools needed to achieve the immediate and substantial investment in information technology systems. • Medicaid systems will be in place in time for the January 1, 2014 launch date of the new Affordable Insurance Exchanges as well as the expansion of Medicaid eligibility. • Assures a simple and seamless enrollment experience for consumers who qualify for Medicaid or CHIP or who are shopping for health insurance in the Affordable Insurance Exchanges.

17. Coordination with Affordable Insurance Exchanges • The Affordable Care Act creates a system of coverage between Medicaid, the Children's Health Insurance Program (CHIP) and Affordable Insurance Exchanges. • Single application. • Eligibility determined for all insurance affordability programs through one simple process.

18. Affordable Insurance Exchange • The ObamaCare Health Insurance Exchange (HIX) opens Oct 1st, 2013. • The ObamaCare health insurance exchanges, or ObamaCare exchanges, are State, Federal or joint-run online marketplaces. • Americans can use the "Affordable" Insurance Exchange online marketplaces to buy health insurance from private health care providers who will compete to cover them. Shoppers can use a price calculator to find the best deal for them and their family. These programs are for folks above the poverty line that do not qualify for Medicaid. • The health insurance exchanges are estimated to provide up to 29 million people with affordable health insurance by 2019. • States can build a health insurance exchange(HIX) on their own, partner with one or more other states, or have the federal government build and run the insurance exchange for them. • The states can apply for funds from the federal government for assistance with the exchange. • There are four tiers of plans you or your employer can purchase on the exchange. They range from lower quality but more affordable "Bronze plans", to "Silver plans" to a more expensive plan with better coverage called a "Gold plan". There is also a "Platinum plan" which is the highest quality and cost plan. Lower premium plans will have higher deductibles.

19. Affordable Insurance Exchange (Part 2) All plans sold on and off the ObamaCare Health Care Exchange must include: • Ambulatory patient services. • Emergency services. • Hospitalization. • Maternity and newborn care. • Mental health and substance use disorder services, including behavioral health treatment. • Prescription drugs. • Rehabilitative and habilitative services and devices. • Laboratory services. • Preventive and wellness services and chronic disease management. • Pediatric services, including oral and vision care.

20. Benchmark Benefit Plans Assures that the coverage gained through the Medicaid eligibility expansion includes mental health services and prescription drugs. • Prescription Drugs. • Tobacco Cessation Services for Pregnant Women. • Family Planning. • Hospice Care for Children. • Tobacco Cessation. • Preventive and Obesity-Related Services. • State Option to Provide Health Homes for Enrollees with Chronic Conditions.

21. Community-Based Long-Term Services & Supports The Affordable Care Act includes a number of program and funding improvements to help ensure that people can receive long-term care services and supports in their home or the community. The law improves existing tools and creates new options and financial incentives for states to provide home and community-based services and supports. • Home and Community-Based Services State Plan Option. • Community First Choice. • State Balancing Incentive Payments Program. • Money Follows the Person (MFP). • Demonstration Grant for Testing Experience and Functional Assessment. • Tools (TEFT).

22. Quality of Care & Delivery Systems  The Affordable Care Act seeks to improve the quality of care and the manner in which that care is delivered, while at the same time reducing costs. Delivery System Improvements: The law provides enhanced federal funding to states to establish health homes to integrate care for people with chronic illnesses. It establishes the Center for Medicare and Medicaid Innovation to focus on producing better experiences of care and better health outcomes at lower costs through improvement. • Health Homes. • Provider-Preventable Conditions Including Health Care-Acquired Conditions. • Quality Improvement. • Adult Quality Measures. • Prevention. • TEFT.

23. Prevention of Chronic Disease Prevention of Chronic Disease and Improving Public Health of the Affordable Care Act promotes prevention, wellness and public health and supports health promotion efforts at the local, state and federal levels. Several provisions under Title IV expand access to health care services that help Medicaid beneficiaries prevent and manage chronic disease. • Preventive and Obesity-Related Services. • Tobacco Cessation for Pregnant Women. • Incentives for the Prevention of Chronic Disease.

24. Preventive and Obesity-Related Services Two provisions Sections 4004(i) and 4106 encourage states to expand and promote coverage of evidence-based preventative services for adults.

25. Children's Health Insurance Program • The Affordable Care Act extends funding for the Children's Health Insurance Program (CHIP) through FY 2015 and continues the authority for the program through 2019. • January 2014, all individuals under 65 years of age with income below 133 % of the federal poverty level (FPL) ($14,500 for an individual and $29,7000 fix a family of four in 2011) many of whom have children enrolled in CHIP, will be eligible for Medicaid. • Children currently covered by CHIP with family incomes between 100 – 133 % FPL will transition to Medicaid but states will retain their ability to claim the enhanced CHIP matching rate. The law provides for a 23% point increase in the CHIP federal matching rate beginning in October.

26. Dual Eligibles The Affordable Care Act creates a new office within the Centers for Medicare & Medicaid Services, the Medicare-Medicaid Coordination Office, to coordinate care for individuals who are eligible for both Medicaid and Medicare ("dual eligibles" or Medicare-Medicaid enrollees). The office is charged with making the two programs work together more effectively to improve care and lower costs. The office is focused on improving quality and access to care for Medicare-Medicaid enrollees, simplifying processes and eliminating regulatory conflicts and cost-shifting that occurs between the Medicare and Medicaid programs, states and the federal government. • Integrating Care for Medicare-Medicaid Enrollees. • Medicare Data. • State Demonstrations. • Waiver Period.

27. Provider Payments • Improving Payments for Primary Care Services. • Q & A: Increased Medicaid Payments for Primary Care Physicians. • Combined State Plan Reimbursement Template for Medicaid PCP Payment Increases . • Disproportionate Share Hospital (DSH) Payment. • Medicaid Emergency Psychiatric Demonstration Project. • Improvements to the Medicaid and CHIP Payment and Access Commission. (MACPAC).

28. Program Transparency The Affordable Care Act promotes transparency about Medicaid policies and programs, including establishing meaningful opportunities for public involvement in the development of state and federal Medicaid waivers.

29. Program Integrity  The Affordable Care Act includes numerous provisions designed to increase program integrity in Medicaid, including terminating providers from Medicaid that have been terminated in other programs, suspending Medicaid payments based on pending investigations of credible allegations of fraud and preventing inappropriate payment of claims under Medicaid. Areas of interest under this provision: • Provider Participation • Pending Investigations of Credible Allegations of Fraud • National Correct Coding Initiative (NCCI) • Recovery Audit Contractors (RACs) • Home Health

30. FACE TO FACE • The Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non­ physician practitioner working with the physician has seen the patient. • The encounter must occur within the 90 days prior to the start ofcare, or within the 30 days after the start of care. • Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

31. Health Homes • CMS expects state health home providers to operate under a "whole-person" philosophy. Health Homes providers will integrate and coordinate all primary, acute, behavioral health and long-term services and supports to treat the whole person.  • Not a physical house. Concentric clearing house with multiple services available to track and care for the patient. • None in Massachusetts.

32. Who is Eligible for a Health Home? • 2 or more chronic conditions. • One chronic condition and are at risk for a second. • One serious and persistent mental health condition. • Chronic conditions listed in the statute include mental health, substance abuse, asthma, diabetes, heart disease and being overweight. Additional chronic conditions, such as HIVIAIDS may be considered by CMS for approval. • States can target health home services geographically. • States cannot exclude people with both Medicaid and Medicare from health home services.

33. Health Home Services • Comprehensive care management. • Care coordination. • Health promotion. • Comprehensive transitional care/follow-up. • Patient & family support. • Referral to community & social support services.

34. Health Home Providers States have flexibility to determine eligible health home providers. Health home providers can be: • A designated provider : May be a physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN or other provider. • A team of health professionals: May include physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals. They can be free-standing, virtual, hospital-based or a community mental health center. • A health team: May include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative practitioners.

35. “The root of the skepticism is the resistance to the process of change itself” ~ Unknown

36. HEALTH CARE REFORM.... WILL IT WORK??

37. PROS • Increased coverage. Thirty-two million Americans who would not have been covered by health insurance either now have coverage or will get the coverage they need starting in 2014. • 3.1 million Americans ages 19 through 25 who may be added to their parents' plans. Many of these youth are working but still cannot afford to pay for health benefits. • Patients with pre-existing conditions will no longer be able to be denied coverage by insurance companies. Insurance companies will no longer be able to drop plan members once they get sick. • People who can't afford health insurance will have the Federal government paying states to add this group to the state's Medicaid program.

38. PROS (Part 2) • Reduced healthcare costs. According to the Congressional Budget Office(CBO), the cost of healthcare could be reduced. Since the Act makes sure 95 percent of citizens have health insurance, preventative healthcare will be more accessible. The newly insured will no longer have to wait until their ailments become so extreme that they are forced to visit the hospital emergency room, a more costly care avenue. • Reduced budget gaps. The Congressional Budget Office (CBO) estimates that the PPACA will reduce the national budget deficit by $143 billion by 2019 because of the Act's associated taxes and fees. In addition, the CBO believes that the Medicare "donut hole" gap in coverage will be eliminated by 2020. • Higher taxes, lower deductions. Americans who don't pay for insurance and don't qualify for Medicaid will be assessed a tax of $95 (or 1 percent of income, whichever is higher) in 2014. The tax will increase substantially to $325 (or 2 percent of income) in 2015, and $695 (or 2.5 percent of income) in 2016. Individuals with annual incomes above $200,000 and couples with incomes above $250,000 will pay higher taxes to help cover costs of the program. And, in 2014, families can only deduct medical expenses that exceed one percent of income, rather than today's 7.5 percent of income.

39. CONS • Shortage of healthcare professionals. A new study by the National Monitor predicts that the implementation of the PPACA, coupled with the nation's aging provider population, could lead to a shortage of 52,000 primary care physicians by 2025. This could leave millions of Americans without access to healthcare. The study also noted that office visits to primary care physicians will likely increase from 462 million to 565 million by 2025, further straining the system. Take into account the aging nurse pool as well and a problem exists. • Higher drug costs. Pharmaceutical companies will pay an extra $84.8 billion in fees over the next ten years to pay for closing the "donut hole" in Medicare. This could raise drug costs if they pass these fees on to consumers.

40. “If you don‘t like something, change it; if you can't change it, change the way you think about it.” ~Mary Engelbreit

41. ACO ACCOUNTABLE CARE ORGANIZATION

42. Accountable Care Organizations (ACOs) are groups of doctors, hospitals and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. They were mandated by the ACA.

43. MEDICARE ACOs •  Medicare Shared Savings Program. • Advanced Payment ACO Model. • Pioneer ACO Model.

44. Medicare Shared Savings Program - A program that helps Medicare fee-for-service program providers become an ACO. • Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives a negative incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States,.. it raises costs, discourages the efficiencies of integrated care and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled and capitation). In capitation, physicians are discouraged from performing procedures, including necessary ones, because they are not paid anything extra for performing them.

45. The Shared Savings Program The Shared Savings Program is designed to improve beneficiary outcomes and increase value of care by: • Promoting accountability for the care of Medicare FFS beneficiaries. • Requiring coordinated care for all services provided under Medicare FFS. • Encouraging investment in infrastructure and redesigned care processes.

46. Advance Payment ACO Model A supplementary incentive program for selected participants in the Shared Savings Program. • The Advance Payment Model is designed for physician-based and rural providers who have come together voluntarily to give coordinated high quality care to the Medicare patients they serve. • Designed for smaller ACO's without the capital to fund care coordination infrastructure. • Upfront and monthly payments....advance on the shared savings projected • Up front fixed payment • Up front variable payment • Monthly payment 35 Advanced Payment ACO's in US - Massachusetts...Harbor Medical Weymouth.

47. Pioneer ACO Model  A program designed for early adopters of coordinated care: • The Pioneer ACO Model is designed for health care organizations and providers that are already experienced in coordinating care for patients across care settings. • Allow these provider groups to move more rapidly from a shared savings payment model to a population-based payment model. • Consistent with, but separate from, the Medicare Shared Services Program. • Work in coordination with private payers by aligning provider incentives, which will improve quality and health outcomes for patients across the ACO, and achieve cost savings for Medicare, employers and patients. • Provide more coordinated care to beneficiaries at a lower cost to Medicare.

48. Massachusetts ACO's • Partners Health Care. • Atrius Healthcare. • Beth Israel Deaconess Physicians Organization. • Mt Auburn Cambridge Independent Practice Associates (MACIPA). • Steward Health Care.

49. How do they Differ? •  The payment models being tested in the first two years of the Pioneer ACO Model are a shared savings payment policy with generally higher levels of shared savings and risk for Pioneer ACOs than levels currently proposed in the Medicare Shared Savings Program. • In year three of the program, participating ACOs that have shown a specified level of savings over the first two years will be eligible to move a substantial portion of their payments to a population-based model.

50. What is Population-based Payment? • A provider entity agrees to accept responsibility for the health of group of patients in exchange for a set amount of money. • Global Payment or Total Cost of Care payment.