Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION

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1 Presented by Kathleen S. Wyka, AAS, CRT, THE AFFORDABLE CA ACT AND ITS IMPACT ON THE RESPIRATORY C PROFESSION

2 At the end of this session, you will be able to: Identify ways RT skills can be utilized for complying with ACA regulations Explain what role the RT has in helping to decrease hospital readmissions

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4 A federal statute signed into law in March 2010 as a part of the healthcare reform agenda of the Obama administration. Signed under the title of The Patient Protection and Affordable Care Act, the law included multiple provisions that would take effect over a matter of years, including the expansion of Medicaid eligibility, the establishment of health insurance exchanges and prohibiting health insurers from denying coverage due to pre-existing conditions

5 ACA TIMELINE 3/23/2010 ACA signed into law 10/01/2012 Hospital readmission penalties for Dx: pneumonia/ami/hf 1/23/2013 Value Based Purchasing 10/01/2014 Hospital readmission penalties for Dx:COPD 3/14/2014 Individual Mandate 2015 Employer Mandate

6 20,000 printed pages If stacked they would be taller than Kobe Bryant They are continually adding to them Only a handful are directly relevant to the Respiratory Care Profession

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9 Value Based Purchasing Program Establishment of ACO s Hospital Readmission Reduction Program

10 Linking provider payments to improved performance by health care providers. This form of payment holds health care providers accountable for both the cost and quality of care they provide. It attempts to reduce inappropriate care and to identify and reward the best-performing providers HealthCare.gov 2010

11 Quality incentive program built on the Hospital Inpatient Quality Reporting (IQR) measure reporting infrastructure Next step in promoting higher quality care for Medicare beneficiaries Pays for care that rewards better value, patient outcomes, and innovations, instead of just volume of services

12 Clinical Process of Care Patient Experience of Care Base Points Consistency Points =Total Performance Score

13 Weighted Value of Each Domain

14 12 Clinical Process of Care Measures 8 Patient Experience of Care Dimensions 2010

15 ROLE OF RT IN VBP PERFORMANCE SCORES Use Evidence Based Medicine document what works, do less with less retire what doesn't work RT s at bedside improves patient satisfaction scores Patient Education Become accountable to quality and outcomes

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17 Accountable Care Organizations According to CMS an ACO is an organization of health care providers (e.g. hospitals, physicians and others involved in patient care) 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. A group of coordinated health care providers forms an ACO which then provides care to a group of patients 12/2012

18 ACO GOALS and RESPONSIBILITIES Deliver seamless, high quality care instead of fragmented care that often results from a Fee-for- Service payment system in which different providers receive different, disconnected payments It will be responsible for maintaining a patientcentered focus, developing processes for evidence based medicine, promoting patient engagement, coordinating care and publicly reporting on quality and cost 12/2012

19 ACO s MAY INCLUDE ACO professionals in group practice arrangements Networks of individual practices of ACO professionals Partnerships or joint venture arrangements between hospitals and ACO professionals Hospitals employing ACO professionals Other Medicare providers and suppliers

20 TYING PAYMENT to IMPROVED CARE at LOWER COST Medicare Shared Saving Program: Medicare continues to pay for services as it currently does for Fee-for-Service beneficiaries CMS benchmark must be achieved to receive shared savings ACO Quality Measures: Quality performance measures link quality and financial performance When measures are met ACO receives a share of the savings

21 ACO QUALITY MEASURES: 4 KEY DOMAINS Patient/caregiver experience (7 measures) Care coordination/patient safety (6 measures) Preventive health (8 measures) At-risk population: Diabetes (1 measure and 1 composite consisting of five measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) Coronary Artery Disease (1 composite consisting of 2 measures)

22 Quality Performance Standards that ACOs Must Meet for Shared Savings Care coordination & patient safety: All discharges for COPD & Asthma age 40 years and older. Hospital admissions for COPD or asthma are a Prevention Quality Indicator (PQI) and should be controlled in an outpatient setting. HF in adults ages 18 years and older. Hospital admissions for HF are a (PQI) and can be controlled in an outpatient setting.

23 Quality Performance Standards Preventive Health: (cont.) PATIENT/CAREGIVER EXPERIENCE: Getting Timely Care, Appointments, and Information How Well Your Providers Communicate Patient Rating of Provider Health Promotion and Education Shared Decision Making Tobacco Use: Screening and Cessation Intervention for patients 18 years and older

24 ACO s IMPACT ON RT PROFESSION? Evolution of ACO s promote consolidation ACO s call the shots will RT s in homecare be abolished? Less acute care admissions means admissions to LTAC s, subacute care, outpatient clinics, patients home (so ACO reimbursement not adversely affected) Decreased utilization and readmissions for COPD

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27 HOSPITAL READMISSION REDUCTION PROGRAM In the August 2012 update to the CMS guidelines, CMS stated: The Hospital Readmissions Reduction Program requires a reduction to a hospital s base operating DRG payment amount to account for excess readmissions of selected applicable conditions, which are acute myocardial infarction, heart failure, and pneumonia. This provision is not budget neutral. A hospital s readmission payment adjustment is the higher of a ratio of a hospital s aggregate dollars for excess readmissions to their aggregate dollars for all discharges, or 0.99 (that is, or a 1-percent reduction) for FY In this final rule, we estimate that the Hospital Readmissions Reduction Program will result in a 0.3 percent decrease, or approximately $280 million, in payments to hospitals. 1 United States, Centers for Medicare and Medicaid Services. (n.d.). Final Rule on Medicare Hospital Readmission Payment Policy. ofr.gov /ofr upload/ofr data/ 2012

28 CMS READMISSION PENALTIES Financial penalty for worse than expected readmission rates Initially for AMI, HF, and pneumonia COPD added in 2014 Readmissions are common and costly Goal to motivate hospitals and communities to reduce readmissions through quality improvement

29 CMS READMISSION PENALTIES (cont.) Risk adjusted rate of all-cause readmissions within 30 days Limited exclusion criteria Rationale: Ensure patients are ready for discharge Reduce risk of infection Medication reconciliation Improve transition of care Promote disease management Educate patients about symptoms to monitor

30 WHAT WE KNOW ABOUT READMISSIONS Readmission rates and spending are significant 18% of patients readmitted within 30 days Rates vary by location from 12.2% to 26.7% in Annual cost = $17 billion Reducing rates is projected to save Medicare $100 billon over 10 years 90% are unplanned readmissions 75% are deemed preventable 19% of readmissions are from unnecessary first admissions (AHRQ)

31 WHAT WE KNOW ABOUT READMISSIONS (cont.) Cause due to a wide range of factors, no one single intervention can address all them all Fragmented care from multiple providers: responsibility and accountability unclear Severity and complexity of chronic disease contribute significantly

32 DAYS TO READMISSION

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34 CHF readmission = 27% COPD readmission = 23% Length of stay.6 days longer 90% were unplanned 40% to 75% deemed preventable Jencks SF, Williams MV, Coleman EA. Re-hospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:

35 Recently discharged patients who underwent post hospital care transitions and their caregivers identified these areas as most essential: Medication self-management A patient-centered record Primary care and specialist follow-up Knowledge of red flags, warning symptom or sign of worsening condition. 10 Coleman, E. A., MD, MPH, Smith, J. D., ND, GNP, Frank, J. C., DrPH, Min, S., AM, Parry, C., PhD, MSW, & Kramer, A. M., MD. (2004). Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. Journal of the American Geriatrics Society, 52(11), doi: /j

36 Patient Education Communication at transition from hospital to LTAC, Subacute, Rehab, PCP and home More effective coordination of patient care Post discharge follow-up Medication self-management

37 Patient Education Opportunity for RT as pulmonary navigators thereby providing more effective coordination of care RT s on discharge planning team Pulmonary Rehab: demonstrate value by showing it decreases readmissions and including as part of discharge plan Value in outpatient settings: Rehab, nursing homes, home care?

38

39 RT s are The pulmonary experts Our role is as patient educators Must provide research that shows our value Presently are not engaged in interdisciplinary teams Need to require a BS degree for entry into profession We are behind other allied health professions RT s are not even mentioned in the Affordable Care Act! (except as a footnote)

40 Paradigm shifts: Away from acute care and to chronic care thru ACO s Away from do-more, pay-more to do-less, pay-less Away from inpatient care and move to outpatient care Community based, interdisciplinary care model Outcomes driven ACO s will manage patient in the home NOT home care company RT s In educational institutions all the programs will learn together highlighting interdisciplinary approach

41 The Affordable Care Act will influence how care is delivered and reimbursed in the US Future implications remain to be seen The impact on RT profession is unknown at this time but holds promise Opportunities for RT s most likely will be related to reducing hospital readmission rates, RT s as physician extenders, therapy based on evidence based medicine and increasing quality standards

42 Thank you for your attention

43

44 ARE THERE ANY QUESTIONS?

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