Federal Healthcare Reform Update May 5, Mr. Dan Posey Ms. Marisa Finley Ms. Gail VanZyl

Transcription

1 Federal Healthcare Reform Update May 5, 2010 Mr. Dan Posey Ms. Marisa Finley Ms. Gail VanZyl

2 A Quick Look at History 1934 FDR s New Deal. 1950s Growth of employer-sponsored insurance, unions push for first dollar coverage, NIH funding 1970 Attempts to control costs include HMO Act, ERISA DRG s 1987-EMTALA provides access 1997 SCHIP SGR Formula Freeze on GME 1912 TR calls for universal coverage 1940s WWII tax policies benefit employer sponsored health insurance 1965 Medicare and Medicaid 1993 Clinton proposal defeated

3 Happy With the Current System? More than 46 million uninsured Chronic Medicare underpayment Increasing regulatory and administrative burdens Medical liability fears Denials of coverage for pre-existing conditions 2009: Medicaid enrollment grew 6.5%.* Health care costs projected to increase from 16.2% to 19.2% of GDP by 2019.* *Truffer CJ et al. Health spending projections through 2019: the recession s impact continues. Health Affairs. 2010

4 Total Health Care Expenditures Per Capita US Dollars 6000 Total Expenditure Australia Canada France Germany Japan United Kingdom United States Year Source: American Medical Association

5 100 Concentration of Total Annual Medicare Expenditures Among Beneficiaries, Source: Data from CMS Beneficiaries Expenditures

6 How Did We Get Here? November 2008: Barack Obama elected President; healthcare reform became the top domestic policy issue for the 111th Congress. February 2009: The first steps to reforming the healthcare system occurred with the passage of the American Recovery and Reinvestment Act (ARRA; P.L ).

7 White House Reform Goals February 26, 2009 President Obama revealed eight healthcare reform goals: Reduce growth of costs Protect families from bankruptcy or debt Guarantee choice of doctors and health plans Invest in prevention and wellness Improve patient safety and quality of care Assure affordable quality coverage for Americans Maintain coverage when you change/lose your job End barriers to coverage for those with pre-existing conditions.

8 ARRA (Stimulus Bill) ARRA included $17 billion in supplemental funding for biomedical research, public health, and other health-related programs within the Department of Health and Human Services (HHS), including $1.1 billion for comparative effectiveness research. ARRA incorporated the Health Information Technology for Economic and Clinical Health (HITECH) Act, which is intended to promote the widespread adoption of health information technology (HIT) for the electronic sharing of clinical data among hospitals, physicians, and other health care stakeholders. Included in the ARRA health funding was $2 billion to fund HIT grant programs, among other incentive payments for both hospitals and physicians.

9 Source: American Medical Association Myths & Misinformation

10 Source: American Medical Association Road map to White House

11 Healthcare Reform Legislation HR Patient Protection and Affordable Care Act Enacted P.L Called PPACA HR Reconciliation Bill Enacted P.L Called HCEARA

12 Dr. Rohack on Passage of Legislation rican-medical-association-president-talks-health-care/

13 Healthcare Reform Legislation CBO estimates: Cost: $940 Billion Insures 32 Million people, leaving about 23 million nonelderly residents uninsured Reduces federal deficits by $143 billion over the period; and an additional $1.3 Trillion

14 What is in the Bill? Insurance Reform Timeline: 2010 High Risk Pools created For people with pre-existing conditions June 23, 2010 No pre-existing condition exclusion for kids For employer plans and new individual plans September 23, 2010 Prohibit rescissions September 23, 2010 No lifetime limits on essential benefits September 23, 2010

15 Insurance Reform 2010 (cont.) First dollar coverage for preventive services September 23, 2010 Dependent children can stay on parents plan to age 26 September 23, 2010

16 Insurance Reform 2013/2014 Co-Ops 2013 Health insurance exchanges 2014 Standardized packages Establishes subsidy amount No annual limits No pre-existing exclusions

17 In Obtain coverage meeting minimum standards for self and dependents, or pay a penalty. Who Is Exempt? (1) uninsured if lowest-price exchange plan costs > 8% of family income; (2) anyone with income below the tax filing threshold ($9,350 indiv./$18,700 couple in 2009); (3) excused for financial hardship (to be defined); (4) religious objectors; (5) Native Americans; (6) undocumented immigrants (also ineligible for Medicaid or premium help); (7) incarcerated persons; and What is in the Bill? Individual Mandates (8) those with a gap in coverage of less than 3 months.

18 Who Remains Uninsured? Those who choose to pay penalty rather than purchase insurance Undocumented: Are not eligible for Medicaid/CHIP, Are not eligible for premium subsidy, Legal Permanent Residents: Are not eligible for Texas Medicaid, Can purchase from exchange and qualify for subsidy

19 What is in the Bill? Taxes On individual High Income tax increased 0.9% for those> $250K Effective 2013 Health Insurer s Fee Tanning salons 10% Starts in July 2010

20 Tax Credit Small business tax credit: Fewer than 25 employees Less than $50K annual average wages Must contribute at least 50% of the cost of coverage From , will cover up to 35% of the employer contributions One in three small businesses in Texas offers health insurance today Texas small employers cite cost as the primary reason they cannot provide coverage

21 Premium Help: Max % of Family Income for Premiums in Exchange Income for a Family of Four From: To: Max % Income for Premiums $22,000 (100% FPL) $29,000 (133% FPL) % $29,000 $33,000 (150% FPL) % $33,000 $44,000 (200% FPL) % $44,000 $55,000 (250% FPL) % $55,000 $66,000 (300% FPL) % $66,000 $77,000 (350% FPL) 9.5% $77,000 $88,000 (400% FPL) 9.5%

22 Healthcare Reform & Physicians

23 What is in the Bill? Physicians Physician Medicare Payments: No SGR fix PQRI was revised: Extended to 2015 Starting in 2015, penalties imposed Physician Feedback Program Starting Jan 1, 2012 Reports to individual docs on episodes of care

24 Physicians (cont.) Value-based modifiers to payments 10% bonus in Health Professional Shortage Areas for Physician Sunshine Act- Report payments from drug or device companies March 21, 2013 Less than $10 exempt, unless cumulative is $100/yr.

25 Accountable Care Organizations (ACOs) Called Shared Savings Program Starting Jan 1, 2012 Defined as: Group of providers and suppliers Have a leadership and management structure Have a mechanism for joint decision-making Formal legal structure to receive payment Examples: Group practices Hospital-physician joint ventures

26 ACOs (cont.) Must agree to participate for 3-year minimum Must agree to take at least 5,000 Medicare beneficiaries Can be eligible for shared savings with the federal government Medicaid demonstration project for ACOs Focus on pediatrics From to

27 What is in the Bill? Independent Payment Advisory Board (IPAB) AKA Mighty Medpac But Medpac still exists Starts making proposals in 2014 Hospitals exempt from its recommendations until 2020 Apparently all aspects of hospital payment are exempt until then Other providers getting update reductions also can t be touched IPAB will make proposals to: Target reductions in cost growth, improve delivery and protect access

28 What is in the Bill? Payments State Medicaid payments for Primary care must be same as Medicare for 2013 and Federal govt to pay the cost. Primary care bonus payment: 10 percent bonus payment under Medicare FY 2011 through 2016 to primary care practitioners (including nurse practitioners, clinical nurse specialists, and physician assistants) and general surgeons practicing in health professional shortage areas. Federal government picks up cost of Medicaid expansion for 4 years (up to 133% Federal Poverty Level).

29 Medicaid (cont.) Hospital DSH payment cuts (beginning 2014) Mandatory coverage of prevention services Starting in 2013 For those assigned an A or B by USPSTF (US Preventive Services Task Force) Mandatory coverage of tobacco cessation for pregnant women effective Oct 1, 2010 Removes certain drugs from exclusion list: Smoking cessation, Barbiturates, Benzodiazine Eff. Jan 1, 2014

30 Children s Health Insurance Program (CHIP) Reauthorized thru 2015 FY 13 - $17.4B FY 14 - $19.1B FY 15 - $5.7B Expand eligibility for certain kids: For those ineligible for Medicaid because of income-disregards

31 IPPS/OPPS IPPS: Hospital Payment Cuts: April 1, 2010 cut of 0.25% FY 11 cut of 0.25% FY 12 and FY 13- Cut of 0.1% FY % FY 15 and % FY 17, 18, % OPPS: Same reductions in payment as inpatient (IPPS)

32 What is in the bill? Transparency Requires each hospital to establish (and update) and make public a list of the hospital s standard charges for items and services provided by the hospital, including for diagnosis-related groups How will this section be interpreted?

33 What is in the Bill? Tax-Exempt Hospitals Each hospital within a healthcare system must meet the following requirements: Must conduct a community health needs assessment At least once every 3 years Must include input from whole community Adopt an implementation strategy In response to the assessment Must establish an emergency medical care policy No discrimination based on ability to pay

34 Tax-Exempt Hospitals (cont.) Must establish a financial assistance policy Charges to people eligible for assistance Limited to what is generally billed to insured patients Gross charges prohibited Billing and collection Cannot engage in extraordinary efforts Before determining eligibility for assistance

35 Other Facilities LTACHs & Rehab Hospitals Payment reductions Quality reporting Pilot test Value Based Purchasing Skilled Nursing Facilities Secretary to develop plan for VBP Payment Classification System: Delay RUG-IV to But MDS 3.0 goes forward on

36 What is in the Bill? Home Health Home Health Payment reductions Plan for VBP, similar to SNF plan Rural Add-On of 3% April 2010

37 What is in the Bill? Hospice Hospice Payment reductions Quality reporting Plan for VBP by Mandatory face-to-face encounter before doctor may recertify eligibility Effective Mandatory medical review For all enrollees in a plan that has a high % of cases > 180 days Effective

38 Nursing Homes Creates Nursing Home Compare Medicare website Standardizes Complaint Form and complaint resolution process Whistleblower protection for nursing home employees

39 What is in the Bill? Fraud & Abuse Medicaid & CHIP: New provider enrollment requirements Increased funding for enforcement New rules on overpayments By 12/31/10: RAC expansion to Medicare Parts C and D; Medicaid Compliance programs

40 IME/GME Redistribution of unused residency slots July Slots at hospitals that close will be re-distributed permanently (current= temporary only). Broadens how hospitals can count residents time in different settings.

41 What is in the bill? PCORI Authorizes a Patient-Centered Outcomes Research Institute (PCORI), a nonprofit corporation, funded by a new fee on health insurance companies. Will develop standards for research and publicly report research.

42 Cures Acceleration Network (CAN) Within NIH Support advances in basic research Private & academic research institutions eligible to apply Appropriates $500M for 2010, sums as needed in subsequent years Cures Acceleration Partnership Awards up to $15 million per project for the first fiscal year Cures Acceleration Grant Awards $15 million for the first fiscal year, up to $15 M for subsequent years may apply to Board for additional funding, not to exceed $15 million for a subsequent fiscal year Cures Acceleration Flexible Research Awards

43 Research cont. National Centers of Excellence- Depression Network created by SAMHSA; grants of $5 M per year Pain research: Pain Consortium recommendations IOM conference on Pain- Report June 30, 2011 Interagency Pain Research Coordinating Committee Post Partum Depression research

44 Research cont. Congenital Heart Disease research Surveillance system Breast Cancer research in young women Emergency Medicine research Women s Health (new depts in AHRQ/FDA) Minority Health (new dept at NIH)

45 Demonstration Projects (DPs) Independence at Home DP For chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician- and nurse practitioner-directed home-based primary care teams aimed at reducing expenditures and improving health outcomes. Wellness Program DP 10 States via health insurance plans Integrated Care Around a Hospitalization DP Bundled payments for Medicaid Medicaid Global Payment System DP 5 states, global capitated payment model

46 Demonstration Projects cont. Medicaid Emergency Psychiatric DP Complex Diagnostic Laboratory Tests DP Medicare Hospice Concurrent Care DP Integrate Quality Improvement and Patient Safety Training Into Clinical Education of Health Professionals Community Based Care Transitions Program 5 yr program beginning

47 Extras Secretary has extraordinary discretion/authority The phrase the Secretary shall appears 1045 times Insurance company executives pay capped At $500K Above that, company can t deduct it Members of Congress must get coverage through the Exchange Ditto for personal staff But NOT for committee staff

48 More Extras Nursing mothers get breaks on the job As often as necessary to express milk In a private place other than bathroom up to one year Employers under 50 employees exempt Restaurant chain menus Must disclose nutritional information Also applies to food in vending machines

49 Two Key Acts of Federal Healthcare Reform Patient Protection and Affordable Care Act Signed by President Obama on March 23, 2010 Health Care and Education Reconciliation Act Signed by President Obama on March 30, 2010

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51 Healthcare Reform & Nursing Now that we know the big picture.let s focus on the impact to our profession.

52 Key Resources for You ANA: olicyissues/healthsystemreform.aspx Kaiser Family Foundation: Federal Government: Specific to Texas site:

53 Healthcare Reform Impact on Nursing Profession Registered Nurses are fundamental to the critical shift need in health services delivery, with the goal of transforming the current sick care system into a true health care system ANA Statement on Patient Protection and Affordable Care Act signed into law 3/23/10

54 Address Key Provisions by Year Four year roll out ( ) Key areas addressed in the rollout Insurance Reform Medicare / Medicaid Reform Prescription Drugs Quality Improvement Prevention and Wellness Medical / Clinical Malpractice Individual and Employer Requirements Our discussion: Impact on Nursing as a profession Impact on you as professional nurse Risks and Opportunities Discuss Federal and State of Texas Impact

55 2010 Insurance Reform Provide dependent coverage for adult children up to age 26 S&W Health Plan currently age 25 Require health plans to provide preventive services without cost sharing Increase patient population in primary care Medicare banning new physician owned hospitals Current hospitals grandfathered Personal opportunity Professional opportunity RN to APN LVN to RN Professional Risk

56 2010 Quality Improvement Financial support for comparative effectiveness research Establish a commissioned Regular Corps and Ready Reserve Corps for service in time of national emergency Professional opportunity Nursing Research Medical Research as co-investigator Personal opportunity

57 2010 Workforce Increase workforce support and support training of health professionals through scholarships and loans Professional opportunity RN to APN LVN to RN Quality Review Case Management Patient Navigators Infection Control Inpatient Nursing Ambulatory Nursing Public Health Nursing

58 2011 Medical / Clinical Malpractice Award 5 year demonstration grants to states to develop, implement and evaluate alternatives to current tort litigation Professional opportunity but limited in Texas due to tort reform already in place

59 2011 Medicare Provide beneficiaries access to: Comprehensive Risk Assessment Creation of personalized prevention plan Incentives to complete behavior modification programs Professional opportunity RN Case Management (hospital, service line, health plan) Patient Navigators Ambulatory Nursing Public Health Nursing

60 2011 Medicare & Medicaid Create an Innovation Center for CMS Professional opportunity Nursing Research Medical Research as co-investigator

61 2011 Medicare & Medicaid Prohibit federal payments to states for hospital acquired conditions Create Community Based Collaborative Care Network Program to coordinate and integrate health care services Professional opportunity Clinical Educators Quality Management Infection Control Professional opportunity Patient Navigators Public Health

62 2011 Quality Improvement Improve access to care by increasing funding by $11 million to establish new programs to support school based health care center and nurse managed health clinics Professional opportunity RN to APN LVN to RN

63 2012 Medicare Create the Medicare Independence at Home demonstration project Professional opportunity Case Management Clinical Educators Home Health Nursing Research

64 2012 Quality Improvement Establish value based purchasing (VBP) program in hospitals Plan VBP for skilled nursing, home health agencies, and ambulatory surgery centers Professional opportunity Quality Management Utilization Review Case Management Nurse Clinical Informatics APN Hospitalists

65 2012 Quality Improvement Require enhanced data collection of race, ethnicity, primary language, disability and sex. Professional opportunity Nursing Clinical Informatics

66 2013 Quality Improvement Require disclosure of financial relationships between health entities and: Manufacturers and distributors of drugs, devices, biologicals, medical supplies Professional risk

67 2013 Medicare Establish a national Medicare pilot program to evaluate bundled payment for acute, inpatient, outpatient, and post acute care services for an episode of care Professional Opportunity APN Primary Care APN Hospitalists RN Inpatient RN Post Acute RN Ambulatory Case Management Utilization Review Quality Management

68 2013 Quality Cut in base payment for excess readmissions Only for certain conditions: 3 in FY 13 (heart attack, heart failure, pneumonia) 4 in FY 15 and beyond Info to be public No appeals Remediation for really bad performers Professional Opportunity Case Management Utilization Review Quality Management Clinical Educators Patient Advocates Phone Triage Nurses Home Health

69 2014 Insurance Require US citizens and legal residents to have qualifying health coverage Permit states the option to create a Basic Health Plan for uninsured Additional 39 million patients with health insurance Professional Opportunity APN Primary Care APN Hospitalists (in all settings) RN Inpatient RN Post Acute RN Ambulatory Case Management Utilization Review Quality Management

70 2014 Prevention & Wellness Permit employers to offer employees rewards of 30 50% of the cost of coverage for participating in a wellness program and achieving standards. Personal Opportunity All nurses Professional Opportunity Personal Trainers Clinical Educators (in preventable chronic diseases i.e. obesity, diabetes)

71 Nursing Workforce Nurse Loan Repayment and Scholarship Programs (NLRP) Expanded to provide loan repayment for students who serve for at least two years as a faculty member at an accredited school of nursing. Nurse Faculty Loan Program Increases from $30,000 to $35,000 in FY 2010 and 2011 HHS to provide $10,000 per year to master s recipients and $20,000 per year to doctorates if 4 out of 6 years are spent as full-time faculty at an accredited nursing school. RNs who have completed these programs or are currently enrolled are eligible.

72 Workforce cont. Public Health Workforce Loan Repayment Program HHS will repay up to one-third of loans incurred by a public health or health professions student in exchange for that student s agreement to accept employment with a public health agency for at least three years. Allied Health Workforce Allied Health Loan Forgiveness Program HHS to make grants to accredited educational institutions that support scholarships for mid-career public health and allied health professionals who seek additional training in their respective fields. Nursing Workforce Diversity Grants Expanding grant program to allow diploma and associate degree nurses to enter bridge or degree completion programs or for scholarships/stipends for accelerated nursing degree programs.

73 Workforce cont. Pediatric workforce: New loan repayment program for psychiatric nurses, social workers, and professional and school counselors who practice in a pediatric medical or surgical subspecialty or in child mental and behavioral health care for at least 2 years in an underserved area. $35,000 per year in loan repayments for participation in an accredited pediatric specialty residency or fellowship. Training for Direct Care Workers Three-year grant program; institution of higher education can subsidize training of individuals at that institution who are willing to serve as direct care workers in a longterm or chronic care setting for at least two years after completion of their training. Geriatric Nursing Career Incentives HHS to award grants to APNs who are pursuing a doctorate or other advanced degree in geriatrics and agree to teach or practice in the field of geriatrics, long-term care, or chronic care management for a minimum of 5 years.

74 Nursing cont. Certified nurse mid-wives pay parity: Mid-wives will receive full payment rate for covered services instead of 65% of physician rate. Effective Jan 1, 2011 Nurse Home Visitation programs: Authorizes states, with federal grant support, to establish evidencebased nurse home visitation programs for maternal, infant, and early childhood purposes. Graduate Nurse Education Demonstration Program in Medicare $50 million per year for FY2012 through FY2015 Up to five eligible hospitals will receive Medicare reimbursement for the educational costs, clinical instruction costs, and other direct and indirect costs of an eligible hospital s expenses attributable to the training of APNs.

75 Key Resources for You ANA: cyissues/healthsystemreform.aspx Kaiser Family Foundation: Federal Government: Specific to Texas site:

76 Contact Info/ Link to Presentation Mr. Dan Posey Director of Government Affairs, Scott & White Healthcare (254) Ms. Marisa Finley Associate Director, Scott & White Center for Healthcare Policy (512) Ms. Gail VanZyl Chief Nurse Executive, Scott & White Healthcare (254) Slides Available online at :