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The Affordable care act

What’s ahead?. The Affordable care act. Kit Wagar ACA Specialist Region 7 U.S. Department of Health and Human Services. An Unsustainable System. The United States leads the world in discovering new approaches to prevent, diagnose, manage and cure illness

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The Affordable care act

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  1. What’s ahead? The Affordable care act Kit Wagar ACA Specialist Region 7 U.S. Department of Health and Human Services

  2. An Unsustainable System • The United States leads the world in discovering new approaches to prevent, diagnose, manage and cure illness • Our institutions educate and train exceptional doctors, nurses and other health care professionals • America spends 50 percent more on health care per person than any other country in the world • But we lag behind in health

  3. High Costs, Low Quality • In the U.S., the cost of health care cost is too high, quality is too low • Nations as diverse as Japan, Spain, Malta and New Zealand spend less than half as much as the U.S., but have better outcomes Source: University of California Atlas of Global Inequality: Health Care Spending http://ucatlas.ucsc.edu/spend.php

  4. The Affordable Care Act:Major Themes • Expand insurance coverage • Provide new consumer protections and consumer choice • Make health care and health insurance more affordable • Improve quality of care • Increase prevention and improve public health • Reduce fraud

  5. Groups Left Behind by the Status Quo • Early retirees and their spouses • People with existing health conditions • Small businesses and their employees • Young adults • Children

  6. Expanded Coverage • Pre-Existing Condition Insurance Plans • Makes insurance available at the same price offered to people without existing medical conditions • Eligibility not based on income, but on situation: • You must be uninsured for six months; • You must have a pre-existing medical condition or have been denied insurance because of your health condition; • You must be a U.S. citizen or a legal resident • These plans operate until 2014, when private insurers will no longer deny coverage based on health condition

  7. Small Business Tax Credit • Tax credits that cover up to 35 percent of the cost of employee health insurance began last year • The tax credit rises to a maximum of 50 percent in 2014 • Nonprofits eligible for a credit of up to 25 percent now, 35 percent in 2014 • Eligibility for the credit: • An employer must pay at least half the cost of health coverage for some workers based on the individual rate • Credit is available to firms with fewer than the equivalent of 25 full-time workers • Average annual wages must be less than $50,000 • The credit phases out as the number of employees rises beyond 10 and average wages rise beyond $25,000 a year Betsy Burton, 64, has owned King’s English Bookshop in Salt Lake for 33 years.

  8. Expanded Coverage • Young adults coverage: • Insurance policies that begin or renew after Sept. 23, 2010, must offer coverage to children under 26, if the plan covers dependents • Big help to graduate students and young adults in entry-level jobs • Narrow exception for young adults with their own offer of employer-based coverage

  9. Fighting Fraud Pays Off • In fiscal year 2009, anti-fraud efforts recovered: • $2.51 billion for Medicare, up 29 percent from 2008 • $441 million for Medicaid, up 28 percent • In 2010, total recoveries for Medicare and Medicaid increased by another 36 percent to more than $4 billion • In fiscal 2010, whistle-blower lawsuits recovered a record $2.5 billion, up 49 percent from the previous year

  10. Expanding Access to Care The Affordable Care Act authorizes $11 billion over the next 5 years for health centers throughout the nation • $9.5 billion is designated for building new health centers in underserved areas or expanding primary care services at existing health centers • $1.5 billion will support major construction and renovation projects at health centers nationwide • This funding is designed nearly to double the 19 million patients who receive treatment today, regardless of their ability to pay

  11. Expanding Access in Kansas • Health Center grants worth $12.4 million received through the 2009 Recovery Act: • Center for Health and Wellness Wichita $1,651,000 • Community HC of Southeast Kansas Pittsburg $1,145,350 • First Care Clinic, Inc Hays $1,651,000 • Gracemed Health Clinic Wichita $1,106,786 • Heart of Kansas Family Health Care Great Bend $569,787 • State Dept of Health and Environment Topeka $180,392 • Konza Prairie Community HC Junction City $765,050 • Lyon County Health Department Emporia $782,330 • Prairiestar HC, Inc. Hutchinson $773,498 • Salina Health Education Foundation Salina $670,149 • Shawnee County Health Agency Topeka $692,911 • The Hunter Health Clinic Wichita $1,678,137 • United Methodist Western Kansas Garden City $707,504

  12. Expanding Access in Kansas • Kansas health centers have received an additional $2.17 million through the Affordable Care Act: • Grants for community health centers: • GraceMed Health Clinic Wichita $525,000 • Community HC of Southeast Kansas Pittsburg $275,000 • Grants for school-based clinics: • GraceMed Health Clinic Wichita $500,000 • Wichita Public Schools Wichita $500,000 • Community HC of Southeast Kansas Pittsburg $370,000

  13. Expanding the Health Care Workforce • Rebuilding the Primary Care Workforce • $1.5 billion for National Health Service Corps to place providers in underserved areas • New scholarships and loan repayment incentives to provide underserved areas with more: • primary care doctors • nurse-practitioners • physician assistants • These programs placed 82 providers in Kansas in FY 2011 • The goal is to train and place 16,000 new primary care professionals by 2016

  14. Expanding the Kansas Workforce • State Health Care Workforce planning grant: • Kansas Department of Commerce Topeka $150,000 • Community Health Center support groups: • Kansas Assn for Medically Underserved Topeka $75,000 • Health Profession Opportunity Grants: • Helping TANF recipients move into health care jobs • Kansas Department of Commerce Topeka $2,796,046

  15. An Expanded Role for Nurses • $15 million for 10 new nurse-managed clinics in FY 2010 • Family Nurse-Practitioners: • Demonstration program for nurse- practitioners to train for a year as primary care providers in federally qualified health centers or nurse-managed clinics • Nurse Faculty Loan Program: • Annual loan limit for doctoral nursing students increased from $30,000 to $35,500 • $31.6 million awarded in FY 2010; $23.45 million in FY 2011 • $25 million from the ACA and $6.6 million from the 2009 Recovery Act • Nurses can cancel up to 85 percent of the loan with 4 years of teaching • Advanced Nursing Education: • Removed this program’s cap limiting support for nursing students pursuing doctoral degrees

  16. Lowering costs, improving care • Preventive care with no cost sharing • All new health plans must cover many preventive services without charging a deductible, co-pay or co-insurance • Medicare beneficiaries became eligible for these no-cost preventive services starting Jan. 1, 2011 • These services include: • mammograms • colonoscopies • vaccinations for flu, tetanus, measles, hepatitis A&B • help quitting tobacco • screenings for diabetes, obesity, high blood pressure, depression and alcohol abuse

  17. Strengthening Medicare • New Medicare benefits beginning in 2011: • a free annual wellness visit • no-fee preventive services • lower costs for prescription drugs • In 2012, Medicare participants receive: • a 50 percent discount on brand-name drugs once they hit the doughnut hole coverage gap • a 14 percent discount on generic drugs • In 2011, the discount was 50 percent on brand-name drugs and 7 percent on generics • The discount rises every year until the coverage gap is gone in 2020

  18. Real Savings for Real People • In 2011, more than 3.58 million seniors saved an average of $604 each because of the drug discount – a total of $2.16 billion • In Kansas, 38,692 seniors saved a total of $23.44 million • From January to October, these savings for local seniors totaled: Number of Total CountySeniorsSavings • Shawnee 1,911 $1,091,496 • Riley County 449 $254,486 • Sedgwick 4,614 $2,575,786 • Johnson 5,501 $3,296,022 • Douglas 802 $430,374 • Chase 19 $14,744 • Coffey 104 $54,710 • Wyandotte 904 $487,330

  19. Making Medicare Smarter • Slowing the growth in Medicare spending will save an estimated $500 billion over 10 years by: • Phasing out extra payments for Medicare Advantage • More aggressive negotiation with suppliers • A genuine focus on reducing fraud • More competitive bids on medical devices and drugs • Taking competitive bids on nine products in nine cities throughout the nation resulted in savings of 35 percent • Expansion of the program to include eight more products in 91 cities is expected to save $28 billion over the next 10 years

  20. Consumer Protections and Choices The Patients’ Bill of Rights • A ban on denying coverage to children under age 19 because of pre-existing conditions • Applies to all group health plans and all insurance policies sold after March 23, 2010 • 2014: Extended to all Americans • A ban on lifetime benefit limits • A phase out of annual limits on insurance coverage • A ban on dropping coverage based on an unintentional mistake on an application

  21. Reducing Health Insurance Costs • More bang for your buck: • Beginning this year, insurers serving individuals and small employers must spend at least 80 percent of premiums on health care services or improving the quality of care • Insurers serving large employers must spend at least 85 percent of premiums on health care or quality improvement • Insurance companies that fail to meet these standards must pay rebates to customers

  22. Making Insurance Affordable • In 2014, tax credits for people with income up to 400 percent of poverty • Maximum annual income of: • $43,560 for 1 person; • $89,400 for family of 4 • These tax credits level the playing field for family farmers, small business people and entrepreneurs • The IRS estimates the average tax credit at more than $5,000 • For people too poor to buy private insurance, Medicaid expands to 133 percent of the poverty level • Maximum annual income of: • $14,484 for 1 person; • $29,726 for a family of 4

  23. Health Insurance Exchanges Beginning in 2014, these marketplaces will allow you to look for the plan that is best for you • You might think of these as a Travelocity for health insurance • Insurance options available at your fingertips • These will be the same exchanges where members of Congress will buy their health insurance plans • Exchanges allow businesses with fewer than 100 workers to pool risk • By buying as a group, small employers will get the kinds of discounts that large employers already receive

  24. Making Health Care Safer • HHS recently launched Partnership for Patients, a groundbreaking push to improve medical care • A $1 billion commitment toward safer care • Partnership for Patients has two major goals: • Reduce preventable hospital-acquired conditions by 40 percent by 2013 • Reduce hospital readmissions by 20 percent by 2013 by reducing preventable complications during the transition from one care setting to the next

  25. Improving Health Care Quality • The first Partnership for Patients grants were announced on Dec. 14: • $218 million awarded to 26 state, regional, national or hospital system organizations • In Region 7, grant recipients include: • Ascension Health $5,797,119 • Via Christi Health System in Wichita • Carondelet Health System in Kansas City, Mo. • Lifepoint Hospitals $5,014,004 • Western Plains Medical Complex in Dodge City • Iowa Healthcare Collaborative $5,355,537 • 123 hospitals in Iowa and Nebraska

  26. Improving Health Care Quality • Linking payments to quality care: • Medicare will phase in new payment models to pay doctors according to patient outcomes, not volume of procedures • Effective January 2015 • Hospitals can qualify for incentives to improve care and reduce infection rates • Effective October 2012 • Hospital performance must be reported to the public on: • heart attacks • heart failure • pneumonia • surgical care • hospital-acquired infections

  27. Improving Primary Care • The Advanced Primary Care Practice • Three-year demonstration project to shift from a complaint-driven system that fragments care delivery to one designed to maintain the patient’s overall health • 500 FQHCs in 44 states received funding to provide: • Enhanced access to care: • expanded office hours • same day appointments, urgent care to discourage expensive ER visits • A team approach led by a physician or nurse-practitioner • Providers may include nurse coordinators, physician assistants, pharmacists and social workers • The goal is to reduce the cost of treating chronic conditions • 28 clinics in Region 7 will participate, including two in Kansas • GraceMed in Wichita and Konza Prairie Community Health in Junction City

  28. Improving Health Care Delivery • To encourage continuity of care, Medicare is encouraging new health care delivery systems • Accountable Care Organizations are groups of providers and suppliers working together to manage and coordinate health care for at least 5,000 Medicare patients • ACOs are expected to save at least $960 million over 3 years by providing better care, preventing illness and reducing redundant tests and unnecessary hospital admissions • The doctors, hospitals and suppliers participating in the ACO share in any savings they achieve • The amount of shared savings is linked to the ACO’s performance on quality standards • Private health insurance plans are now following this model

  29. Accountable Care Organizations New rules regarding ACOs became final in October: • Quality of care will be based on 33 performance measures in five key areas: • Patient/caregiver experience of care • Care coordination • Patient safety • Preventive health • Care provided to at-risk population and frail elderly • The one-sided risk model for new or small ACOs • These will share in the savings they achieve for Medicare • A two-sided risk model for experienced groups • These will share the risk of losses in exchange for a larger share of any savings

  30. Other New Approaches • Pilot program for bundled payments for acute care episodes to encourage coordinated care for seniors • Penalties for hospitals with: • high rates of hospital-acquired infections • high rates of re-admission within 30 days of discharge • Electronic Health Records • Health plans required to begin adopting rules for the electronic exchange of health information • Using electronic health records will: • reduce paperwork • cut costs • reduce medical errors • standardize billing

  31. Testing the Best Ideas • Innovation advisors announced January 3: • 73 individuals from 27 states: • In January, advisors began 6 months orientation and applied research focusing on: • Health care economics and finance; • Population health; • Systems analysis; and • Operations research • Their organization will receive a stipend of up to $20,000 and they will be expected to: • test new models of care delivery in their own organizations and communities • form partnerships with local organizations to drive delivery system reform • Kelly Taylor, an RN at Mercy Clinics in Des Moines, Iowa, is the only innovation advisor selected in Region 7

  32. Simply Awesome Consumer Site:www.Healthcare.gov • New one-stop consumer site for information on insurance options • Details about the new protections under the Affordable Care Act • Information at your finger tips allows you to shop for insurance – prices, benefits, insurer ratings

  33. A final thought….. “Opportunity is missed by most people because it is dressed in overalls and looks like work.“ ----Thomas Edison

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