Patient Protection and Affordable Care Act (ACA)

1. Patient Protection and Affordable Care Act (ACA) • Individual mandate (2014) • State insurance exchanges • Expansion of Medicaid program • Changes to private insurance • Employer requirements mandates • Medicare changes

2. Untruthful Assertions • Cuts Medicare by $1000 per person • Both ACA and the Ryan plan reduce increases in spending in the future by over $700 billion over 10 years • Establishes death panels • Payment to physicians for holding advance care planning discussions was cut from the Act

3. U.S. spending much more for older ages Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009. 

5. Medicare • Reduce payments to Medicare Advantage • MA plans were paid 113% of FFS • Some bonuses for high quality programs • Balance payments to high/low areas • Establishes an “Independent Payment Advisory Board” • Early donut hole relief – eventual elimination • Coverage for prevention services

7. Independent Payment Advisory Board • Recommend cost savings • Produce public reports – access, quality, costs • Make recommendations to President and Congress • Prohibited from “rationing” or “changing benefits or eligibility” or “Medicare premiums” • Hospitals and hospices not subject to recommendations until 2019

8. Donut Hole Relief 2011 • $250 rebate • 255, 996 FL seniors received the rebate • Total amount to FL seniors - $63,999,000 • Part D coverage gap discounts • 252,989 • Ave. per senior - $600 • Total amount - $151, 807,700 Kff.org, 1/7/13

9. Prevention & Wellness in FL • Free preventive services • 1,662,014 FL seniors received free services • 70% of FL Part B enrollees (65.5% US) • Annual wellness visit • 151,133 FL seniors had an annual wellness visit • 6.9% of FL Part B enrollees (5.4% US) Kff.org, 1/7/13

10. Older Adult Workforce • Funds Geriatric Education Centers • Expand Geriatric Academic Career Award to other disciplines (nursing, pharmacy, etc.) • New Geriatrics Career Incentive Award • Advanced training opportunities • Professionals • Direct care workers

11. Elder Justice • Create an Elder Justice Coordinating Council • Report published in May 2013 • http://www.aoa.gov/AoA_programs/Elder_Rights/EJCC/Meetings/docs/2013_05_13_EJCC-Proposals.pdf • $400 million for Adult Protective Services • $100 million for state demonstration grants • $26 million to create Elder Abuse, Neglect and Exploitation Forensic Centers

12. New Models of Care • Innovation Center at CMS • Foster patient-centered care & coordination • Models • Accountable Care Organizations • Bundled payments • Medicare Coordinated Care • Partnerships for patients • Comprehensive Primary Care

13. Problems with Medical Payments • Fee-for-service • Provider (not the consumer) decides what is needed • Insurance (not the consumer) pays the fees • Provider is incentivized to do more • Capitation (“by the head”) • Insurer decides what is needed • Insurer pays provider regardless of use • Provider is incentivized to do less

14. Accountable Care Organizations (ACO) • An organization of physicians and hospitals that agree to cost and quality targets • Strong primary care base • Payment is linked to quality (instead of volume) • Savings are achieved through improvements in care • Savings are shared between providers and CMS

15. Bundled Payments • “Bundling” expenses that used to be separate • Hospital admission and after care • Surgery and a “warranty” • Considerations • Hard to predict costs • Difficult cases may be avoided • Doesn’t discourage unnecessary care

16. Medicare Coordinated Care • Funds coordinated care for people with chronic conditions • 15 programs • Face-to-face meetings with client • Helped with medications • Facilitated communications (“hub”) • Helped with transitions • 8%-33% reduction in hospitalizations • Cost neutral

17. Comprehensive Primary Care • 4 states (OR, CO, AK, NY) • Components • Risk adjustment • Access and continuity • Non-visit services & fees • Planned care for chronic conditions • Patient and caregiver engagement • Coordination od care

18. Partnerships for Patients • Reduce hospital-acquired conditions and readmissions • Elements • Hospital Engagement Networks (TMH) • Care Transitions (5 sites in FL) • Patient and family engagement • Provides resources to health care providers to better educate staff and patients/families

19. Elephant in the Room - LTC • Nursing homes - $100,000/year • Many become impoverished and go on Medicaid • Low satisfaction • CLASS act – (part of ACA) – would have established a national LTC insurance • Dropped by Democrats • Are some interesting new models • Eden Alternative, Greenhouse Model

21. 4 2 3 1 5 1 – Affordability & Access - 35 4 – Support of family caregivers - 40 2 – Choice of setting & provider - 41 5 – Effective transitions - 14 3 – Quality of life & quality of care - 43 State Scorecard on LTSS Commonwealth/AARP 2014

22. Few Good Things in LTSS in ACA • National panel of LTC experts • Report issued Sept. 2013 • Funding for LTC Ombudsman Program • Funding for LTC training and recruitment • Nursing home transparency • Some financing options • Money follows the person • Home health and HCBS

23. Nursing Home Transparency • Disclose ownership, financers, etc. • Take steps to reduce violations • Establish quality assurance programs • Provide dementia care training • Data collection requirements • Pilot program – extend to all states a national criminal background check system

24. Good Resources • Kaiser Family Foundation • http://kff.org • CMS Innovation Center • http://innovation.cms.gov/initiatives/#views=models • Eden Alternative • http://www.edenalt.org • Greenhouse Project • http://thegreenhouseproject.org • Autumn Blossoms • http://autumnblossoms.org