Healthcare Reform & School-Based health Centers

Healthcare Reform& School-Basedhealth Centers Maryland Assembly on School-Based Health Care May 17, 2012 Cindy Friend, RN, BSN, MSN, MBA/HCA Managing Director

Agenda • Overview of the Patient Protection and Affordable Care Act (ACA) • ACA Impact on SBHCs • Emerging Health Care Delivery Models • Accountable Care Organizations (ACO) • Patient-Centered Medical Home (PCMH) • Opportunities for SBHCs to become involved in the Healthcare Reform movement • Strategies to assist SBHCs in quality improvement efforts Continuous Improvement is a Quality Movement

Patient Protection & Affordable Care Act On March 23, 2010, President Obama signed comprehensive health reform, the Patient Protection and Affordable Care Act (ACA), into law The ACA includes provisions to expand coverage, control health care costs, and improve the health care delivery system Continuous Improvement is a Quality Movement

Overview of the ACA • Create state-based American Health Benefit Exchanges through which individuals can purchase coverage • Premium and cost sharing credits available to individuals/families with income between 133-400% of the federal poverty level (the poverty level is $18,310 for a family of three in 2009) • Create separate Exchanges through which small businesses can purchase coverage • Require employers to pay penalties for employees who receive tax credits for health insurance through an Exchange, with exceptions for small employers • Impose new regulations on health plans in the Exchanges and in the individual and small group markets • Expand Medicaid to 133% of the federal poverty level Continuous Improvement is a Quality Movement

ACA Provisions • Individual Mandate • Requirement to have coverage • Employer Requirements • Requirement to offer coverage • Other Requirements • Expansion of Public Programs • Treatment of Medicaid • Treatment of CHIP Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Premium and Cost-Sharing Subsidies to Individuals • Eligibility • Premium credits • Cost-sharing subsidies • Verification • Subsidies and abortion coverage Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Premium Subsidies to Employers • Small business tax credits • Reinsurance program • Tax Changes Related to Health Insurance or Financing Health Reform • Tax changes related to health insurance • Tax changes related to financing health reform • Benefit Design • Essential benefits package • Abortion coverage Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Health Insurance Exchanges • Creation and structure of health insurance exchanges • Eligibility to purchase in the exchanges • Public plan option • Consumer Operated and Oriented Plan (CO-OP) • Benefit tiers • Insurance market and rating rules • Qualifications of participating health plans • Requirements of the exchanges • Basic health plan • Abortion coverage • Effective dates Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Changes to Private insurance • Temporary high-risk pool • Medical loss ratio and premium rate reviews • Administrative simplification • Dependent coverage • Insurance market rules • Consumer protections • Health care choice compacts and national plans • Health insurance administration Continuous Improvement is a Quality Movement

ACA Provisions (cont) • State Role • Regulator mandates • Cost Containment • Administrative simplification • Medicare • Medicaid • Prescription drugs • Waste, fraud, and abuse Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Improving Quality/Health System Performance • Comparative effectiveness research • Medical malpractice • Medicare • Dual eligible • Medicaid • Primary care • National quality strategy • Financial disclosure • Disparities Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Prevention/Wellness • National strategy • Coverage of preventive services • Wellness programs • Nutritional information • Long-Term Care • CLASS Act • Medicaid • Skilled nursing facility requirements Continuous Improvement is a Quality Movement

ACA Provisions (cont) • Other Investments • Medicare • Workforce • Community health centers & school-based health centers • Trauma care • Public health and disaster preparedness • Requirements for non-profit hospitals • American Indians • Financing • Coverage and financing Continuous Improvement is a Quality Movement

ACA Impact on SBHCs The ACA requires HHS to establish new programs to support School-Based Health Centers (Title IV, Section 4101(a)) Authorizes the Health Resources and Services Administration (HRSA) to administer the School-Based Health Centers Capital (SBHCC) Program Continuous Improvement is a Quality Movement

SBHCC Program Grants are intended to address capital funding that is needed to improve delivery and support expansion of services at SBHCs Applicants must demonstrate how their proposal will lead to improvements in access to health services for children at a SBHC Continuous Improvement is a Quality Movement

SBHCC Program (cont) • A cap of $500,000 has been established as the maximum amount of Federal funding that can be requested in a SBHCC application • An eligible applicant may submit one application proposing a maximum of 10 projects • This may include any combination of site-specific, stand-alone facility projects, and one project to purchase moveable equipment, for example • HRSA received approximately $100 million to fund grants to an estimated 200 SBHCC grants in FY 2011 For more information visit: http://www.hrsa.gov/grants/apply/assistance/sbhcc/ Continuous Improvement is a Quality Movement

Funding Opportunity Announcement • HRSA issued a Funding Opportunity Announcement (FOA) in October 2010 • In June 2011, HRSA awarded 278 grants under the SBHCC Program FOA totaling $95M • $934,435 was awarded to 4 Maryland SBHCs • May 9, 2012, HHS announced $75M available through the SBHCC program for the renovation and construction of SBHCs Continuous Improvement is a Quality Movement

Healthcare Reform Delivery Models Accountable Care Organizations (ACOs) Patient-Centered Medical Homes (PCMHs) Continuous Improvement is a Quality Movement

ACO Overview A group of providers that come together for the purpose of rendering coordinated, high quality care Providers includes hospitals, primary care, specialists, and other health care providers Establish patient population management and innovative care delivery model Model based on shared accountability and funded through shared savings arrangements Continuous Improvement is a Quality Movement

ACA and ACOs ACO mentioned in all draft reform bills Included in Section 3022 of the ACA, entitled Shared Savings Programs Authorized CMS to create an ACO program by no later than January 1, 2012 Continuous Improvement is a Quality Movement

CMS ACO Programs CMS has launched a couple of programs to incentivize providers to link together and exchange data in order to lower costs and share savings • Medicare Shared Savings Program • A program that helps a Medicare fee-for-service program providers become an ACO • Advance Payment Initiative • A supplementary incentive program for selected participants in the Shared Savings Program • Pioneer ACO Model • A program designed for early adopters of coordinated care (no longer accepting applications) For more information visit: http://innovations.cms.gov/initiatives/ACO/index.html Continuous Improvement is a Quality Movement

ACO Accreditation Options National Committee for Quality Assurance (NCQA) Program launched in November 2011 Six organizations had applied for ACO accreditation in January 2012 Continuous Improvement is a Quality Movement

ACO Standards (per NCQA) ACO Structure and Operations Access to Needed Providers Patient-Centered Primary Care Care Management Care Coordination and Transitions Patient Rights and Responsibilities Performance Reporting and Quality Measures Continuous Improvement is a Quality Movement

PCMH Overview 1967: The American Academy of Pediatricians (AAP) introduced the term “medical home” and it was AAP policy within a decade 1978: The World Health Organization (WHO) outlined some of the basic tenets of the medical home and the importance of primary care 1990’s: Medical Home concept embraced by Institute of Medicine (IOM) 2002: Study by Family Medicine resulting in The Future of Family Medicine: A Collaborative Project of the Family Medicine Community 2004: American Academy of Family Physicians (AAFP) PCMH Demonstration 2006: Patient-Centered Primary Care Collaborative (PCPCC) was established 2008: First release of NCQA Recognition standards Continuous Improvement is a Quality Movement

Joint Principles • Whole person orientation • Safety and quality • Care coordination and integration • Personal Provider • Enhanced Access • Continuity of Care • Capacity and Accountability For more information visit: http://www.pcpcc.net/ Continuous Improvement is a Quality Movement

PCMH Framework Well-organized and on-time visits Enhanced access with a self-selected provider for continuity (same day appointments, 24/7 clinical support, alternatives to the 1:1 visit) Proactive care management (evidence based clinical care, panel management, reminder systems, registries) Care coordination across settings (assistance with referrals, tracking for tests and referrals, care during transitions) Continuous Improvement is a Quality Movement

PCMH Framework (cont.) Patient engagement, and participation in care decisions (provider-patient relationship, patient-centered, and consumer driven) Connections to community resources to extend support for self-care management Health outcomes focused and plan for continuous improvement Data driven use of health IT as a tool to support the advancement of primary care Continuous Improvement is a Quality Movement

A Formula for Success Well-trained workforce organized as a multi-disciplinary care teams Mutual accountability among the team and between team and patients System designed to support care management and coordination through enhanced access, continuity, and information availability Cross boundary cooperation and partnership among all provider types Technology infrastructure for information management and exchange Payment reform to support the work Continuous Improvement is a Quality Movement

PCMH Activity in Maryland On April 13, 2010, Governor O’Malley signed House Bill 929: Patient Centered Medical Home Program into law Statute authorizes the Maryland Health Care Commission (MHCC) to establish a multi-payer PCMH program MHCC is also permitted to authorize a single carrier PCMH program Effective from July 1, 2011 through December 31, 2015 Continuous Improvement is a Quality Movement

PCMH Activity in Maryland Continuous Improvement is a Quality Movement

PCMH Certification Options National Committee for Quality Assurance (NCQA) The Joint Commission (TJC) URAC (formerly the Utilization Review Accreditation Commission) Accreditation Association for Ambulatory Health Care (AAAHC) Continuous Improvement is a Quality Movement

Certification Options Comparison Continuous Improvement is a Quality Movement

PCMH Standards & Requirements (based on NCQA) Continuous Improvement is a Quality Movement

Opportunities Stay current on healthcare activities Take advantage of funding opportunities Tap into community resources Collaborate and coordinate among SBHCs Adopt and utilize health IT Continuous Improvement is a Quality Movement

Strategies for Quality Improvement Identify a quality improvement champion Establish a healthcare transformation team Engage a subject matter expert to facilitate transformation Conduct comprehensive clinical, technical, and business assessments Identify and engage Stakeholders Continuous Improvement is a Quality Movement

Strategies forQuality Improvement (cont) Develop/evaluate programs and initiatives Progressive program promotion/awareness Coordinate efforts Cost-sharing Adopt technology Participate in community and political events Continuous Improvement is a Quality Movement

Tips for Transformation Assess Plan Prepare Leverage Resources Execute Study & Scrutinize Continuous Improvement is a Quality Movement

Healthcare Reform & School-Based health Centers