Hospital Revenue Streams and Health Care Reform Opportunities. Ruth Ann Norton, GHHI Jack Rayburn, Trust for America’s Health Beth Bafford, Calvert Foundation Michael McKnight, GHHI (moderator ) May 29, 2014. Health Care Reform Opportunities. National Healthy Homes Conference
Hospital Revenue Streams and Health Care Reform Opportunities
Ruth Ann Norton, GHHI Jack Rayburn, Trust for America’s Health Beth Bafford, Calvert Foundation Michael McKnight, GHHI (moderator) May 29, 2014
Health Care Reform Opportunities
National Healthy Homes Conference May 29, 2014 Jack Rayburn Senior Government Relations Manager @ jjrayburn
Overview Prevention opportunities in ACA CDC and community-based prevention Medicaid rule change opportunity Hospitals and Community Benefit
About TFAH: Who We Are Trust for America’s Health (TFAH) is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.
The Affordable Care Act
ACA & The Road to Health The Affordable Care Act recognizes that health means more than the absence of disease and that every part of our life must be focused on creating health Clinical preventive services like screenings and counseling All parts of society must work together to make the healthy choices the easy choice Each of us as individuals has a responsibility to be as healthy as we can be
Insurance matters Coverage for preventive services Every new health plan, since 2010, must include coverage of evidence-based, effective preventive services, such as screenings for type 2 diabetes, immunizations and mammograms, without co-pays. Since January 1, 2011, seniors on Medicare receive many preventive services, with no co-payments–such as annual wellness visits, cervical cancer screening, diabetes screening, mammograms and immunizations for the flu and pneumonia. Prevention in ACA
Four strategic directions Healthy and Safe Community Environment Clinical and Community Preventive Services Empowered People Elimination of Health Disparities National Prevention Strategy
Healthy and Safe Environments Businesses and employers can: “Ensure that homes and workplaces are healthy, including eliminating safety hazards (e.g., trip hazards, unsafe stairs), ensuring that buildings are free of water intrusion, indoor environmental pollutants (e.g., radon, mold, tobacco smoke), and pests, and performing regular maintenance of heating and cooling systems.” National Prevention Strategy, page 17
Recent Community Prevention Investments Communities Putting Prevention to Work (CPPW) Prevention and Public Health Fund Community Transformation Grants (CTG) Tobacco Prevention, Quitlines, National Media Campaign Coordinated core chronic disease funding for state health departments And…
Prevention Investments 2014 PICH grants (not PPHF) Preventive Health and Health Services block grants to states Immunizations Diabetes Prevention Heart Disease and Stroke Prevention Racial and Ethnic Approaches to Health (REACH) And much more…
Partnerships to Improve Community Health (PICH) “PICH is a new 3-year initiative to improve health and reduce the burden of chronic diseases. Eligible applicants include a variety of governmental agencies and non-governmental organizations, including local public health departments, school districts, local housing authorities, local transportation authorities, and American Indian tribes…to work through multi-sectoral community coalitions.” Letters of Intent due June 5, 2014 www.cdc.gov/chronicdisease/ for more information
Community-based Prevention Future of this work to be determined by: Success of current efforts Letting the world know of those successes Creating partnerships that go deeply into the transforming health system Creating sustainable resources by leveraging new funding streams
Medicaid Support for Community Prevention Recent Medicaid EHB rule change to allow reimbursement for non-licensed providers Waivers and other CMS authorities to pay for additional covered services, or to pay additional entities, or for services in non-traditional setting MA Pediatric Asthma 1115 Waiver Diabetes Prevention Program TX 1115 Waiver Coverage of tobacco quit lines in Medicaid
Medicaid Payment for Non-licensed Providers Centers for Medicare and Medicaid Services (CMS) clarified the statute in the recently issued Essential Health Benefits rule. Medicaid will now reimburse for preventive services recommended by licensed providers and provided, at state option, by non-licensed providers.
What is the Opportunity for Community Prevention? A broader array of health professionals could be reimbursed for providing preventive services to Medicaid beneficiaries Health Educators Community health workers Care Coordinators Home Visiting Staff Lactation Consultation Developmental screening YMCA Diabetes Prevention Program Parenting Education
What are the Steps? Define what you want to do. Gather the required information. Meet with your state Medicaid agency to request that they submit a State Plan Amendment (SPA). Meet with local Managed Care Organizations (MCOs) to explore workforce innovation partnerships.
Describe the Issue and Solution Explain the health issue you are addressing. Describe the intervention. Provide the evidence of effectiveness and, if available, return on investment.
Define the Change What provider(s) do you propose? What services will they provide? Which Medicaid beneficiaries would be eligible for the services?
Specify Provider Qualifications Educational background Training Experience Credentialing or registering Employment model
Explain Service Delivery What preventive services Evidence of effectiveness Referral process (from licensed provider) Unit of service Service limitations if any Location limits or requirements if any Reimbursement level
Hospitals as Community Health Leaders ACA Sec. 9007 Expands and clarifies not-for-profit community benefit requirements IRS proposed rules; awaiting final rule Seek out completed needs assessments, comment, and offer to partner http://cdc.gov/policy/chna Aligning fiscal incentives (i.e., via ACOs) may offer other opportunities to partner.
Partner and Persevere Collaborate with state Medicaid agency to submit state plan, implement, monitor, improve. Negotiate with Managed Care Organizations to implement, monitor, improve. Partner with health care delivery system to implement and measure outcomes/savings. Work with public health agency to implement and measure outcomes.
For more information Please visit www.healthyamericans.org to view the full range of Trust for America’s health policy reports. Or www.healthyamericans.org/health-reform for health reform implementation information. Email: email@example.com Twitter: @jjrayburn or @healthyAmerica1
There are 5 major trends happening in the health system today, most driven by changes in the ACA Government Providers Payors Integrated health systems 5 Gov’t as innovator 1 4 2 3 Physician & hospital consolidation Consumerism New payment models Coordination of care
Within the current system, there are certain trends that favor community health management… Understand who is at risk for patient care & show savings Government Providers Payors Integrated health systems Gov’t as innovator Physician & hospital consolidation Consumerism New payment models Coordination of care
…but the most relevant trend is the rise of integrated health systems Integrated systems are likely more willing and well-equipped to discuss payments for community health Government Providers Payors Integrated health systems Gov’t as innovator Physician & hospital consolidation Consumerism New payment models Coordination of care
Addressing Root Causes
A Model That Benefits Families
Health Impact & Benefits of GHHI
Over 5,000 GHHI units completed nationwide Impact on asthma: 60-67% reduction in asthma-related client hospitalizations 25-60% reduction in asthma ER visits 50% increase in participants never having to visit the doctor’s office due to asthma episodes 55% increase in participants reporting their child’s asthma as well controlled 62% increase in participants reporting asthma-related perfect attendance for their child (0 school absences due to asthma episodes) 88% increase in participants reporting never having to miss a day ofwork due to their child’s asthma episodes
Sustainable Funding for Healthy Homes
Without health care sector investment, not enough healthy homes funds to meet the need Impact on costs makes healthy homes ideal for new, sustainable investment from the health care sector - business case Increased emphasis on community health and prevention aligns with healthy homes Around the country several programs have gotten reimbursement from Medicaid, hospitals, and managed care organizations
Medicaid Rule Change implications
Education delivered to families Case Management To take advantage, each state has to submit a State Plan Amendment (SPA) to CMS outlining services, payment structure, and what certifications will be used for those professionals Rule changes “Who” but not “What” for the services that are eligible – some structural remediation is still beyond CMS’ current scope.
Multnomah County Environmental Health Services (MCEHS) Began with HUD Healthy Homes program for in-home nursing care management, environmental assessments, education, and supplies to reduce asthma triggers, as well as connecting families with community resources. Expanded to the Community Asthma Inspection and Referral (CAIR) program. Community Health Nurse and Community Health Worker conducts 7 visits. In 2010 MCEHS negotiated with OR Department of Medical Assistance Programs and CMS to develop Healthy Homes targeted case management, allowing for Medicaid reimbursement. Kim Tierney serving on a panel at NHHC for more information
Asthma Network of West Michigan (ANWM) Karen Meyerson – Provides comprehensive home-based case management, environmental assessment, and education. Health outcomes and cost savings (64% reduction in hospitalizations, 60% reduction in ER) from ANWM home visiting program led to partnership with Priority Health, a managed care organization Has seen net savings of $800/year for each child
Companies that agree to provide most Medicaid benefits to people in exchange for a monthly payment from the state More flexibility in what MCOs provide under that contract than what can be provided in traditional fee-for-service Medicaid reimbursement. Incentivized to deliver cost effective services Monroe Plan for Medical Care, in NY, an EPA Asthma Leadership Award winner, launched a program that included educational materials, home environmental assessments, and supplies. For every $1 spent, $1.48 was saved in direct medical costs through a 60% reduction in hospitalizations and 78% fewer ED visits.
Healthy Homes Waiver
Massachusetts Pediatric Asthma Pilot MA expanded a 1115 waiver to allow expenditures for services: home visits, education, care coordination by community health workers, and environmental supplies for asthma 5-year period Focus is on high-risk pediatric asthma cases – patients with hospitalizations or emergency room visits for asthma Aim is to satisfy cost savings requirement from reduced hospitalizations and emergency room visits to counteract costs of additional services. Still working on programmatic details to start reimbursement. Speak with Stacey Chacker, Director, Health Resources in Action Environmental Health Department for more information
Making it happen
Relationships are key – getting to the right decision makers Process will take time Make life easier for state Medicaid offices Waiver is a more rigorous process than State Plan Amendment Data is key including costs and impact, make the business case Do not reinvent the wheel – reach out to partners across the country who have undergone the process
State Innovation Models Initiative
CMS providing $730 million for developing state models for multi-payer payment and health care system delivery transformation MD designed their proposal on creating Hubs that will connect community based services with medical services. Used asthma and home-based services as their model. The grant would pay for services in Year 1-3, if ROI is proven, MD payers will pay for those services Year 4-5
Opportunities from Hospital Community Benefits
Community benefit investments can encompass “physical improvements and housing” and “environmental improvements.” According to AHA there are 2,894 Nongovernment Not-for-profit hospitals and 1,037 state and local government community hospitals Connect with the right office at the hospital – title may be Community Health Development but it varies (e.g. marketing) Become part of the stakeholder group looking at community health needs. Does the community have an asthma issue? Does the community have a lead poisoning issue? Stress the incentive of having their community benefit investments go towards something that also produces cost savings
Hospital Incentives – Reducing Readmissions
ACA set up Hospital Readmissions Reduction Program Reduced payments for excess readmissions First three conditions are: AMI (heart attack), pneumonia, and heart failure COPD and THA/TKA (total hip and total knee arthroplasty) will be added in October 2014 ACA also encourages the formation of Accountable Care Organizations for Medicare, incentivizing providers to keep patients healthy Maryland has new global waiver for hospitals (per capita payments)
Ruth Ann Norton President & CEO, Green & Healthy Homes Initiative firstname.lastname@example.org 410-534-6447 Jack Rayburn Senior Government Relations Manager, Trust For America’s Health email@example.com 202-223-9870 Beth Bafford Senior Officer of Strategic Initiatives, The Calvert Foundation Beth.Bafford@calvertfoundation.org Michael McKnight Senior Program Officer, Green & Healthy Homes Initiative firstname.lastname@example.org