Advancing Health Care Reform: The ACA and Medicare

Aging Advocacy Summit

Presented by Joyce DubowAugusta, MENovember 14, 2012

Presentation overview

• How consumers can engage in the “3 aims” and help to reform health care

• Approaches to quality improvement and delivery in health reform legislation (ACA)

• ACA and Medicare• Future of Medicare• Implications of sequestration

• Better healthcare: – Improve individual patient experiences of care along the Institute

of Medicine’s six domains of quality: Safety, Effectiveness, Patient-centeredness, Timeliness, Efficiency, and Equity.

• Better health: – Encourage better health for entire populations by addressing

underlying causes of poor health, such as physical inactivity, behavioral risk factors, lack of preventive care and poor nutrition.

• Reduced costs: – Lower the total cost of care resulting in reduced monthly

expenditures for each Medicare, Medicaid or CHIP beneficiary by improving care.

The Three Aims (DHHS)

Patient/Person Centeredness/Engagement

Patient Engagement: 2 pathways (1)Engagement in one’s own health and health care; and

Center for Advancing Health- “actions individuals must take to obtain the greatest benefit from the health care services available to them” (Jessie Gruman, et al., 2010)

Judy Hibbard- Consumers taking on new roles and behaviors, such as choosing high performing providers; selecting evidence-based treatments; collaborating with their providers; taking preventive actions; self-management; being vigilant to prevent errors

(2) Engagement in policy development and governance to ensure patient perspectives are addressed

Why Patient Engagement Now?

Greater sense of urgency due to fiscal constraints of federal and state budgets and the unwillingness of purchasers to contribute to a system that doesn’t produce good results

HIT, and the need to tie clinical and patient decisions to evidence

A demand for greater accountability through measurement and public reporting

How will we know success?

Health care that gives each individual and family an active role in their care;

Care that adapts readily to individual circumstances as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds;

Sees a person as a multi-faceted Requires a partnership between the provider and the patient

with shared power and responsibility Gives the patient access to understandable information and

decision support tools Determines whether patients achieve their desired outcomes.

(AHRQ Report to Congress, 3/2011)

Problem drivers

• Scientific uncertainty• Perverse economic and practice incentives• System fragmentation• Opacity to cost and quality• Changes in health status• Lack of patient involvement

We get what we pay for, but not what we want

• Incentives for high volume and intensity• Inadvertent reward for poor care (e.g., payment for

readmissions, correction of mistakes)• Procedures paid more than primary care• No incentive to integrate care• Payment does not differentiate between good/poor

performance (no reward for high quality, no penalty for poor care)

Where we need to go

Current system • (Too) often, unsafe• Fragmented, uncoordinated,

unnecessary care• Provider-focused• Timely (?), rushed• Inefficient, wasteful• Disparate (geography,

gender, age, race, ethnicity)• Costly, >unaffordable

IOM Aims for improvement• Safe• Effective• Patient-centered• Timely• Efficient• Equitable

How we get there…• Payment redesign to focus on

results and value• Quality and consistency in

treatment• Timely evidence that is

independent, and understandable

• Clinical records that are reliable, shareable, and secure

• Transparency requirements on cost, quality, including outcomes

IOM, the Healthcare Imperative, 2010

Health Care Reform: The ACA

Infrastructure to support quality goals

Evidence basePerformance measuresHealth Information TechnologyRobust workforce

• Infrastructure: develop evidence, measures, HIT; test new ideas; certify shared-decision making tools

• New models of care: Shared Savings Program (ACOs); medical/health homes

• Accountability: transparency/public reporting• Financial incentives/payment reform• Workforce reform/strengthen primary care• Wellness and health promotion• *(HITECH provisions in ARRA “meaningful use” of

HIT have significant implications for quality)

ACA quality provisions that relate to delivery reform

• Make care safer by reducing harm caused in the delivery of care.• Ensure that each person and family is engaged as partners in their care• Promote effective communication and coordination of care• Promote the most effective prevention and treatment practices for the

leading causes of mortality, starting with cardiovascular disease• Work with communities to promote wide use of best practices to

enable healthy living• Make quality care more affordable for individuals, families, employers,

and governments by developing and spreading new health care delivery models.

National Strategy for Quality Strategy Improvement in Health Care (NQS)

Infrastructure

ACA: evidence for clinical and patient decisions: PCORI

• Patient-Centered Outcomes Research Institute, a private, not-for-profit entity to: – identify research priorities and a research agenda– conduct research, with priority to AHRQ, NIH– release and disseminate findings (which many

not be used in making Medicare coverage determinations, or for reimbursement or incentive programs.)

Patient-Centered Outcomes Research Institute (PCORI)

• PCORI doesn’t actually define patient engagement or patient-centeredness, but rather incorporates these concepts in its approach to research

• Research focuses on outcomes that people notice and care about: survival, function, symptoms, and health-related quality of life PCORI poses the following questions

• :• “Given my personal characteristics, conditions and preferences, what

should I expect will happen to me?” • “What are my options and what are the benefits and harms of those

options?” • “What can I do to improve the outcomes that are most important to

me?” and • “How can the health care system improve my chances of achieving the

outcomes I prefer?”

• PCORI models another aspect of patient engagement—inclusion of patients at the governance level

• Performance measurement to improve quality, safety and efficiency, promote accountability, payment, and delivery reform– HHS will:

develop and implement a national strategy (3-21-11)• identify and fund gaps in measures • oversee a process for collecting and aggregating data • develop a framework for public reportingengage in a consultative process with stakeholders on

selection of national priorities and quality measure (5-11)

ACA : quality infrastructure: capacity to measure performance

Infrastructure: measure development and reporting

• The Center for Medicare and Medicaid Innovation to test innovative payment and service delivery models that enhance quality of care provided to Medicare and Medicaid beneficiaries; implement innovations as they are ready for prime time

• Examples of initiatives: ACOs, bundled payments, Primary Care Initiative, FHQC Advanced Medical Homes, Medicaid Incentives for the Prevention of Chronic Diseases

http://www.innovations.cms.gov/

ACA: CMMI to test new ideasInfrastructure

• Physicians rewarded for P4R through 2014, then those who fail to report lose $

• Physicians participating in MOC eligible for bonuses• HHS to provide physicians with information on their

resource use• In 2013, public reporting on Physician Compare• “Value-modifier” to reward physicians who deliver

better care, lower costs

ACA: advance accountability, reward good quality, greater efficiency

• Medicare Shared Savings Program (ACOs)• Medical Homes pilot (Health Homes in Medicaid)• Medicare Community-based Care Transitions

program• Independence-at-home demonstration

ACA: new delivery modelsDelivery reform

ACOs in the traditional Medicare program (MSSP)

• Governance• Process to promote patient-centeredness,

patient engagement, use of evidence• Quality measurement and reporting• Beneficiary notices• Data sharing• Risk sharing

ACO: whole-person orientation

• Seamless, coordinated, integrated care, available 24/7

• Responsive, respectful, care that recognizes patients as equal partners in care decisions and delivery

• Ongoing efforts to examine care to improve performance, eliminate disparities

Patient engagement in ACOs ACO functions to demonstrate patient engagement:

Patient involvement in governanceUse of a patient experience surveyProcess for evaluating and addressing needs of population servedSystems to identify high-risk individualsMechanisms in place to coordinate care via enabling technologiesWritten standards for beneficiary access and communicationProcess to allow for shared decision makingCommunicating clinical knowledge in a way that is understandable

to patients

• Hospital readmission reduction program– Reduced payment for “excess” readmissions for 3

high cost/high volume procedures (acute MI, HF, Pneu)

• Public reports of readmission rates on Hospital Compare• Assistance for hospitals with high rates of readmission

• Reduced payment for hospital/healthcare acquired conditions (e.g., bedsores, complications from extended use of catheters, injuries caused by falls) in the 25 percent of hospitals with highest rates)

ACA: accountability, incent better care, lower costs

Financial incentives

Payment to incent improvement

• Bundled payments encourage individual and shared accountability for entire episodes of care (including acute and post-acute care) or for a bundle of services– Reimbursement for all the services needed by a

patient for a treatment or condition across multiple providers or settings

Payment reform

• Increase payment to primary care providers (Medicare bonuses, Medicare rates for Medicaid providers)

• Establishing community health teams to support PCMH (grants, contracts)

• Support for training clinicians in primary care• Community-based collaborative care networks (with

FHQCs) to serve low-income individuals • ACOs, PCMH pilots

ACA: strengthen primary careDelivery reform

• Physicians rewarded for P4R through 2014, then those who fail to report lose $

• Physicians participating in MOC eligible for bonuses• HHS to provide physicians with information on their

resource use• In 2013, public reporting on Physician Compare• “Value-modifier” to reward physicians who deliver

better care, lower costs

ACA: advance accountability, reward good quality, greater efficiency

Accountability/transparency/public reporting

• “Meaningful Use” Use of technology to achieve significant improvement in care

• Financial incentives ties payment specifically to the achievement of advances in health care processes and outcomes

• Stage 1 identifies core objectives– basic functions to enable an EHR to support care

improvement (vital signs, demographics, medications, allergies, problem list, smoking status)

– Provide patients with electronic versions of their health information

HITECH“Meaningful use”

Summary of ACA steps to improve quality:an advocacy agenda

• Build the evidence base: comparative effectiveness research• Incent HIT and data exchange• Promote accountability through transparency/public reporting• Align payment with performance

– Bundled, episode-based payments– Penalties for preventable re-hospitalizations– MA bonuses for attainment/improvement in quality

• Improve health service delivery– Primary care; Medical homes; ACOs– Care coordination

• Promote wellness and prevention• Adopt enhanced role for patients through shared decision

making and greater engagement through self-efficacy• Appropriations

Public Policies to Support Patient Engagement

Provider payment to incent patient-centered delivery of carePublication of patient experience and patient-reported outcomesShared decision making grounded in evidenceValue-based benefit design to encourage better patient choicesEncourage patient-centered delivery Investment in and support

of EHR adoption to facilitate patient access to their health information; enhance communication with clinicians; and enhance care coordination

Encourage patient-centered delivery models through support of primary care, shared savings, etc.

Potential Saved if USA “bends the curve” of Health Care Spending

$5.2

$4.2

$2.6

$1

$2

$3

$4

$5

$6

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Current projection (6.7% annual growth)

Constant (2009) proportion of GDP (4.7% annual growth)

NHE in trillions

Total National Health Expenditures, 2009–2020, Current Projection and Alternative Scenario

Potential SavingsWe are here

Yellow line =CBO Estimated savings achieved

by ACA

Will all these ideas work?

Core Goals and Priorities for Health System Performance Improvement

QUALITY • Getting the right

care• Coordinated care• Safe care• Patient-centered

care

ACCESS• Universal

participation• Affordable• Equitable

EFFICIENCY SYSTEM CAPACITY TO IMPROVE

LONG, HEALTHY, AND

PRODUCTIVE LIVES

Source: Commonwealth Fund Commission on a High Performance Health System.

Medicare Reform

Switching gears to

36

MEDICARE IS A TARGET IN BUDGET DEBATE

Current Financing Unsustainable in Long-Term • ACA Improved Short Term Outlook (10 yrs)

• Medicare’s share of GDP: Long Term Outlook (20 yrs+)

• 3.7 % GDP in 2011• 4.2 % GDP by 2022• 6% GDP by 2040

• Cost Growth in Medicare caused by: – Health care cost growth– Aging of the population

System-wide and Medicarecost containment one and the same

37

$260

$39 $17

$66 $33

$156

$145

Hospitals

Skilled Nursing

Hospice

Home Health

All Other Services

Medicare Advantage

Other Medicare Provisions***

Medicare Savings from the ACA2013–2022 (billions)

***Other provisions include increases in Medicare payments to Disproportionate Share Hospitals that serve many low-income uninsured persons, effect on federal spending for prescription drugs and biologics (including savings from eliminating the provisions that close the donut hole), and repeal of IPAB. 

Deficit Reduction Proposals (Round I)National Commission on Fiscal Responsibility and Reform(Simpson-Bowles)

Bipartisan Policy Center Debt Reduction Task Force

(Domenici-Rivlin)

Reform Sustainable Growth Rate mechanism for determining Medicare physician fee updates (costs $240B)Reform or repeal CLASS Act (costs $76B)Extend Medicaid rebates to Medicare/Medicaid dual eligibles in Medicare Part D (saves $49B)Reduce Medicare payments to hospitals for graduate medical education (saves $60B)Reform Medicare cost-sharing rules, cap beneficiary out-of-pocket spending, restrict first-dollar coverage in Medicare supplemental insurance (saves $110B) Restrict first-dollar coverage in TRICARE for Life (saves $38B)Enact malpractice reform (saves $17B)

Enact premium support pilot for federal employees (saves $18B)Reduce Medicare fraud (saves $9B)Cut Medicare payments to providers for bad debts (saves $23B)Accelerate home health payment changes in the ACA (saves $9B)Place dual eligibles in Medicaid managed care ($12B)Reduce funding for Medicaid administrative costs ($2B)Broaden scope of Independent Payment Advisory Board to all federal health spending

Phase out tax exclusion for employer-sponsored health insurance beginning in 2018 (saves $113B)Raise Medicare Part B premiums (saves 123B)*Increase rebates for Part D drugs (saves $100B)*Redesign Medicare cost-sharing (saves $14B)*Bundle Medicare payment for acute and post-acute care (saves $5B)*Transition Medicare to premium support, beginning in 2018 (saves $172B)Eliminate barriers to enrollment in managed care options for dual eligibles (saves $5B)*Incentivize government to control Medicaid cost growth (saves $20B)Cap non-economic and punitive damages for malpractice (saves $48B)Introduce excise tax on sweetened beverages (saves $156B)

Source: Commonwealth Fund

Major Health Policies Proposed inDeficit Reduction Proposals (Round II)

House Republican Budget Resolution President’s Framework

Assumes “doc fixes” are continued and fully offset

Repeals the tax and coverage provisions from health care reform, but keeps most Medicare savings (but not the Independent Payment Advisory Board)

Block-grants Medicaid in 2013 and holds growth to rate of inflation plus population growth

Enacts tort reform

Transforms Medicare to premium support program in 2022 and limits per beneficiary growth of premium support inflation

Assumes continuation of “doc Fixes”

Proposes health care savings from standardizing the Medicaid matching rate, prescription drug reforms, patient safety initiatives, and anti-fraud measures

Strengthens Independent Payment Advisory Board by broadening its mandate and limiting Medicare per beneficiary growth to GDP+0.5% instead of GDP+1%

SOURCE: Committee for a Responsible Federal Budget, Summary Table of Fiscal Plans, April 2011, available at http://crfb.org/sites/default/files/CRFB_Fiscal_Plans_Summary_Table.pdf 40

Characteristics of the Medicare PopulationPercent of total Medicare population:

NOTE: ADL is activity of daily living. SOURCE: Income data for 2009 from U.S. Census Bureau, Current Population Survey, 2009 Annual Social and Economic Supplement. All other data from Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2008 Access to Care file.

Income <200% FPL ($21,660 in 2010)

Cognitive/Mental Impairment

Long-term Care Facility Resident

3+ Chronic Conditions

Under-65 Disabled

Fair/Poor Health

Age 85+

2+ ADL Limitations

Sequestration

Switching gears to

Sequestration: percentage reductions for FY 2013 by category of spending

• Non-exempt defense discretionary 9.4• Non-exempt nondefense discretionary (after-

school programs, special ed, reduced FBI, border security, reductions in oversight of air traffic control, food inspection, water, air protection, NIH research, FEMA, 8.2

• Medicare 2.0• Nonexempt defense mandatory 7.6• Nonexempt nondefense mandatory 10.0

Impact of Sequestration on Older Adults (NCOA)

$54.5 billion in non-defense discretionary cuts in FY13• 17 million fewer congregate and home-delivered meals for seniors• 1.9 million fewer senior transportation rides to medical

appointments, grocery shopping, and other needs• 1.5 million fewer people receiving personal care services, such as

in-home help with bathing and dressing• 290,000 senior households losing their heat due to a $285 million

cut in the Low-Income Home Energy Assistance Program• 6,400 fewer unemployed low-income older adults getting hired

and paid because of cuts to the Senior Community Service Employment Program

Conclusion: Consumer have a horse in the race!