The Health Reform EditionThe Health Reform Edition

The Game Show…..The Game Show…..that is not a gamethat is not a game

Rules:• Question on health reform is asked. • Joes (audience) allowed to provide an

answer, then….• Pros (Dr. Clancy) allowed to provide an

answer.• Lightning Round – not enough time for

debate as I think I am right and you are wrong.

Question 1.

The March 2010 health reform Bill has how many pages?

Answer

1,990 pages and more than 400,000 words

2. What are the 4 Cs that explain why health reform was needed?

The 4 C’s of the Push for Health Reform:The 4 C’s of the Push for Health Reform:

1. Cost – US health care costs too much

2. Coverage – insured and uninsured

3. Clinicians – currently practiced, not enough

4. Care Quality / Efficiency – not good enough

CostCost

Losing Ground on US Competitiveness

CoverageCoverage

Insurance IssuesInsurance Issues

• Lifetime limits

• Pre-existing conditions

• Cancelling coverage

UninsuredUninsured

• 47,000,000 uninsured in the US.

• 650,000 uninsured in Oklahoma,

• 150,000 uninsured in Tulsa region or 1:5

Probability of late vs. early diagnosis of cancer, uninsured compared to those with

commercial insurance, 1994

1.7

2.6

1.4

1.5

0.0 1.0 2.0 3.0

Colorectalcancer

Melanoma

Breast cancer

Prostatecancer

Source: Roetzheim, et. al., 1999; KFF Chartbook

47 million uninsured in the US - Individuals without insurance are 1.4 to 2.6 times more likely than the insured to be diagnosed with last versus early stage cancer.

Bedlam Derm Clinic 2009Bedlam Derm Clinic 2009

Bedlam Derm Clinic 2009Bedlam Derm Clinic 2009

CliniciansClinicians

US short by 125,000 - 250,000 US short by 125,000 - 250,000 physicians in next 10 years physicians in next 10 years AAMCAAMC

• Increase in US population

• Increase in life expectancy

• Baby boomer demand

• Declines in medical school class sizes.

• Oklahoma 49th in primary care physicians per capita. United Health Foundation 2009

Care Quality and EfficiencyCare Quality and Efficiency

Chronic Disease = Re-admissions• Congestive Health Failure

• COPD

• Diabetes

• Psychiatric Illness– Schizophrenia– Bipolar Disorder

Oklahoma has a very high rate of Heart DiseaseOklahoma has a very high rate of Heart Disease

3. Where does Oklahoma rank when quality of care is plotted against cost of care?

Quality ofCare

Cost of Care

a. Here ?

d. Here ? b. Here ?

c. Here ?

OK

COMMONWEALTH FUND State Scorecard Summary of Health System Performance

Although Oklahoma health status is very poor, Although Oklahoma health status is very poor, health spending per capita is in the top quartile.health spending per capita is in the top quartile.

Dartmouth Health Atlas 2009Dartmouth Health Atlas 2009

Not OK!!Not OK!!

4. How many major Federal health reform bills are active?a. 1b. 2c. 3d. 4

3 Federal Responses 3 Federal Responses alive in 2010…………..alive in 2010…………..1. Patient Protection and Affordable Care Act

– March 2010 2. American Recovery and Reconstruction Act

– Stimulus Bill - 20093. Public Health Services Act - 1944

Federal Health Reform Legislative Process Federal Health Reform Legislative Process

2010 Federal Health Reform - ACA

1944 Public Health Services Act - PHSA

Agency Policies, Procedures and Rules • Health and Human Services• Centers for Medicare and Medicaid• Agency for Health Research and Quality• Centers for Disease Control• Health Resources and Services Administration

House, Senate andWhite House Negotiations

Passed Into Law

2009 Stimulus - ARRA

Practice of MedicineIn Community

Modified Law ? Repealed Law?

5. Beyond increasing health care coverage to the uninsured and insurance industry regulation…. name 8 additional areas covered in the March 2010 health reform bill?

Health Reform Basic Areas:1. Health Care Coverage – 32 million now covered. 50% through

Medicaid. In Tulsa, 100,000 newly insured.

2. Insurance Reform – limits on limits.

3. Workforce Initiatives – expand public health, nursing, PAs, nursing, primary care, FQHCs as teaching sites.

4. Access to Care – primary expansion through FQHCs.

5. Quality of Care – reimbursement based on reporting, performance.

6. Efficiency of Care – lower payments per visit, more patients in need.

7. Reimbursement Changes – bundled care, “risk” pushed to providers.

8. Greater detection of fraud, waste and abuse – more OIG agents. Not practicing evidenced based medicine is “waste and abuse.”

9. Faster transitions from research to patient care.

10. Center for Medicare and Medicaid Innovation – creativity in health care design and payment.

Insurance Reform • No longer lifetime dollar limits on health care coverage,

no denying of coverage for pre-existing conditions and no cancelling policies because someone gets sick.

Extending Care - By 2014, plans underway for many Americans currently without health care coverage.

• Expanding eligibility for Medicaid• Allowing children to be on parents plans up to the age

of 26• Mandating those in certain income categories to

purchase health care coverage – some subsidized. • Creation of insurance exchanges that allow individuals

to be included with larger groups in purchasing private – non-profit insurance plans.

Newly Insured

• Health insurance expansion will cover an estimated 32,000,000 of the 47,000,000 currently uninsured in the US.

• Roughly 16,000,000 will be covered through

health insurance exchanges and 16,000,000 through Medicaid expansion. ROI on insuring more in Oklahoma through Medicaid is positive….

• In the Tulsa region, this will initially be in the

range of 30,000 newly insured patients and may grow to as many as 100,000 patients seeking health care and medical homes.

Workforce and Medical Education

• Primary Care

• PAs, NPs

• Teaching Health Centers – resident physician expansion family medicine, internal medicine, pediatrics, geriatrics, psychiatry, dentistry and pediatric dentistry.

Workforce Planning

• Loan Payback Programs – There is an expansion of the National Health Service Corp loan payback program, highlighting primary care. Included within this program - physicians receiving loan payback can split time 50% patient care to the underserved and 50% towards medical and resident teaching.

• Patient Centered Medical Home teams – Funding will

become available to expand training in the Patient Centered Medical Home team model.

• Public Health – Funding will be available to promote Public Health training of medical students with a focus on epidemiology, disaster and emergency response and team-based patient care.

6. Access : What will be the primary site for expansion of health care to the newly insured (currently underserved)?

FQHC Expansion: – Continued ramp up in capital, workforce and

operations support of Federally Qualified Health Centers.

– Peak funding is 2011. – $ 11 Billion over the next 5 years.– Morton, Community Health Connections and

Indian Health Resource Center.

FQHC Distribution

FQHC utilization

7. Do the health reform and other major Federal bills allow opportunities for community-driven creativity in redesigning health care delivery ?

a. Nob. Yes

Creative CommunitiesCreative Communities

1. Beacon Communities Grant – health information exchange

2. Center for Medicare and Medicaid Innovation

3. Health Workforce Planning grants

4. Health Information Extension grants – Oklahoma Foundation Medical Quality

Center for Medicare and Medicaid Innovation • Within CMS, this new center is created which allows for

communities and organizations to create their own programs that improve the quality and efficiency of care and lower the cost of care.

  • Bundling of Care – Programs for 10 conditions for

bundling of all care 3 days prior to the primary interventions and for 30 days post intervention will begin by 1-1-2013.

• Accountable Care Organizations (ACO) – Shared

governance organizations that are accountable for the quality, cost and overall care of Medicare patients assigned to a particular ACO.

7. How will health reform cover its costs?7. How will health reform cover its costs?

Cost of health reform:

• Decreased Payments - The legislation cuts about $455 billion over 10 years from projected payment increases to hospitals, insurance companies and others under Medicare and other government health programs.

• Increased Taxes - Revenue increases over 10 years include: $210 billion from increasing the Medicare payroll tax; $107 billion from fees on insurance companies, drug makers and medical device manufacturers; $32 billion from the excise tax on high-value insurance plans; and $2.7 billion from a tax on indoor tanning services.

Decreased Hospital Reimbursement

• There will be a phased in reduction in the usual annual increases in payments for hospital based care.

• There will be a phased in dramatic reduction in

“DSH” - payments to hospitals.

• Hospitals will see penalties for readmission of myocardial infarction, congestive heart failure and pneumonia patients as well as for hospital acquired infections.

Changes in Physician Reimbursement • Primary care gets a 10% bump. • From 2011 – 2014, physician quality of care

reporting and quality of care reimbursement will be implemented.

• “Meaningful use” of health information technologies will require:– Use of electronic health records– Health information exchange– Reporting of quality of care data.

• Initially, physicians will receive enhanced payment for “meaningful use.”

• Beginning in 2015, physicians will receive lower reimbursement for non-participation in quality initiatives and “meaningful use.”

Fraud Detection and Compliance

• Non-Profit Hospital Reporting – Non-profit hospitals will be required to justify their non-profit status as well as their attention to community need by: – Performing and publishing a Community Health Needs Assessment and

Implementation Strategy every 3 years. – Publishing and promoting a financial assistance policy for patients unable

to pay their hospital bills. – Publishing and promoting their emergency care policies. – Limiting charges to uninsured patients to the same levels as insured

patients.

• Fraud, Waste, Abuse – Will see increase in funding for fraud detection ($ 150,000,000 for 2011), new powers for OIG, closer monitoring for kickback, promotion of whistle blowers and reporting of clinicians to National Practitioners Data Bank.

• Sunshine Act – Requires physicians to report all relationships and payments from industry (pharmaceutical, biological, device and IT).

9. Where are the new areas for “profit” post health reform ?

Delivering Health CareDelivering Health Care

Today Curve:

• Volume• Procedures• Specialty Care• Hospital Care• Cost based payment

Revenue

2010 2012 2014 2016

Tomorrow Curve:

• Quality• Efficiency• Performance• Bundling • Reduce expenses

“By 2014, you must learn how to make money at Medicare payment levels…”

Revenue per patient

Cost per patient

Commercial Medicaid Medicare Uninsured

20102010DollarsDollars

Payor SourcePayor Source

Medicare100%

10. Why do people hate the health reform legislation?

Why hate the health reform legislation ?1. Higher taxes

2. Lower reimbursement for some clinical services

3. Forced insurance coverage

4. Forced mandates on States

5. Big change in how we do things……

11. Is there a way to organize all of this in your head so that the “emerging future” makes some sense ?

a. No

b. Yes

c. Maybe

d.

Does not matter, it is allall going to be repealed starting in November.

2009 – 2018 A time of great change…..• Pre-health reform Implement health reform• Uninsured Many newly insured• Physician centered care Patient centered

medical home• Individual practitioners Team care• Paper EMR Health information exchange• Volume based care Performance, quality,

efficiency focus• Fee for service Bundled payment• Primary care focused GME add specialty GME• Distant relationship with payors “All In”

partnerships

““All In”All In”

• All In – In poker, the “all in” strategy involves betting all of your chips on a single hand and declaring “I am going all in.” Other players must respond by also going “all in”, or folding. It is a risky move but often used when a player is losing ground and must catch up to stay in the game.

• A similar analogy is playing out in communities across the US. Health disparities are so severe in some of these regions, that these at-risk communities cannot economically compete.

WorkforceWorkforce• Expanded, dedicated, diverse, culturally Expanded, dedicated, diverse, culturally competent, team-oriented skills to promote quality, competent, team-oriented skills to promote quality, efficiency and equityefficiency and equity• Facile with health Information technologiesFacile with health Information technologies

Access to CareAccess to Care• Right clinician at right Right clinician at right location at right timelocation at right time• CommunityCommunity embeddedembedded

Safety, Quality and EfficiencySafety, Quality and Efficiency• New system promotes New system promotes high quality - efficient care high quality - efficient care with no errors, team carewith no errors, team care• Leverages health information Leverages health information technology technology

Linked to Broader Linked to Broader Determinants of HealthDeterminants of Health• Education, urban design,Education, urban design, economic development, safetyeconomic development, safety• Health literacy, early childhoodHealth literacy, early childhood

Payment ModelsPayment Models• Promote safety, quality, efficiency,Promote safety, quality, efficiency, access for all, physician retention foraccess for all, physician retention for care of the underservedcare of the underserved

““All In” Integrated Model for All In” Integrated Model for High Performance Health High Performance Health Systems for the UnderservedSystems for the Underserved

Community Medicine is far more than the medical school……..

Workforce• Partnership with TU • SCM Track and Recruitment• Summer Institute• PA program initiated• Bedlam L team-care• EMR sophistication• Public Health certificates / MPH• Preventive Medicine fellowships

Access to Care• Bedlam E / L• FQHC expansion• School-based Clinics• Tulsa Housing Auth. Clinics• North Tulsa Regional Ctr• Tisdale Specialty Clinic

Safety, Quality and Efficiency• LEAN • Patient Centered Medical Home and IMPACT Outreach Teams• Doc 2 Doc • Health Access Network • Greater THAN Health Information

Linked to Broader Determinants of Health• Educare and Promise Neighborhoods• OU Urban Design - CHED• OU Pharmacy - health literacy• OU Social Work – Turley• YMCA Wellness and LIVESTRONG• OU Community Engagement Center and Public Schools

Payment Models• Loan payback programs• PMPM and case rates for team care• Bumps for EMR and e-prescribing• Preparing for quality reporting• Direct to employer contracts• Summit on Urban Health• Center for Medicare and Medicaid Innovation, HRSA

Tulsa “All In” Integrated Tulsa “All In” Integrated Model for High Performance Model for High Performance Health Systems for the Health Systems for the UnderservedUnderserved

LEAN InitiativeLEAN InitiativeSavings (July-06 to June-09)

0

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

Jul-06

Aug-0

6

Sep-0

6

Oct

-06

Dec-

06

Jan-0

7

Feb-0

7

Mar-

07

Apr-

07

May-

07

Jul-07

Aug-0

7

Oct

-07

Nov-

07

Jan-0

8

Apr-

08

Jun-0

8

Jul-08

Oct

-08

Dec-

08

Apr-

09

May-

09

Jun-0

9

RIE + Blackbelt TotalSavings Calculation Trend

Wellness for those with majormedical illness and chronic disease

Clinical Services Network Supported by Medical EducationClinical Services Network Supported by Medical Education346 clinicians, 98 specialized programs at 52 sites of practice346 clinicians, 98 specialized programs at 52 sites of practice

Traditional Hospital-Based ServicesTraditional Hospital-Based Services(5 hospitals, 18 programs)(5 hospitals, 18 programs)

St. John – St. John – 24 / 7/ 365 Internal Medicine hospitalist teams, ICU team, geriatrics team*, general surgery teams, orthopedics trauma fellowship, dialysis team, procedures team, palliative care, vascular team. Hillcrest Medical Center – Hillcrest Medical Center – 24 / 7/ 365 Family Medicine hospitalists, in-house OB Gyn 24 / 7 / 365 services, Maternal Fetal Medicine program.Saint Francis Hospital – Saint Francis Hospital – Emergency Medicine faculty and residents, 24 / 7/ 365 OU Peds hospitalist teams, Psychiatry consultation team. Laureate Psychiatric Hospital – Laureate Psychiatric Hospital – 24 / 7/ 36524 / 7/ 365 Inpatient psychiatry careJane Phillips Hospital – Jane Phillips Hospital – inpatient Family Medicine hospitalist and ob care.Resident Moonlighting – St. John, Saint Francis, Hillcrest. General medicine, OB.

Traditional OU Clinics Traditional OU Clinics (5 OU Clinics, 37 specialized programs) (5 OU Clinics, 37 specialized programs)

Schusterman Center – Schusterman Center – “green card” ER referral from hospitals, general medicine clinic, geriatrics, HIV / Hepatitis, dermatology, geriatric psychiatry, psychiatry, adult diabetes, pediatric diabetes, gestational diabetes, general pediatrics, pediatric pulmonology, pediatric urology, OB, gynecology, perinatology, hypertension, headache, nephrology, Flu Clinics, student and employee health, OU Pharmacy, pain management, patient centered medical home teams.OU Family Medicine Center – OU Family Medicine Center – green card ER referrals from hospitals, family medicine, sports medicine, physical therapy, STEP Pharmacy, patient centered medical home teams.Warren Clinic – Warren Clinic – peds behavioral health, peds GISt. John Bernsen Center – St. John Bernsen Center – green card ER referrals from hospitals, OU Surgery Clinic, OU Vascular Clinic, OU Neurology Clinic.Ramona Clinic – Ramona Clinic – Family medicine and obstetrics

Community Health Clinics (27 clinic sites and Community Health Clinics (27 clinic sites and programs)programs)

Primary Care - Primary Care - 2 Bedlam Evening Clinics / week, 6 Bedlam Chronic Care / Longitudinal Clinics / week – patient centered medical home teams, Family and Children’s Services Primary Care Clinic in a mental health center, 2 Tulsa Housing Authority Apartment Clinics, 19 School-Based Clinics, Mobile Sooner Schooner II Clinics, Neighbors Along the Line Clinic, Day Center for the Homeless PA Clinic 5 days per week.

Specialty Care - Bedlam Surgery Clinic, Bedlam Women’s Clinic, Bedlam Dermatology Clinic, Shriner’s Telemedicine Clinics, Bedlam Pharmacy Network, Bedlam Case Management, Bedlam Pharmacy Consultation, Web-based Visits, Web-based Consultations, Bedlam Specialist Referral Network, Xavier Breast Clinics, Optometry / Wound Care, Bedlam HIV and Hepatitis Clinic,

Specialized Community Health Teams (20 programs) Specialized Community Health Teams (20 programs)

IMPACT Mobile Psychiatric Team, Community Health Connections and Morton Obstetrics Clinics, Porter and Hominy Obstetrics Outreach, Margaret Hudson High School Clinic, Neighbor for Neighbor and Morton Heart Intervention Program, Child Abuse Network – severe child abuse intervention team, Oklahoma Bio-ethics Center, Oklahoma Institute for Disaster and Emergency Medicine, Greater Tulsa Health Access Network (Greater THAN), Indian Health Resource Center Psychiatry - OB Programs, Youth Services of Tulsa Clinic team, Youth Services of Tulsa outreach clinic, Laura Dester – child abuse shelter, OU Nursing Prenatal Outreach – Inter-conception Care. Harvard Center for Child Development partnership. Tulsa Health Department Dysplasia Clinic, US Probation Office Clinic.

Coming Soon – Coming Soon – ER frequent flyer case management team, pediatric bone cancer, Wayman Tisdale Specialty Health Center

OU Wayman Tisdale Specialty Health Center: OU Wayman Tisdale Specialty Health Center: OU Cancer Center, OU Diabetes CenterOU Cancer Center, OU Diabetes Center, , diagnostic testing, diagnostic testing, urgent / cardiac care in the heart of an underserved area urgent / cardiac care in the heart of an underserved area

We Can Fight Everything or We Can Build Something Great….We Can Fight Everything or We Can Build Something Great….